Palpitations and Dizziness in a 65-Year-Old-Man: Difference between revisions

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

Revision as of 19:07, 8 October 2007

Author(s) A.A.M. Wilde
NHJ edition: 2005:5,189
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

A 65-year-old male presented with palpitations and dizziness of sudden onset, without any associated chest pain or other symptoms. His medical history includes an inferior myocardial infarction three years ago, treated with primary percutaneous transluminal coronary angioplasty (PTCA). No acute complications were reported and he had been without symptoms ever since. With the exception of a low blood pressure (90/60 mmHg), physical examination reveals no abnormalities. His ECG is shown in figure 1 (standard calibrations).

What is your diagnosis?

Answer

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