Ventricular tachycardia

A 43 year old male came to JIPMER Hospital with chief complaints of palpitation since last 3 days which was acute in onset, intermittent to continuous in nature, regular in nature, associated with chest pain and giddiness.Palpitation were associated with history of nausea and one episode of vomiting. Patient was a known case of hypertension since last 7 years and was on regular treatment. Patient was also giving history of acute anterior wall myocardial infaction in 2014, for which he was treated at private hospital. Coronary angiography done at that time was suggestive of single vessel diseases of Left anterior descending coronary artery for which PCI was tried but it got failed. Patient was on medical management since that time. But again in Nov 2016 patient develop acute onset chest pain with palpitation, sweating for which he was investigated at private hospital and diagnosed to have Acute coronary syndrome/unstable angina. Medical management was given. Coronary angiogram was suggestive of single vessel disease of LAD ( 100% stenosis)  with chronic total occlusion. ECHO was done , which was suggestive of severe left ventricular dysfunction (LVEF=35%) with moderate mitral regurgitation with left ventricular apical aneurysm and he was started on prophylactic amiodarone, antiplatelets, beta blocker and ACE inhibitor.Patient was asymptomatic but he develop recent episode of palpitation. Patient went to private hospital, ECG done, BP at that time was 70 mmhg, DC cardioversion was done follwing which patient was refeered to JIPMER Pondicherry Hospital for further management. ECG of the patient during the episode of tachycardia is given below.

ECG 1 (Click on the image to enlarge it)

ECG 2

ECG 3

Description of the ECG-Broad complex regular tachycardia at heart rate around 190 beats per minute, QRS of RBBB morphology, QRS duration 240 msec, normal axis, there were no capture beats, no fusion beats, no AV dissociation seen, no visible P wave seen, negative concordance seen from lead V1-V6, rS seen in lead V6, 

 ECG 4 (After giving DC cardioversion)

 

Description of the ECG-Noraml sinus rhythm at rate 86 beats per minute, LAD,LAHB, RBBB, QS wave seen in lead V1-V6

So from both the above ecg the diagnosis of this patient is Ventricular tachycardia. 

Lets discuss how to approach in a patient with Broad complex  tachycardia

Thank you.

Atrial tachycardia

A 62 year old female came to JIPMER cardiology OPD with history of acute onset breathlessness along with giddiness 10 days back. Patient went to  local government hospital. ECG of the patient was done and following which patient was referred to JIPMER hospital for further management. During evaluation at JIPMER hospital patient pulse was 80 beats per minute, irregular, BP 110/70 mmhg. Patient was a known case of Diabetes mellitus. There was no history of Hypertension, coronary artery diseases. ECG of the patient done at JIPMER hospital is shown below.

ECG (Click on the image to enlarge it)

Description of the ECG- Narrow complex irregular tachycardia at around 160 beats per minute, normal axis, P wave seen, P wave are positive in lead V1, I, PR interval 160 msec, RP interval 200 msec, ST segment depression with T wave inversion present in lead V4-V6, so the diagnosis is atrial tachycardia.

Approach in a patient with narrow complex tachycardia

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Ventricular tachycardia in young male

A 19 years old male came to JIPMER hospital  with  chief complaints of palpitaion since two month along with dyspnoea on  exertion NYHA class I. There was no history of giddiness, syncope, chest pain, orthopnea or PND. During evaluation patient pulse was 98 beats per minute, BP 110/70 mmhg, CVS S1S2 were normal, RS Bilateral normal vesicular sound were present. ECG of the patient is shown below.

ECG 1

Broad complex regular rhythm at heart rate around 100 beats per minute, RBBB  morphology, LAD,Early transition present in lead V1, V2, Positive concordance present, intermittent capture beats seen which are narrow complex with PR interval of  160 msec, QT interval 320 msec so the ecg is suggestive of ventricular tachycardia

ECG 2 of the patient

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Congenital heart block

A 14 year old male resident of Pondicherry came to JIPMER hospital with history of recurrent episode of syncope since last one month, patient went to local hospital and diagnosed to have Complete heart block and referred to our  hospital for further management. During evaluation at our hospital patient pulse was 70 beats per minute, BP-110/70 mmhg, CVS-S1S2 normal, RS-Bilateral normal vesicular breath sound were present. Previous hospital ECG was not available at the time  of evaluation at our hospital. ECG of the patient done at our hospital is shown below

ECG 1(Click on the ECG to enlarge it)

Description of the ECG-Sinus rhythm at 84 beats per minute, PR interval 360 msec, Normal axis, narrow QRS complex, no ST-T wave changes QT interval 360 msec, QTc-430 msec so the ecg of the patient was suggestive of first degree AV block

ECG 2

Sinus rhythm at 75 beats per minute, normal axis, narrow QRS complex, PR interval 320 msec, no ST-T wave changes seen so the ECG is suggestive of first degree AV block.

Patient underwent EPS study which was suggestive of suprahisian second degree AV block. Patient underwent successful pacemaker insertion at our  centre.

Thank you
Dr Praveen Gupta

Atrial fibrillation with fast ventricular rate in a patient with DCMP with CRT-P

A 56 years old female comes to JIPMER, Pondicherry, India with chief complaints of acute onse palpitation since last two days with dyspnoea of NYHA class III with orthopnea and paroxysmal nocturnal dyspnoea. Patient was a known case of Dilated cardiomyopathy with normal coronary artery with Left bundle branch block with severe left ventricular dysfunction (LVEF 30%). She underwent CRT-P implantation at JIPMER hospital on July 2013. She was on tablet enalapril, carvedilol, lasix, aldactone. During evaluation in the emergency her pulse rate was 140 beats per minute, BP=100/50 mmhg, CVS S1S2 were normal, RS-Bilateral equal air entry, no crepitations.Patient ECG done in the emergency department is shown below.

                                                ECG 1(Click on the image to enlarge it)

Description of the ECG-Heart rate around 140 beats per minute, irregular, No visible P wave seen, left axis deviation seen, QRS complex LBBB morphology, QRS duration 150 msec, Intermittent biventricular pacing spikes are seen, associated QRS complex of LBBB morphology, QRS duration 120 msec so the ecg diagnosis is Irregular, broad complex tachycardia suggestive of  supraventricular tachycardia, so the ecg is suggestive of Atrial fibrillation with fast ventricular rate.

ECG 2 

So the diagnosis of the patient is atrial fibrillation with fast ventricular rate. Patient underwent successful AV nodal ablation at JIPMER hospital for rate control.

Lets discuss how to approach in a patient with Tachycardia

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Anterior wall myocardial infarction ECG

A 65 years old male comes to JIPMER Hospital, Pondicherry, India with chief complaints of acute onset retrosternal chest pain since last one hour. Patient was a known case of dyslipidemia since last three years and was on treatment. During evaluation in the emergency department patient pulse was 105 beat per minute, BP-140/100 mmhg, RS-Bilateral normal vesicular breath sound were present, CVS-S1S2 were present. ECG of the patient in the emergency department is shown below.

                      ECG ( Click on the image to enlarge it )

Description of the ECG- Sinus rhythm at 105 beats per minute, normal axis, ST segment elevation seen in lead V1-V6, lead I, avL, ST segment depression seen in lead III,avF, PR interval 120 msec, so the ECG was suggestive of acute extensive anterior wall myocardial infarction.

Patient was immediately admitted and was given injection streptokinase.

Thank  you.

ECG feature of Left main coronary artery stenosis

A 58 years old male came to JIPMER hospital emergency with chief complaints of  retrosteranl chest pain since last 2 months which increased since today afternoon 12 o clock. Patient was a known case of diabetes  mellitus, hypertension since last one and half years and was on oral medication for the same. During evaluation in the emergency department patient pulse was 90 beats per minute, BP-170/100 mmhg, CVS and Respiratory system was normal. ECG of the patient done in the emergency department which is shown below.

Click on the image to enlarge it

Image 1

ECG-Sinus rhythm at 100 beats per minute, Inferior axis nearly 90 degree in view of equiphasic QRS in lead I, there is diffuse ST segment depression with T wave inversion in lead I,II,III,avF,avL, V2-V6. There is ST segment elevation in lead avR, V1. PR interval 120 msec, QT interval 360 msec, QTc interval  464 msec.

So in a patient with DM, HTN the ECG was suggestive of acute coronary syndrome ?? NSTEMI ?? USA.Presence of ST elevation in lead avR, V1 and diffuse ST segment depression localise the lesion most likely at Left main coronary artery. Patient underwent coronary angiography which is shown below.

Image 2

Image 3

Coronary angiography of the patient suggestive of Critical left main coronary artery stenosis nearly 90-95% which confirm our ECG localisation of culprit artery.Also there were lesion in the Left anterior descending artery, Left circumflex artery, right coronary artery.

Thank you.