35 year old male (on vacation) presents to the fire station complaining of an irregular heart beat.
History of present illness: Patient states he walked up to the top of the lighthouse earlier in the day and started to feel palpitations.
Past medical history: Healthy
Meds: None
Vital signs are assessed.
- Resp: 18
- Pulse: 54 (irregular)
- BP: 130/84
- SpO2: 99 RA
The cardiac monitor is attached.
A 12 lead ECG is captured.
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?
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.
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).
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
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
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.
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.
Good point, RM.I would be royally freaked out if I was in AF, holiday heart syndrome or not! Tom
Its aRTERIAL FLUTTER and 1st degree heart block
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.
What about the ST elevation in V3 and V4?
@ 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.
LQT, with pulse that slow?
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 =)
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.
Involuntary confinement. lol. Nice one Stalin.