This ECG is from a 47 year old female presenting with palpitations of 3 hours duration.
|Click to enlarge|
- 156 bpm mean rate
- Varies between ~135 - 185 bpm
- Irregularly irregular
- Nil p waves
- Normal (+45 deg)
- PR - Nil p waves visible
- QRS - Normal (60-80 ms)
- QT - 240-280ms (QTc Bazette ~ 360-470 ms)
- ST Elevation lead aVR (1mm)
- ST Depression leads I, II, III, aVF, V4-6
- Atrial Fibrillation with rapid ventricular response
- a.k.a 'Fast AF'
- Inferolateral ischaemic changes
- ? Rate related
Our VAQ style question for this ECG was :
47 year old female presents complaining of palpitations onset 3 hours age. She denies chest pain and is not short of breath. She has no prior medical history. Blood pressure is 120/75.
Her ECG is above.
a) Describe and interpret her ECG (30%)
b) Outline your management options (70%)
Management Options in Atrial Fibrillation
There are several considerations in the management of AF which include:
- Rate vs. rhythm control
- Electrical vs Chemical rhythm control
- Risk vs Benefit
- Drug to use
- ? Underlying precipitant
- Infection / ischaemia / structural / endocrine / metabolic etc.
- Follow-up / disposition
- Ablation suitability
Despite being one of the commonest arrhythmia encountered in medicine there is considerable variability in the clinical management of atrial fibrillation. There are a number of international guidelines and protocols regarding AF management, including:
- European Society of Cardiology Guidelines 2010
- American College of Cardiology Foundation / American Heart Association / Heart Rhythm Society Guidelines 2011 Update
- American College of Cardiology Foundation / American Heart Association / Heart Rhythm Society 2006 Guideline
- Canadian Cardiovascular Society Guidelines 2010
- NICE Guideline 2006
- Ottawa Aggressive Protocol for Recent Onset Atrial Fibrillation/Flutter
- Western Australia Cardiovascular Health Network Guidelines 2011
AF Related Calculators (links to MDCalc)
References / Further Reading
Life in the Fast Lane
- Atrial Fibrillation here
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.