Cardiology Series: Case 8

ANSWERS WILL BE POSTED TOMORROW 3/9/17 AT 18:00 CET

A 67-year old man presents with shortness of breath and lightheadedness.

You obtain an immediate ECG result:

Source: Press on hyperlink.

1. Describe the ECG changes above without making a diagnosis.

2. What is the most likely diagnosis in this patient ?

3. Describe the criteria that differentiates this diagnosis from Supraventricular Tachycardia (SVT).

4. How would you manage this patient ?

5. What are the possible complications that may arise in this man ? 

Source: https://www.ncbi.nlm.nih.gov/pubmed/20887902

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1. Heart Rate= 150 beats/min
Rhythm= Regular

Absent P waves and Atrioventricular dissociation with Right Bundle Brunch Block like QRS complexes (Broad Complex Tachycardia).
Fusion and Capture Beats seen in AVL and V3.

2. Ventricular Tachycardia (VT).

3. Brugada Criteria to differentiate SVT from VT

Source: https://academic.oup.com/europace/article/13/4/465/427753/Diagnostic-criteria-of-broad-QRS-complex

4. Management

Connect to a cardiac monitor, have a defibrillator to hand.

Unstable or pulseless VT are hemodynamically compromised and require immediate cardioversion. Use asynchronized DC shock.

Stable VT

• Give high flow oxygen by face-mask
• Obtain Intravenous access. Send U&E, cardiac enzymes, Ca2+,Mg2+. Correct low K+ or Mg2+
• Obtain 12-lead ECG
• Arterial Blood Gases-if evidence of pulmonary oedema, reduced concious level or sepsis.
• Amiodarone IVI
• If torsade de pointes is evident on the ECG as polymorphic widened QRS complexes, give magnesium sulphate 2g IV over 10 min
• If this fails, try another DC shock.
• After correction of VT, establish the cause from history/investigations
• Maintenance anti-arrhtyhmic therapy e.g. amiodarone
• Prevention of recurrent VTs: use implanted ICD automatic defibrillators. In refractory cases, radiofrequency ablation may be tried.

5. Complications of Ventricular Tachycardia: Ventricular Fibrillation (VF) and Sinus Arrest.