EXTRA COPY — ECG Blog #549 — Why CP? — EXTRA COPY —

 XXXXThe ECG in Figure-1 is from a middle aged woman who presented with palpitations and dizziness of 2 hours duration. No chest pain. BP ~120/70 mm Hg.

Figure-1: The initial ECG in today's case. (To improve visualization — I've digitized the original ECG using PMcardio).

QUESTIONS: 

• How would you interpret the ECG in Figure-1?
• Is this NSVT (NSVT) or aberrant conduction? (How certain are you of your answer?)
• What would you do?
• Does this ECG show anything else?

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DISCLAIMER:

My follow-up of the above case is unfortunately limited. That said — What counts is the approach. This matches the clinical reality that we often encounter patients for whom we need to initiate management before we know with certainty what the diagnosis is from the initial tracing.

Take another look - now with beats numbered

What are the hints to the likelihood of VT vs aberrant?

Figure-2: XXXX

MY APPROACH:

XXXXX 

underlying rhythm = AFib

despite AFib - constant C (coupling interval)

post-ectopic pauses

atypical lbbb morphology (transition by V3 !!!

Figure-3: XXXX

Why VT?

XXXXX 

Always good to go back to the 12-lead

Although I don't have follow-up - note ST dep = ? post OMI

You'll have to repeat the ECG after treatment of VT to see if ST persists?

Figure-4: XXXX

XXXXXX

XXXXXX

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Acknowledgment: My appreciation for the anonymous contribution of today's case. 

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THE CASE (from Ahmed Abbas — Anonymous! 

Dear Dr.Grauer. I hope you are doing well.

Today i present to you a case of a 49 year old woman,pre DM, presented to our urgent care center with dizziness and palpitations for the past 2 hours.

 

she denies and chest pain, shortness of breath , or syncope.

Her vitals were BP 118/63, sat 99 on RA, pulse 182.

 

Here ECG showed atrial fibrillation with runs of nonsustained Vtach,her troponin was negative , received 150mg of amiodarone  then transported to hospital.

 

kindly help us interpreting the ECG with the details you usualy provide.

my questions:

1. were those runs of psvt or appatently conducted atrial fibrillation?

2. the widw complex qrs after narrow ,is it ashman?

3. what causes the re-entry if there is one?

 

Your insights are always helpful and appreciated.

Best Regards — Ahmed

MY REPLY:

Very interesting case — so much that I’d like to use it for an ECG Blog if you can give me follow-up.

 

I received 2 ECGs. The 1st one has the date of October 9 @ 7:23 on it — so it is a current (and not a previous tracing). But I have NO idea as to when this 1st ECG occurred with respect to the 2nd ECG that shows NSVT. Was the patient initially in sinus rhythm when she presented with “dizziness and palpitations” but no CP (chest pain)? Or was this after receiving Amiodarone. WHEN did she develop AFib?

 

ECG #2 shows as you say AFib with runs of NSVT (although since beats #1-thru-6 at the beginning of the tracing are all ventricular — we have no idea as to HOW LONG this first run was? (ie, it could have been sustained VT).

 

The few narrow (supraventricular) beats that we do see are irregularly irregular. So despite what looks like a “sinus P wave” in front of beat #23 in lead V3 — this is almost certainly a “fib wave” for a rhythm of underlying AFib.

 

The runs of WCT (wide-complex tachycardia) are fairly but not completely regular. There is a somewhat rightward frontal plane axis (more positive in II,III than in lead I) — and with lbbb-like conduction in the chest leads — BUT this is not “typical” lbbb conduction because there is already a predominantly positive QRS for the wide beats as early as lead V3 (and with true lbbb conduction, transition occurs later, typically by V5 or V6).

In addition — there is a “post-ectopic pause” after beats #6 and after #22 — and that is much more commonly seen following VT.

Finally — there is NO reason for aberrant conduction. Ashman occurs when you have a wide beat occurring after a relative pause ... See ECG Blog #70 and ECG Blog #71 for details about Ashman. But there is no preceding pause to set up conditions for aberrancy — and the same shape wide beat occurs for beats #10 and 14 despite different preceding coupling intervals. These are ventricular beats!

QRS morphology of these wide beats is consistent with RVOT VT (ie, lbbb-like in the chest leads; right frontal plane axis).

 

But GO BACK to ECG #1 — and note the flat (abnormal!) shape of the ST segment in lead V2 (should normally show a gently upsloping ST segment with slight ST elevation) and the clearly FLAT ST segments in V3,4,5 (and definite slight ST depression in V3). So if you only did a single normal Troponin — MORE troponin values should have been done since the 1st Troponin can sometimes be normal despite acute coronary occlusion.

Bottom Line — I am missing details as to what happened when ... but ECG #1 is not normal in a patient who develops runs of VT (and if this was the initial ECG before ECG #2, then I wonder if she had a silent acute posterior OMI?

 

ECG #2 shows AFib with runs of NSVT with RVOT VT morphology.

 

What happened? As I mentioned — I’d love to use this as an ECG Blog if you can answer some of my questions. I’d be happy to acknowledge you (a number of years ago I had you as from Amman, Jordan when you sent me a tracing that I published as a blog. Is that the way you would want me to acknowledge you? Or do you prefer for this case to be anonymous. Just let me know.

 

Hope the above is helpful — 

 

ABBAS REPLY:

Dear Dr grauer

Thank you for your reply. 

The ecg showing nsvt is the initial rhythm at presentation. Only complaining of dizziness, she came to the clinic at 16:45.

 

ECG with sinus rhythm was after we administered amiodarone and transported the patient, it was recorder at the receiving facility at 19:23. 

 

I am not sure if they gave something else in the hospital, I will check tomorrow and let you know. 

 

As for publishing, that would great but as anonymous, because I was not directly involved in the management of the patient,it is recorded in my new job in UAE,I am still new to the place and I don't want colleagues to accuse me of stealing there efforts. 

 

Best regards — Ahmed Abbas