Puzzle 2004 3 123, One to one, one to two, two to one? What is the rhythm? - Answer: Difference between revisions
Puzzle 2004 3 123, One to one, one to two, two to one? What is the rhythm? - Answer (view source)
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a wide-complex tachycardia, it is always important to look for the P wave. In this particular ECG, a P wave cannot be seen with certainty; one may presume that the small deflections immediately following the QRS complex in both the fast and slower rhythms are P | a wide-complex tachycardia, it is always important to look for the P wave. In this particular ECG, a P wave cannot be seen with certainty; one may presume that the small deflections immediately following the QRS complex in both the fast and slower rhythms are P | ||
waves. In that case, during the slower parts, every other P wave is not seen. The rate is typical for atrial flutter (300 beats/min at the atrial level) and the occasional doubling of rate suggests alternating 2:1 and 1:1 conduction to the ventricles. | waves. In that case, during the slower parts, every other P wave is not seen. The rate is typical for atrial flutter (300 beats/min at the atrial level) and the occasional doubling of rate suggests alternating 2:1 and 1:1 conduction to the ventricles. | ||
The QRS width is 160 ms and it should be noticed that the initiating part of the QRS complex is particularly slow. This would be compatible with preexcitation of the ventricles. While a ventricular origin of the rhythm cannot be excluded, the alternating rate with similar QRS morphology renders ventricular tachycardia less likely, as this is only possible in the rare diagnosis of ventricular tachycardia with occasional 2:1 exit block. Similarly, atrial tachycardia with exit block and aberrant conduction is unlikely. Hence, atrial flutter with alternating 1:1 and 2:1 conduction to the ventricles over an accessory pathway (i.e., preexcitation) is the most likely diagnosis. The bypass is located at the left side of the heart (positive delta wave in lead | The QRS width is 160 ms and it should be noticed that the initiating part of the QRS complex is particularly slow. This would be compatible with preexcitation of the ventricles. While a ventricular origin of the rhythm cannot be excluded, the alternating rate with similar QRS morphology renders ventricular tachycardia less likely, as this is only possible in the rare diagnosis of ventricular tachycardia with occasional 2:1 exit block. Similarly, atrial tachycardia with exit block and aberrant conduction is unlikely. Hence, '''atrial flutter with alternating 1:1 and 2:1 conduction to the ventricles over an accessory pathway (i.e., preexcitation) is the most likely diagnosis'''. The bypass is located at the left side of the heart (positive delta wave in lead | ||
V1) but its exact localisation (lateral or posterior) cannot be determined in the absence of limb lead recordings. The differential diagnosis includes atrial flutter with aberrant conduction over the right bundle branch and alternating 1:1 and 2:1 AV-nodal conduction. | V1) but its exact localisation (lateral or posterior) cannot be determined in the absence of limb lead recordings. The differential diagnosis includes atrial flutter with aberrant conduction over the right bundle branch and alternating 1:1 and 2:1 AV-nodal conduction. | ||