She presented complaining of palpitations and dysponea. Clinical examination finding were consistent with cardiac failure.
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- Mean ventricular rate 72 bpm
- Regular atrial activity ~75 bpm
- Repeating pattern
- Sinus complex --> sinus complex --> premature ventricular complex (PVC)
- see P waves buried in the PVC best seen lead I and lead V2
- Sinus complexes
- Sinus Complexes
- PR - Prolonged (~220ms)
- QRS - Prolonged (180-200ms)
- QT - 440ms
- QRS - Prolonged (140ms)
- QT - 400ms
- Appropriate discordant ST segment and T wave changes
- Sgarbossa criteria negative
- 1st Degree AV block
- Regular PVC's
What happened ?
The majority of the patient's ECG changes were pre-existing, only the frequent PVCs were new.
The patient had a normal potassium and equivocal troponin.
Previous echo, ~1yr prior, showed:
- LV Dilation with inferolateral akinesis
- Severe systolic impairment
- Severe mitral regurgitation with possible chordae rupture.
- LA dilation
- Severe pulmonary hypertension
The patient has significant other co-morbidites and was unsuitable was invasive cardiac intervention and was therefore for medical managment. This episode of cardiac failure was treated with fluid restriction, diuretic increase, and medication maximisation.
References / Further Reading
Life in the Fast Lane
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.