Complete heart block

A 56 years old female came with history of dyspnoea on exertion along with giddiness since last one month. Patient was a known case of diabetes mellitus, and hypertension since last 6 years. Patient pulse during evaluation in the emergency department was 38 beats per minute,  Patient ECG is shown below.

ECG (Click on the image to enlarge it)

ECG is showing bradycardia, there is AV dissociation as you can see P wave (marked by black arrow), are occurring independently of QRS complex, atrial rate was 110 beats per minute, while qrs rate was 38 per minute, there is left axis deviation, qrs complex were of narrow in duration with normal morphology. So the diagnosis of the patient was complete heart block.


Patient was implanted permanent pacemaker and later was discharged in stable condition.

Thank you

Praveen Gupta

Junctional rhythm

A 60 years old male came with  complaints of giddiness along with dyspnoea on exertion since last 10 days.  During evaluation patient pulse was 38 beats per minute  Patient ECG is shown below.

ECG (Click on the image to enlarge it)

ECG  is showing bradycardia with heart rate around 38 beats per minute, QRS complex of RBBB morphology,  QT interval 520 msec, QTc was 416 msec, few P waves are seen which appears to merged into QRS complex in lead II,III,avF and they were inverted in nature, suggestive of rhythm originating from junction of atrium and ventricle below the HIS bundle or infra his in origin  impulse (presence of broad complex RBBB type QRS) Final diagnosis was severe sinus node dysfunction with junctional bradycardia.

On blood investigation patient serum potassium was 5.2 meq/dl, while serum creatinine was 2.3 mg/dl. Patient was started on anti hyperkalemia  measure in the form of calcium gluconate along with insulin glucose drip but patient bradycardia did not improved.  Decision was taken for pacemaker implantation. Permanent pacemaker implantation was done with AAI mode and later was discharged in stable condition. 

Thank you

Praveen Gupta

ECG changes in hyperkalemia

A 58 years old male who was admitted in intensive care unit developed acute onset palpitation along with giddiness.  Patient pulse was 150 beats per minutes, Blood pressure was 110/70 mmhg. Patient was on oral potassium supplement  to treat hypokalemia which he develop due to acute gastroenteritis. Patient serum potassium at the time of ecg was 6.0meq/dl.

ECG 1(Click on the ecg to enlarge it)

ECG is showing broad complex rhythm at rate around 170 beats per minutes, left axis deviation, QRS complex were of left bundle block morphology, there were monomorphic QRS complexes in lead  of there was no fusion beat or capture beat or fusion beat, also P wave were also not clearly visible. Possibility of both ventricular tachycardia or sine wave pattern due to hyperkalemia was kept. Patient was started on anti hyperkalemia measure and also injection amiodarone was given.

Patient ECG was repeated after 10 minutes

ECG was showing ST elevation in lead V3-V6. Patient cardiac Troponin came negative. ECG again done after five minutes. ECG is shown below.

Ecg is showing junctional rhythm with deep T wave inversion in lead V2-V5. P wave were not visible, QT interval was 420 msec, QTc 470 msec There were no other ST-T wave changes.

Patient was given anti hyperkalemia measure and he improved subsequently. His ecg  became normal. His echocardiography was normal and there was no regional wall motion abnormality.
His normal ecg  not available.
So the final diagnosis of the patient was hyperkalemia due to oral potassium supplement intake.

Lets discuss ECG changes in hyperkalemia

Reference-Braunwald 10th edition, Chapter no 12, Page no 147

In hyperkalemia earliest ecg changes seen is narrow and peaking T wave. There is shortening of QT interval along with widening of QRS duration. There is decrease in the P wave amplitude along with prolongation of PR interval, which lead to second or third degree atrioventricular block. There will be complete loss of P wave along with junctional escape rhythm or so called sinoventricular rhythm.
In the latter instance, sinus rhythm persists with conduction between the sinoatrial and atrioventricular nodes and occurs without producing an overt P wave. Moderate to severe hyperkalemia occasionally induces ST elevations in the right precordial leads (V1 and V2), simulating an ischemic current of injury or Brugada-type patterns. Very marked hyperkalemia leads to eventual asystole, sometimes preceded by a slow undulatory (or sine wave) ventricular flutter like pattern.

Thank you

Praveen Gupta

Trifascicular block

A 45 years old male came with history of dyspnoea on exertion NYHA class III since the past 1 month. There was no history of coronary artery diseases or acute coronary syndrome in the past. During evaluation  pulse rate was 110 beats per minute, blood pressure was 110/60 mmhg, Echocardiography was suggestive of severe global left ventricular dysfunction . Patient ECG is shown below.

ECG 1

Sinus rhythm at rate around 100 beats per minute, left axis deviation, PR interval  240 msec suggestive of 1 degree heart block, there are rS complex in lead II,III,avF with qR in lead avL, suggestive of left anterior hemiblock, QRS complexes showed right bundle branch morphology with qrs duration of 120 msec so the ecg of the patient is suggestive trifascicular block (1 degree heart block with left anterior hemiblock with right bundle branch block)

Another ECG of the same patient is showing trifascicular block

ECG 2 (Click on the image to enlarge it)

Let's discuss what is trifascicular block

Trifascicular block indicate conduction abnormality in all the three fascicle of cardiac conduction system (Right fascicle, left anterior fascicle and left posterior fascicle). It will manifest on the ecg in the form of RBBB with Left anterior hemiblock with prolonged PR interval or 1 degree AV block or RBBB with left posterior hemiblock with prolonged PR interval.

Patient angiogram was done showed normal coronary artery so the final diagnosis of the patient was idiopathic dilated cardiomyopathy with trifascicular block. Patient was started on standard heart failure medication and was discharged in stable condition.

Thank you

Praveen Gupta

2.1 Atrioventricular Block with intermittent complete heart block

A 60 year old female came complaints of giddiness on and off since last one week. Patient was a known case of diabetes mellitus and was on oral hypoglycemic agents. ECG of the patient done in the emergency is shown below.

ECG 1 of the patient

ECG was showing sinus rhythm at rate around 60 beats per minutes, PR interval was 260 msec, atrial rate was 120 beats per minutes, so there were two P wave seen, second P wave appear to merged into T wave, QRS axis was normal, QRS complexes were narrow in duration, there was no other ST-T wave changes seen ,so the diagnosis of patient was 2.1 AV block.
Patient ECG was repeated after one hours. ECG is shown below.

ECG after one hours

ECG is showing atrial rate of 100 beats per minutes, ventricular rate of 41 beats per minute, there was complete AV dissociation as there was no relationship between P wave and qrs complex suggestive of complete heart block.
So the final diagnosis of the patient was 2.1 AV block with intermittent complete heart block. Patient underwent successful VVI pacemaker implantation and later patient was discharged in stable condition.

Thank you,
Praveen Gupta

Congenital heart diseases-Tetralogy Of fallot

A 15 years old male came with complaints of dyspnoea on exertion  since 3 month of age along with cyanosis and clubbing of bilateral upper and lower limb fingers. On pulse oximetry oxygen saturation was 80%. On cardiovascular examination,, ejection systolic murmur was present in the 2 left intercostal space.  with single S2(A2),  ecg of the patient is  shown below.

ECG

ECG is showing heart rate around 75 beats per minutes, there is right axis deviation with axis being 120 degrees, there is tall R wave or qR wave seen in lead V1 suggestive of right ventricular hypertrophy, peaked P wave seen but they were not fulfilling the criteria for right atrial abnormality, there is rapid transition of QRS complex from lead V1 to lead V2.

 Patient echo done which was suggestive of right ventricular hypertrophy along with large subaortic ventricular septal defect with right to left shunt with overriding of aorta suggestive of tetralogy of fallot.

Let's discuss ECG in tetralogy of fallot (TOF)

Characteristic feature in ecg in a patient with TOF is

Peaked P wave, narrow duration 

Right axis  deviation

Right ventricular hypertrophy but no evidence of right ventricular strain pattern

Sudden QRS transition from lead V1 to lead V2

rS complex in lead V5,V6 when there is reduced pulmonary blood flow with decreases left ventricle fillin

Q wave with dominant well developed R wave in lead V5,V6 in patient with mild pulmonary stenosis with balanced shunt indicating good LV filling

Reference -Perloff pediatric cardiology 6th edition, chapter 18, Page 385

Thank you.

Praveen Gupta

PSVT

A 75 years old female came to JIPMER hospital, Pondicherry, India with chief complaints of acute onset palpitation on and off since last one hours along with atypical chest pain and giddiness. Patient was a known case of Hypertension and diabetes mellitus since last 15 years for which she was on oral medication. Patient was also giving history of similar palpitation one week back. During evaluation in the emergency patient pulse was 190 beats per minute, BP-110/70  mmhg, ECHO was suggestive of concentric LVH, there was no regional wall motion abnormality. Patient ecg done in the emergency department is shown below.

Tachycardia ECG

ECG is suggestive of narrow QRS complex tachycardia, regular in rhythm, rate around 190 beats per minute, there were no clearly visible P wave, most likely P wave merged into the QRS complex, no significant ST-T wave changes were seen. Because P wave merged into the QRS complex so the RP interval is less than 70 msec.  So the ecg is suggestive of Short RP tachycardia with differential diagnosis being AVNRT (Atrioventricular nodal reentry tachycardia), AVRT (Atrioventricular reentry tachycardia)or rarely possibility of Atrial tachycardia(AT)

Another tachycardia ECG

Patient was given carotid sinus massage, but she did not improved so injection adenosine 6 mg was given via antecubital vein. Tachycardia subsided within few minutes. ECG after tachycardia subsided is shown below.

ECG is showing normal sinus rhythm at 66 beats per minute, PR interval 140 msec, normal axis, no ST-T wave changes seen.

So final diagnosis of the patient was PSVT with Differential diagnosis being AVNRT, AVRT, Atrial tachycardia.


Let discuss how to approach in a patient with PSVT

Thank you.

Praveen Gupta

Idiopathic fascicular left ventricular tachycardia (IFLVT)

A 13 year old female came to JIPMER hospital, Pondicherry India with chief complaints of acute onset palpitation of 2 hours duration. Patient was giving history of two episode of similar  palpitation over the last 6 months for which she was admitted at private hospital. Last episode of palpitation was treated with DC cardioversion. During the time of admission patient pulse was 190 beats per minute, regular, normal volume. Her Blood pressure was 110/80 mmhg, RS was normal, CVS was normal, ECHO heart of the patient was normal. ECG of the patient done in the emergency department is shown below.

ECG during the episode of tachycardia

Broad complex, regular tachycardia at the rate of 190 beats per minute, QRS duration 120 msec, Left axis deviation, there is rS complexes seen in lead II,III,avF suggestive of left anterior hemiblock pattern, QRS complex were of RBBB morphology in lead V1, V2, P wave are seen intermittently merged into the qrs complexes, there is complete AV dissociation but no capture beat no fusion beat seen. So the ECG is suggestive of ventricular tachycardia originating from left ventricle, most likely left posterior fascicular tachycardia.


Another tachycardia ECG of the patient

Tachycardia ECG of the patient

Patient was given injection verapamil, following which her tachycardia subsided. Her sinus ecg is shown below.

ECG is showing sinus rhythm at 75 beats per minute, normal axis, T wave inversion was seen in lead II,III,avF, V3-V6 suggestive of cardiac memory T waves.

Patient underwent electrophysiology study which conform our diagnosis. Patient underwent successful radiofrequency ablation. Later she was discharged in stable condition.

So the final diagnosis if Idiopathic fascicular left ventricular tachycardia

Lets discuss about idiopathic fascicular left ventricular tachycardia

Idiopathic fascicular left ventricular tachycardia (IFLVT) is the most common idiopathic ventricular tachycardia of left ventricle. It  is characterised by right bundle branch block (RBBB) morphology and left axis deviation on the ECG. The QRS duration during the time of tachycardia is relatively narrow.  This tachycardia is highly sensitive to verapamil. It is originating near the posterior fascicle.

It occur mainly in young adults (15 to 40 years) and mainly affects males (60-80%0. Patient most frequently present with paroxysmal episodes of palpitation. Although most episodes occur at rest, exercise, emotional stress and catecholamine infusion can act as triggers.

Electrocardiographical features

Baseline ECG is normal in most patient though it may present T-wave inversion immediately after tachycardia (cardiac memory).

 IFLVT usually shows a QRS complex duration inferior to 140-150 ms and fast initial forces (RS interval of 60-80 ms). 

The ECG varies depending on the site of origin of the tachycardia:

1. Posterior fascicular ventricular tachycardia (P-IFLVT). It is characterised by right bundle branch block (RBBB) morphology and left axis suggesting that the exit of the circuit is located in the inferoposterior septum.It occur in 90-95% of cases. 
2. Anterior fascicular ventricular tachycardia (A-IFLVT). It is the second variant in terms of frequency. Its ECG pattern typically shows RBBB morphology and right axis. The earliest activation has been described in the anterolateral wall of the left ventricle.
3. Upper septal fascicular ventricular tachycardia. This presentation is exceptional. As a general rule, it presents RBBB but a few cases with morphology of left bundle branch block have also been described. 

Thank you

Praveen Gupta

2016 ACC Focused Update on New Pharmacological therapy for heart failure

Amiodarone,DRUG OF THE MONTH

Acute myocardial infarction in women

Cardiology MCQ 1