ECG of interest

[jtmathew 43]

Had a cool ECG on my desk this am. Anyone care to take a stab at interpretation?

[crossbone2007 39]

What I see: Sinus rhythm at 60 bpm, ST segment depression, left bundle branche block. Maybe inferior MI. Can you tell a bit more about the patient at presentation?

 

Sent from my VS980 4G using Tapatalk

 

 

[crossbone2007 39]

Upon further inspection, you also have short PR interval with wide QRS complex (due to the bbb i guess).

 

Sent from my VS980 4G using Tapatalk

 

 

[jtmathew 43]

32 yo fem presenting as an outpatient to the clinic for a repeat ECG. She was found to have this abnormal ECG upon her arrival to the ED 2 days prior where pt c/o dizziness.

 

So far, you are right on all counts. What is the diagnosis?

[jtmathew 43]

Not MI. Difficult to diagnose MI with a Lbbb because existing morphology prevents seeing elevation/depression.

[Timon 404]

NSR w/ Left Ventricular Hypetrophy with LBBB and Left Ventricular Strain? That along with a possible Anterior Wall MI (STEMI V1 + V2 w/ ST depression V5 & V6)?

[crossbone2007 39]

Just dizziness? No fever, chest pain, SOB? No congenital heart defects?

 

Sent from my VS980 4G using Tapatalk

 

 

[jtmathew 43]

Don't know the hx of the patient prior to performing her ecg as an outpatient. When I saw her, perfectly healthy and normal presentation. Crossbone was on to something with the short PR. Keep looking

[Timon 404]

I initially put WPW, but then deleted it. Maybe thought I was imagining a delta wave.

[jtmathew 43]

We have a winner. Which type?

[crossbone2007 39]

Timon, I thought that too but I wasn't sure.

 

Sent from my VS980 4G using Tapatalk

 

 

[marktheshark89 317]

Wpw

[crossbone2007 39]

WPW type B,

 

Sent from my VS980 4G using Tapatalk

 

 

[jtmathew 43]

I called this wpw type B but because of the dominant S wave in v1 and v2 but the cardiologist called it type A and I have yet to ask him why. I will follow and let you know. As far as treatment, I believe an ICD is in order. Patient is symptomatic and at high risk for SCD. Other than that, any pharm treatment indicated for this young lady?

[crossbone2007 39]

I thought it was tybe b because of the LBBB appearance in V1.

Class III drugs such as amiodarone for now and radiofrequency ablation as soon as possible to prevent SCD.

 

 

Sent from my VS980 4G using Tapatalk

 

 

[UGoLong 2,783]

As far as I know, an ICD is not usually indicated in asymptomatic WPW patients. If no arrhythmias, monitoring is often suggested. If arrhythmias, catheter ablation is usually the first line treatment.

[crossbone2007 39]

UGoLong, I think he said the patient was symptomatic. I was suggesting amiodarone for now until ablation. Well, I'm a student, no clinical yet.

 

Sent from my VS980 4G using Tapatalk

 

 

[UGoLong 2,783]

No problem; cases are a chance for all of us to learn.

 

Dizzy suggests maybe an episode of paroxsymal SVT. I'd probably do a Holter monitor to see what the rhythm is at times like that. Would consider a trial of diltiazem before amiodarone given the possible complications of amiodarone use, especially on a patient so young.

 

 

Sent from my iPad using Tapatalk HD

[winterallsummer 327]

Yep often you may find WPW presenting without the classic delta wave, but you will see short PR leads throughout.  I believe usually CCB is the initial treatment in such a case.

[jtmathew 43]

Thanks for the help guys. I assumed ICD was the first course. Would it be indicated with syncope? What if the holter shows asymptomatic psvt or pvt? Just the CCB or do you consider ablation? Would you worry about runs of tachycardia becoming symptomatic at some point?

[UGoLong 2,783]

An ICD wouldn't be the first course, especially in one so young and presumably without significant cardiomyopathy.

 

The Holter monitor -- or an event recorder -- would let us understand what the rhythm was that caused the syncope. It could have been anything from a long sinus pause, to PSVT, to PAF with RVR, or even something unrelated to WPW, like a long run of NSVT. I would definitely get an echocardiogram ASAP to rule out cardiomyopathy, especially hypertrophic obstructive cardiomyopathy. HOCM, in the context of dehydration, can cause syncope.

 

Until the event can be captured and understood better, I would be loath to recommend surgery, including an ablation. Trying a CCB seems like a reasonablly conservative approach at start. An EP study, with a possible ablation, may very well be in the cards later.

 

Hope this helps. This is only me talking and others might try something else. A 32-year-old woman has a lot of living to do yet and I'd want to avoid rocking her world any more than is necessary.

[jtmathew 43]

So i spoke with another cardiologist regarding the original ECG and he concurred that it was, indeed, type B but added that typing WPW is obsolete. He pointed me to the following algorithm for determining location of an accessory pathway:

 

http://www.uptodate.com/contents/image?imageKey=CARD/70648&topicKey=CARD%2F953&source=outline_link&utdPopup=true

 

Following the algorithm gives me accessory pathway locacted in the right anteroseptal wall due to isoelectric delta in aVL and LBBB pattern.

[GreatChecko 326]

So WPW as a dx is obsolete? Preexcitation Syndrome Type B?

[PA2016! 40]

Or is it typing WPW as A or B is obsolete and location the bundle of kent is more clinically important? 

[jtmathew 43]

according to him, "typing A or B is obsolete". EP only cares about location of the accessory pathway.