35 year old male presents to the fire station with palpitations after heavy alcohol consumption

35 year old male presents to the fire station complaining of an irregular heart beat.

The patient states that he walked up to the top of the lighthouse earlier in the day and started to feel palpitations.

He is on vacation and has been “drinking a lot” all week. He denies chest pain or shortness of breath although he appears anxious.

Past medical history: Healthy
Medications: None
Allergies: NKDA

Vital signs are assessed.

  • RR: 18
  • HR: 54 (irregular)
  • NIBP: 130/84
  • SpO2: 99 RA

The cardiac monitor is attached.

TOMB062409B_wm

A 12 lead ECG is acquired.

TOMB062409C_wm

Breath sounds are clear bilaterally.

The patient is adamant that he does not want to be transported to the hospital. He states that he just wants a printout of the 12 lead ECG to show his private physician.

What is your interpretation of this ECG?

How would you explain to this patient the risk of refusing care/transport?

Discussion

notched J-pointsThis ECG shows atrial fibrillation and early repolarization. There are notched J-points with upwardly concave ST-segments and prominent T-waves in the inferior leads (II, III, aVF) and the left precordial leads (V4-V6).

Although the atrial fibrillation is concerning, the early repolarization pattern is probably normal for a 35 year old male. Having said that, it would be nice to have an “old” ECG for comparison.

It can be scary when there is coincidental T-wave inversion in lead aVL with early repolarization since we often rely on a reciprocal change in lead aVL to rule-in acute inferior STEMI!

This can sometimes happen when the QRS complex is negative in lead aVL and the frontal plane axis is nearly vertical. See another example at Dr. Ken Grauer’s ECG Review #47.

In 1978 Ettinger et al. coined the term “holiday heart” to describe abnormal heart rhythms (typically atrial fibrillation) in otherwise healthy individuals following excessive alcohol consumption. It is usually temporary and resolves within 24 hours.

Atrial fibrillation is a risk factor for stroke. The risk increases with age, hypertension, diabetes, and underlying cardiovascular disease, including heart failure. This patient’s risk is relatively low, but the issue should be brought to the patient’s attention.

As Stephen Smith, M.D. points out in the comments, Holiday Heart Syndrome typically has a rapid ventricular response. It is possible this patient has AV nodal disease unless we can attribute the slow ventricular response to good health and increased vagal tone.

In this case paramedics contacted online medical control, the risks of refusing care were discussed with the patient, and he signed a refusal against medical advice.

References

Ettinger P, Wu C, De La Cruz C, Weisse A, Ahmed S, Regan T. Arrhythmias and the “Holiday Heart”: alcohol-associated cardiac rhythm disorders. Am. Heart J. 1978;95(5):555–62. doi:10.1016/0002-8703(78)90296-X.

Wolf P, Abbott R, Kannel W. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983-988. doi:10.1161/01.str.22.8.983.

Updated 01/01/2016

22 Comments

  • McTerzlins says:

    I agree with the computerized interpretive statement: AF with slow VR. In a previously healthly guy like this on vacation, I would put "holiday heart syndrome" at the top of my list for potential causes. I would strongly encourage him to be transported, and be sure to explain the risk of clot formation and consequent CVA/PE after autoconversion without anticoagulation.

  • Iain says:

    Hi, I'm not a cardiologist or medic, though I do develop software for automated analysis of the QT interval, so have seen a lot of ECGs, and am keen to learn more about what patterns indicate different diagnoses, hence the subscription to this blog.I would have thought the absence of P-waves together with the irregular beat might indicate Atrial Fibrillation, though my understanding is that AF is usually accompanied by a high heart rate (it certainly was when my mother was admitted to hospital with AF).

  • Tom B says:

    McTerzlins – I hadn't considered "holiday heart syndrome" but it makes perfect sense! Interesting thought.I agree with your ECG dx and that exactly what I was looking for with regard to the risk of refusing care.Thanks for the comment! Tom

  • Tom B says:

    Iain – Very good point! New onset AF is typically in the neighborhood of 130 beats/min. Bradycardic AF is unusual in the absence of meds for rate control or metabolic derangement. We can see a couple of asystolic pauses that approach 2 seconds (3 seconds is an indication for an implantable pacemaker).Tom

  • Anonymous says:

    Another good case. I obviously thought AF and he needs to goto hospital due to clots. However I had never heard of holiday heart syndrome so thanks for the comment… just when you think you know something theres always a differential, thats why i love this job.

  • Rogue Medic says:

    But how are you going to explain to your doctor if you have aphasia from a stroke?While there is nothing about the rhythm that would indicate the stroke symptoms that the patient might experience, or even the likelihood of having a stroke, . . . . Agreeing to a refusal without presenting all of the risks of permanent disability and death in a way that is clearly understood by the patient, and repeated back by the patient, is not a good idea.Some would even recommend having the patient write out their understanding of the risks of permanent disability and death on the refusal form themselves. Making it clear that the patient may not be in any condition to recall the events of this refusal may be helpful in getting them to understand.

    • Jessica says:

      I like the idea of having high risk patients write out their own refusals, will keep that in mind in the future. Thanks for the advice!

  • Tom B says:

    Good point, RM.I would be royally freaked out if I was in AF, holiday heart syndrome or not! Tom

  • raja says:

    Its aRTERIAL FLUTTER and 1st degree heart block

  • Julia says:

    Diagnosis: Atrial Fibrillation with slo ventricular rhythm.
    Management: Emphasize the importance of transporting him to a hospital with a cardiac facility management. Since this has been a dysrhythmia already, this can further lead to a more lethal rhythm such as Ventricular fibrillation or ventricular tachycardia which really need a prompt management especially that he had this episode for the first time.

  • Mak19 says:

    What about the ST elevation in V3 and V4?

  • Medic-Minx says:

    @ Raja – 
    The correct term is ATRIAL Flutter of which this is not. The baseline is chaotic and fibrillatory; it's also irregular and lacks P-waves and slow. It's Atrial Fibrillation with SVR (slow ventricular rate). Flutter has flutter-waves which are a saw-tooth pattern.

  • steve says:

    LQT, with pulse that slow?

  • Igor PT says:

    Mark: Benign early repolarization (BER). We have good R waves, and the same pattern  in inferior leads, as the tiny ST depression in aVR, showing the opposite polarity of the ST from the BER. Not totally impossible to be ACS, but almost  =)

  • JB says:

    Transport is mandatory,  If pt is explained risks of clotting and tachycardia and still refuses it is possible to get law enforcement involved for a involentary commitment.
    I would never let a case of new onset afib with palpations released under there own care.

  • David says:

    Involuntary confinement. lol. Nice one Stalin.

  • JB – If the patient is mentally competent, and wishes no transport, and you can't convince them after explaining the risks, an LEO won't do it. My thoughts on this patient: initially were A-Fib, but after reading about Holiday Heart Syndrome, I am leaning toward this. Since he presented to the fire station with symptoms, I would use that as a marketing point for transport. He came there knowing he needed help. A "quick" check at the local ER will help him out. The risks of this are considerable, but don't warrant forcing the patient with the assistance of LE.

  • Emanuele Guerra says:

    It is definitly a low response atrial fibrillation. Of course transport is mandatory, because if symptoms occourred withi 24 hours it is possible to cardiovert or with drugs or electrically.
     

  • Chris says:

    If you transport this pt without consent, you are going to prison for kidnapping. He is CAOx3…he could refuse even if he was having an MI if he was alert and oriented. I’m a little scared right now…

  • Holiday heart should have a rapid ventricular response. This patient is either taking an AV nodal blocker already, or has AV node disease.

  • Terry says:

    Chris— kidnapping??? Going to prison??? I agree as everyone else the patient should go to the hospital but you can’t force them. We all have the right to make stupid decisions leading up to and including death. Documentation calling med control and getting a signed refusal is crucial. Kidnapping is when you take someone against their will to do bodily harm or seek a ransom. Taking someone to the hospital against their will is not kidnapping. Unlawful detainment??? I’ll buy that.

  • Mainvein says:

    Before determining refusal, I’m requesting a BAC. If he’s been heavily drinking, what is his current state? I’m ok with an informed decision if he is sober. If he’s not, all bets are off, he’s going to the ER.

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