tag:blogger.com,1999:blog-549949223388475481.post7058704836516857977..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.Unknownnoreply@blogger.comBlogger10125tag:blogger.com,1999:blog-549949223388475481.post-73557625422163557352018-12-05T09:58:36.968-06:002018-12-05T09:58:36.968-06:00indeedindeedDominic Larose MD CMFC(MU) FACEPhttps://www.blogger.com/profile/12841805037815499459noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-82482684121770327842018-12-03T12:42:02.504-06:002018-12-03T12:42:02.504-06:00Dominic, That refers to sinus tachycardia. Not to ...Dominic, That refers to sinus tachycardia. Not to the use of a beta blocker to terminate at th that refers to sinus tachycardia. Not to the use of a beta blocker to terminate A dysrhythmia. Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-66850646065621746782018-12-02T20:10:47.010-06:002018-12-02T20:10:47.010-06:00Thanks, see response to similar comment above. No ...Thanks, see response to similar comment above. No ablation occurred so far, it seems that they believed that the rhythm (whatever it was) is unlikely to return after stopping flecainide as it did not return during hospitalization, so they did not perform ablation. It seems they are also under the impression of atrial flutter. Maybe they are wrong. Luckily for me, it did not matter for the ED management and ischemia interpretation. Thanks for the comment!Pendellhttps://www.blogger.com/profile/06506068475871794508noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-10340076597038935262018-12-02T20:05:29.910-06:002018-12-02T20:05:29.910-06:00Thanks for this great comment. I think you make a ...Thanks for this great comment. I think you make a great case for AVNRT. I believe you are probably more correct without further info. I looked through the chart again in hopes that some later events would help us sort it out, but the only documented arrhythmias after our conversion was AF. No further documented episodes of AVNRT, no EP study, etc. So we can't be sure but I think you have a good point. I do still think diltiazem has a small chance of converting AF/flutter for some reason.Pendellhttps://www.blogger.com/profile/06506068475871794508noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-64367186477440324442018-12-02T08:38:26.433-06:002018-12-02T08:38:26.433-06:00As shown in the commit trial, beta blockers increa...As shown in the commit trial, beta blockers increase the risk of cardiogenic shock when there are risk factors for it, such as tachycardia. https://www.ncbi.nlm.nih.gov/pubmed/16271643Dominic Larose MD CMFC(MU) FACEPhttps://www.blogger.com/profile/12841805037815499459noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-30343301340575188512018-12-02T08:36:07.396-06:002018-12-02T08:36:07.396-06:00This comment has been removed by the author.Dominic Larose MD CMFC(MU) FACEPhttps://www.blogger.com/profile/12841805037815499459noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-50516804044846641822018-12-01T15:46:41.904-06:002018-12-01T15:46:41.904-06:00Beta blocker is probably no safer than calcium cha...Beta blocker is probably no safer than calcium channel blocker in this situation.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-15760268526703094422018-11-27T07:17:56.824-06:002018-11-27T07:17:56.824-06:00I think this is either avrt or avnrt. In cases of ...I think this is either avrt or avnrt. In cases of flecainide toxicity the qrs are usualy wide. Even with flecainide on board 200 per minute flutter is pretty slow. <br /><br />By looking at the pre and post conversion ECG, you can identify retrograde atrial activity pretty clearly. For instance, look in aVL pre and post,you will see a clear negative P wave seen during the tachycardia, that disappears post conversion.<br /><br />There is a published algorithm that helps to differentiate avrt from avnrt according to localisation and polarity of retrograde P waves. You look for polarity of P waves in I II III aVF and V1. Here, the retrograde P is mildly positive in I, positive in II III aVF, and negative in V1. This would localise the concealed bypass tract to right anterior or right antero septal.<br /><br />On top of this, the patient converted with diltiazem, so the likelihood of avrt or avnrt was extremely high. So my diagnosis is AVRT. Here is the reference to the paper to localise the bypass tract: https://www.sciencedirect.com/science/article/pii/S0735109796004901<br /><br />Has the patient been referred to electrophysiology to consider ablation, which in indicated anyway since it is either AVRT or atrial flutter?Dominic Larose MD CMFC(MU) FACEPhttps://www.blogger.com/profile/12841805037815499459noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-43876616603935386272018-11-27T00:32:26.524-06:002018-11-27T00:32:26.524-06:00Very interesting discussion of a great arrhythmia ...Very interesting discussion of a great arrhythmia / ischemic mix case!<br /><br />Although I'm a bit skeptical about "flutter rapid conversion" as CCB don't convert a fluttering atrial wave. Furthermore, we can suspect a positive retrograde atrial wave in AVR, V3, V6, although it's a bit difficult to figure the axe. <br /><br />Without any conversion strip, my vote would go to a nodal re-entry converted by adenosine (then come back) and converted by diltiazem (and not come back, because of longer action). 200 is a reasonable speed for AVRNT.<br /><br />Lastly, talking of semantic, I agree that the atrial rhythm after conversion can be an atrial ectopic, although atrial vector in II seems positive to my eye. It's more AVF that looks negative. Although I disagree that "sinus rhythm is defined by the presence of a conducting upright P wave in lead II". An upright wave in II just means that the impulse comes from somewhere near the sinus node. Furthermore, normal atrial axe is generally defined as 0-90 or 0-100, which is narrower than what a positive II would define. I prefer to teach that a positive P both in I and AVF is necessary (but not sufficient) to define a sinusal rhythm.<br /><br />Cheers.<br /><br />Alain Vadeboncoeur<br />Montreal Heart InstituteAlain Vadeboncoeurhttps://www.blogger.com/profile/06938164177722777952noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-18322800230186326132018-11-26T06:35:55.885-06:002018-11-26T06:35:55.885-06:00In a patient of suspected Mi with a fast ventricul...In a patient of suspected Mi with a fast ventricular rate ,use of iv calcium channel blocker could precipitate heart failure and perhaps iv beta blocker would be a better choice for reduction of heart rate.whats your opinion ? Subhasish Singh herehttps://www.blogger.com/profile/18022600313880536118noreply@blogger.com