An Irregular Rhythm at Older Age: Difference between revisions

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m (New page: {{NHJ| |mainauthor= '''A.A.M. Wilde''' |edition= 2007:4,157 }} Figure 1|thumb An 86-year-old man presents in your outpatient clinic with stable angina...)
 
 
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[[Puzzle_2005_4_157_Answer|Answer]]
[[Puzzle_2005_4_157_Answer|Answer]]
The ECG shows sinus rhythm with a rate slightly below
60 beats/min. The PR interval is slightly prolonged
(220 ms) and QRS width is normal (80 ms). The
electrical axis is at –30°. An old inferior myocardial
infarction might be present.
The rhythm is slightly irregular. This refers in particular
to the 6th P wave, which comes earlier and is
slightly different in morphology (most clearly seen in
lead III). Hence, this should be referred to as an atrial
extrasystole. The PR interval of this extrasystole is
further prolonged (360 ms). Although atrial prematurity
is generally followed by hampered AV-nodal
conduction (i.e. this is normal AV-nodal physiology),
a normal AV node should be expected to have recovered
completely from previous conduction at these
long coupling intervals. Hence, and as also indicated
by the baseline prolonged PR interval, his AV node is
no longer functioning optimally. The β-blocker might
of course be contributing to that.
At the most right part of the ECG a long RR
interval is seen. Again an atrial extrasystole is present
which is now blocked. The coupling interval of this
extrasystole is shorter than that of the first atrial extrasystole
and is, not unexpectedly given the significantly
hampered AV conduction of the first extrasystole, now
blocked. The PR interval of the following sinus beat
is within normal limits, one more argument for a
functional defect in a less than optimally functioning
AV node.
'''In summary: sinus rhythm with first-degree AV block, (blocked) atrial extrasystoles.'''

Latest revision as of 19:59, 25 January 2010

Author(s) A.A.M. Wilde
NHJ edition: 2007:4,157
These Rhythm Puzzles have been published in the Netherlands Heart Journal and are reproduced here under the prevailing creative commons license with permission from the publisher, Bohn Stafleu Van Loghum.
The ECG can be enlarged twice by clicking on the image and it's first enlargement
Figure 1

An 86-year-old man presents in your outpatient clinic with stable angina pectoris (NYHA 2/4). There is no further medical history with the exception of hypertension for which he is being treated with metoprolol 100 mg daily. Physical examination reveals no abnormalities. His ECG is shown in figure 1 (only extremity leads).

What is your electrocardiographic diagnosis?

Answer

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