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Cardiac Case... ideas?


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What would you do...

CASE: 

31 yr old CC M incidentally in office for family member's check up acting normally when he suddenly states, "I'm having palpitations right now" and grabs chest. This episode lasted about 2 minutes or less but we were able to capture it with EKG (EKG 1) . The EKG 2 was about 1 minute after his symptoms subsided. 

During this episode there was a loud systolic murmur auscultated, which completely resolved when his symptoms resolved.

He has occasional sensation of "dropped beats" and a few more lengthy episodes similar to today. About 2 years ago saw cardiology after a similar episode at home,   echo and 24 hour holter ordered, no events perceived during holter. Both tests reported as normal and cardiology didn't ask to see him back.   

For at least a year of so he "hasn't been feeling himself"  with occasional dizziness and just feeling "out of it."  He's never sure if it "nerves or something more" but he's quite concerned. 

His only medical history is anxiety and PRN benzo use which is very rare.

No hx of long qt and no OTC ,  Rx drugs, or illicit drugs. 

 

My friends, school me please - can QT prolongation come and go like this? What's his next step? And that murmur during the episode? 

Love to hear your thoughts. 

 

EKG 1.JPG

EKG 2.JPG

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Wish we could see onset and termination, but sounds and looks like possible symptomatic paroxysmal atrial tach. The QTc (imo) isn't really that concerning as the EKG machine appears to be calculating using Bazett's formula, which isn't the most accurate outside of 60-100bpm. At rates >100 Framingham formula or Fredericia are more accurate:

Framingham--> QTc = QT + 0.154 (1 – RR). On your first EKG (rate 134) I calculate a QTc of 420ms using Framingham 

Fredericia--> QTC = QT / RR ^(1/3). Using this formula I calculate QTc of 437ms. 

Either way, I would check electrolytes, maybe a drug screen, and Rx 48 hour holter. If you're worried about missing an event on a 48 hour, maybe look into a Zio patch. Pt wears them for like 2 weeks and mails in the patch at the end of the period to be read. Very slick. 

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Just a thought; I see upsloping ST depression in both EKGs,especially in the anteroseptal leads. Wish I knew more about his family history. This could be nothing, but personally I'd do a stress echo on him to rule out ischemia. (I have a patient who had his first MI at 38, and all 8 of his siblings -- and both parents -- have  cardiac histories.)

His QTc (corrected for heart rate) doesn't change all that much. 500 is usually when we start to think about it. I would be sure he wasn't taking something that affects that (see torsades.org for the big list.)

There is not a great reason for a young guy to have a rate of over 130 at rest unless he has a lot of anxiety. Might try a low dose beta blocker (metoprolol 12.5 or Bystolic 5) to see if you could take the edge off. You could also do bloodwork for TSH, potassium (4.0 is our minimum), and magnesium (2.0).

Just my 2 cents after being up for 20 hours...

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What condition can cause paroxysmal tachycardia, CP/SOB/dizziness/syncope, is associated with an intermittent systolic murmur heard best at the apex and yet would allow for a normal stress/echo since the pt. isn't sx. at that time?  Treatment is typically a beta-blocker.  This condition that I'm thinking of is most prominent in older teens/young adults and may be precipitated with stimulants/stress.  Demos used to show a 6:1 predominance in females (maybe because they actually go see someone).

A shunt has already been excluded presumably from the prior echo/? doppler.  I would go so far as to say that many Holter studies are inappropriate (unlikely to yield a finding) and patients would be better served with event monitors.

A question for students, and don't look it up.  QTc varies between males/females but what is a nice round number to keep in mind to get your attention for actual prolongation?

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3 hours ago, GetMeOuttaThisMess said:

What condition can cause paroxysmal tachycardia, CP/SOB/dizziness/syncope, is associated with an intermittent systolic murmur heard best at the apex and yet would allow for a normal stress/echo since the pt. isn't sx. at that time?  Treatment is typically a beta-blocker.  This condition that I'm thinking of is most prominent in older teens/young adults and may be precipitated with stimulants/stress.  Demos used to show a 6:1 predominance in females (maybe because they actually go see someone).

A shunt has already been excluded presumably from the prior echo/? doppler.  I would go so far as to say that many Holter studies are inappropriate (unlikely to yield a finding) and patients would be better served with event monitors.

A question for students, and don't look it up.  QTc varies between males/females but what is a nice round number to keep in mind to get your attention for actual prolongation?

You thinking AVNRT? 

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Takotsubo should have shown up in the echo. AVNRT usually has a missing or retrograde p, unlike the EKG (if the rate of 134 is an event). Still would be interested in labs (including TSH level) and more pt history (BMI, ROS, FH) in particular.


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2 hours ago, UGoLong said:

Takotsubo should have shown up in the echo. AVNRT usually has a missing or retrograde p, unlike the EKG (if the rate of 134 is an event). Still would be interested in labs (including TSH level) and more pt history (BMI, ROS, FH) in particular.


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Pt is returning for labs soon. Cbc,cmp, tsh, lipids from 1.5 years ago were all WNL. 

BMI is 23. Bp's have ran about 140-150's/80's and HR 80's to 110 in office historically. States BP is better (120's-130's systolic) when checked at grocery store, but resting HR is often high normal.  

ROS/additional hx:  + for occasional palps, fast heart rate, occasional  chest "discomfort" which is non exertional. occasional dizziness but no syncope, anxiety, acid reflux, neck/shoulder pain.  Pt used to exercise often, but now fearful that heart will race and has stopped exercise. 

FHx reported as HTN, HLD, depression in father. Father had one episode of chest pain (late 40's - 50's) resulting in ER w/u cardiac cath which was negative. Mother very healthy, treated for osteoporosis. Only sibling is very healthy with no known medical conditions. Maternal grandmothers are very healthy. Maternal grandfathers' hx not well known. 

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Some zebras are always possible but the combination of being young and having preexisting anxiety is often seen. Labs are a good idea, along with stress test with imaging; given his few risk factors, echo imaging should be fine.

 

Then you are a position to ease his anxiety and perhaps decrease the tachycardia that way; underlying anxiety with palpitations and paroxsymal sinus tach are the ultimate mind-body connection, especially if the underlying anxiety has not been well-addressed. You can tell him that "You had the full workup; your chances of having a heart attack are very low. Relax and enjoy life."

 

A low dose beta blocker as above can be used and it's a low enough dose that stopping it or skipping doses shouldn't be a problem.

 

If the problem persists, I'd probably send him to electrocardiology.

 

 

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My wife and I ate at Takotsubo's last night!  Great Japanese food.  On the more serious side, a couple of simple considerations include MVP (tachyarrhythmia, thus palpitations that are sustained, typically lasting under a minute and don't awaken folks nocturnally) and then one that you're already checking on which is hyperthyroid storm which should be more prolonged in nature.  Watch for concurrent confusion/disorientation and everyone's favorite, loose stools/diarrhea.

One might ask why didn't the MVP show up on the echo?  The answer is it can be stimulate exacerbated to where you would only notice it during that time.  Treatment?  Cardio-selective beta-blocker.

Another thought for consideration.  "Sinus tach" as noted on the auto read interpretation usually stays below 130 bpm (ask anyone who has taken a prior paramedic course, much less PA school).  So even though the P waves are identifiable how many times do we see rhythms with a second P wave buried in the QRS complex?

QT prolongation, without having to mess with determining QTc is >500 ms, thus a nice round number.

Bottom line, it isn't a normal EKG with regard to ST segments.  With regard to EKG interpretation, if the electrophysiologist has to sit there for a few minutes and use his calipers (people still use these?) then I'm sure not going to try to tell him what it is unless it is clear cut.

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