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| [[Puzzle_2005_5_189 - Answer|Answer]] | | [[Puzzle_2005_5_189 - Answer|Answer]] |
| [[Image:Puzzle_2005_5_189_fig2.jpg|Figure 2|thumb]]
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| The ECG shows a broad QRS complex tachycardia
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| (QRS width 130 ms). The RR intervals are 280 ms
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| (heart rate 214 beats/min). The electrical axis is in the
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| left upper quadrant (leftward shift). There is a left
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| bundle branch block morphology (negative complex
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| in lead V1) with positive complexes in the other precordial
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| leads.
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| In the differentiation between ventricular tachycardia
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| and supraventricular tachycardia with aberrant
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| conduction, the position of eventual P waves is crucial.
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| The most optimal leads to look at for P waves are leads
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| II and V1. A close look at lead II reveals a negative P
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| wave after every second QRS complex: before the first
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| QRS complex, after the 2nd QRS complex, after the
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| 4th, etcetera (figure 2) which is an enlarged version of
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| lead II. These negatives P waves are most likely retrograde
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| P waves in the presence of 2:1 ventriculoatrial
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| (VA) dissociation. And this is a strong argument for
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| ventricular tachycardia (specificity 98%, sensitivity 66%,
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| Brugada et al. <cite>brugada</cite>). The origin of the tachycardia is
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| most likely the inferior part of the intraventricular
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| septum, compatible with a history of an inferior wall
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| MI.
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| '''Conclusion, the correct diagnosis is ventricular tachycardia with 2:1 VA dissociation.'''
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|
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| ==References==
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| <biblio>
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| #brugada pmid=2022022
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| <biblio>
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