ECG of the Week: ECG of the Week - 7th August 2017

Wednesday, 9 August 2017

ECG of the Week - 7th August 2017 - Interpretation

The following ECG is from a 59 yr old female who presented to the Emergency Department complaining of palpitations.

Click to enlarge

Rate:

Mean ventricular rate 144 bpm

Rhythm:

Irregular
Nil regular P waves visible
Notching terminal QRS complexes #8 and #9 in aVF

? fibrillation waves ? Retrograde P ? SA activity

Axis:

Normal

Intervals:

QRS - Normal

Additional:

ST Depression leads II, III, aVF, V3-6
ST elevation lead aVR
T wave inversion leads II, III, aVF

Interpretation:

Atrial fibrillation

Rapid ventricular response
ST / T wave changes likely rate-related demand ischaemia

Clinical Factors in Atrial Fibrillation

There are several features to establish on assessment of the patient in atrial fibrillation that will influence both the immediate and long-term management strategies, including:

Onset and duration of symptoms
Likelihood of paroxysmal episodes
Evidence of compromise from AF

Chest pain, cardiac failure, hypotension etc.

Current medications

Especially anti-coagulation and anti-arrhythmics

Potential precipitant / cause

E.g. sepsis, electrolyte abnormality, endocrine disease

Suitability and contra-indications to management options

E.g. fasting status, anaesthetic risk, drug allergy / intolerance, bleeding risk

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

Anti-coagulation

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: