Over the next 3 weeks we have a series of ECG's from a single patient.
69 year old female presenting with palpitations and mild dysponea.
Nil chest pain, no overt cardiac failure, and an acceptable blood pressure.
History of cardiomyopathy, chronic AF, LVF, and has an ICD in-situ.
 |
| Click to enlarge |
Wide (broad) complex tachycardia at a rate of about 150/min. There appears to be positive concordance in the precordial leads. Marked left axis deviation (LAD). Duration of the QRS interval is about 0.15s.
ReplyDeleteMy two biggest differentials would be that this is most likely ventricular tachycardia. There appears to be atrial activity at a constant relationship to the QRS complex so there's possibly a 1:1 retrograde conduction to the atria. However, I can't rule out antidromic tachycardia or some preexcited atrial tachyarrhythmia like atrial flutter (rate = 300/min) with 2:1 A-V conduction. I'm sure the ECGs in the following weeks will shed light on the true nature of this WCT. This does not favor SVT with aberrancy.
Rate: 150 bpm
ReplyDeleteRegularity: regular
P-waves: possibly present in V1 (long RP, normal PRi), maybe upright in II? As Jason notes with the V-rate we should consider a 2:1 mechanism such as F-waves
PRi: normal if present or long RP if VA conduction
QRSd: ~140ms
Axis: left
QTi/QTc: appears normal
ST/T-waves: appropriately discordant
DDx: VT, AVRT; less likely: AF w/ aberrancy as the morphology is decidedly not a normal RBBB/LBBB.
Given the presence of possible P-waves or F-waves in V1 I'd likely give adenosine first line if I treated this in the field. Followed by procainamide if no improvement.