Rhythm puzzle J.M.E. van Dijen, L.V.A. Boersma, P.J. van Hartingsveldt, E.F.D. Wever
______________________ II
41
A patient with chest pain An 81 -year-old male was referred to the emergency ward because ofchest pam radiating to the left arm, and nausea. He had no palpitations. The | arterial blood pressure was 130/90 mmHg. His ECG on admission is shown in figure 1. He had a history a large anteroseptal myocardfial ~~~~~~~~~~of infarction in 1976, leaving a large
v
aneurysm and a markedly reduced
-.
.9
a
:
I
ventricular ejection fraction of ,A,, Tleft 19%. A recent ECG (figure 2)
-
showed sinus rhythm with a normal PR interval (0.20 sec), QRS duration
of 0.14 sec, left heart axis', and left bundle branch block (BBB) cona_:S__|.@d_".,l._|.
.
are visible figuration; Qwaves
_____________________________________________________
Figur
I and aVL.
1. Mr,
i
in leads
Scintigraphy performed
recently showed slight pen-infarction ischaemria. His clinical status had been
stable until now. The patient underwent electrical cardloversion with 50 J resulting in sinus rhythm with relief of symptoms. A recurrent myocardial
infarction
N
a [ 110111 E211a f H r-f i
;_
was excluded; no acute myocardial ischaemia was detected.
What would your diagnosis and Answer
N 2
M
You wil find the answer on page 435.
Figure 2 J.M.E van Den. LVA. Bow_a. PJ. van Haveldt E.F.D. Wever. Departrnent of Cardiology, Heart Lung Centre Utrecht, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein. Address for correspondence: E.F.D. Wever. E-mail: [email protected]
418
Netheriands Heart Journal, Volume II, Number 10, October 2003
Anwwr to rhythm puzzle (peg 416) The patient's symptoms were not catued by an acute coronary syndrome but by a wide-QRS tachycardia (QRS duration, 0.14 sec, figure 1). The diffcrential diagnosis of a wide-QRS tachycardia is as follows: 1. Ventricular tachycardia (VT); 2. Supraventricular tachycardia (SVT) with either functional or preexstent BBB or IV conduction delay; 3. Atrioventicular reentry tachyardia with anterograde conduction over an accessory bypass (WolffParkdnson-White syndrome). Carotid sinus massage and intravnous administraton of adenosine may be of help in settling the diagnosis. Figure 1 shows VA disocation befirc the first, fifth, ninth, and twelfth QRS complexes (see leads I, 11, and V1). The fiffh QRS complex is preceded by thre QRS complexes, the first two ofwhich show VA conduction with slightlyincreasing VAduration (see leads I and V1). Between the fifth and sixth, the ninth and tenth, and the
twcelfi and tiirteentl QRS complexes, no atral activity is seen. Thus, the VA ratio is >1. This rules out the diagnosis of antidromic circus movement tachycardia during which a 1:1 AV ratio is obligatory. Also, atal tachycardia is excluded (AVratio 1). The QRS complex in V1 was positive, thus, the tachycardia had a RBBB morphology. The electrical heart axs was orientated to a superior direction, more leftward when compared with the ECG during sinus rhythm. The R/S nadir interval (V3) is about 0.10 sec. Considering these tatures, the diagnosis must be set at VT. If the hacmodynamic saituation is stable during VT, the patient may be treated with intravenousadministraton of an antiarrhythmic drug (e.g. procainamide): For firther differentiation (VT versus SVT), electrical cardioversion using low energy (5 or 10 J) may be useful. Successftl low-energy cardioversion points to the diagnosis of VTI.
Productinformatle van de in dit tijdschrift opgenomen advertenties
Productinformatie COZAARO 50 en COZAA*R 10
Kinzalmonos 40/80 - Kimalkomb 80
SAMENSTELLING: Cs 50bvpartaet5mg bkmim ng_en'COZa 100obaprWtbtl00 kmgkmksarw. INDICATES: Essamntil hnne. Tw2diabsdci mstprotdhunAtervwgin*gvndprograsm van nmia dmps. mdion nsodl kiand damming wordinwdoogd niijidn. DOSERING: Hp se. 50 mrmnmal damp 100 mg. TWpe2-d*icimW taphar. Galknalijs amivangpdeamr is 50 mg mml -. Deddoss ke wordinwe r*ar 100 mammal dp. C ' mWn mtand"mantdyaown, mat Wio-_ kuvllne a indira vamlgmknilina 1wogI~caamias woedmn gacmbms bdl indn itintgroapmnwwordtvarwannearde 9-tt DNTRA-HIECAS: gohvooru mvandebmtV d vnvan diproict. a hp nlactate.WAASUMNENEN : Awcoqpw nsii pidintI mat ilrbwisculalm volwmdaplatie, psilnt e w lpov nanvanhrtaan t_mp*lwt lm gaitiosrdardfumctie. mnst.nom,gestoondlav rncda,irradUmpnWmomanhmmakima rN*mnoup Idnuri g d1Uggbiuvn kfllumapaandidurica of kmlhnmuppnasnn.84 dt vanvn ton mos hat aunI'ium zog20di wordn gcotr d. Gmuink bij anirn: 'Cs is niat bij mndnr ondmrmoct EBwEN: aBkignaijnondermw.rduizdiptaidkinortoa tNdohlmSnen l (amnmkd>m5jnmolt Nadein.toducieavnhetgmnmuI zijnondmrndarazarnemgmllnvanovergwi*i mt* Mnift mactl. ani-oadm warnr zestling wo de b-r anglat. mat aoh ontofkn mld. VERGOEDINO EN -Wol hahlb_hsrctl en/of swelling van hatugaat de l,m. phwynn
_mumduUIq~ 40 mg, 80 mg tlmlaxnt of 80 mg telmisartan on 12,5 mg hydrochothleide per tablet. l _mtiegeet. laila: Eseotft bhprtensle. Bij petinten aluee pop DAgie wbe -mare tdrts asim, It eimaib geiadtwd. _werla warbij ie Miidhmk wavedeeaiewelem Aepme beerek to brlken kan I tabli, sma iags. Om doirgms fltlw dewegi Uiegt 40 .g. d we SO g. W borti d dosis .ed gi ar - m stIkbt tat mtlg eeeffkiiate is wanwrlefleatl B w A serleg mt eliat eebkd paning ve de pate ldiWteawt bedreagi: A maximal. Ip iwedg 40m6g. OirectwertaWes we m_mrap ioa*rveetgeembksati wan tdierteawbpdrochloethlazieaulida reelgMi VWe iu de maaaer .weesge. Ae.pssleeatvAAe.dega-iataMtiftgbljdmaAe. g e, astep bwr- of u e1ig_lbhtedd van hot PmIt zagersebap a hi g vanoIN&ih eba Vsrwechtighid -tbg -----S. u sleflasufkltlsa. e.eIkNb clial Is gbode in A wldpAb gedee rvnle pbgeteeeI alerraaaiplaetatle. intrFieveecmire un erbebcadiempepath M wetemaApI-, A mmdWisem, dea-e.Adtmne.hima ihhpereMink, 1wsdaft, #tw mg- of demme d g hea aemAae w wip eadftin met btj,ti bei leew leWsne-de *em. iz h gplhilg gIk ws. stmlbewei as tamlawlee ong.eeAn dIe As hallemepigele oeelagee, aesgeel dft magIi e ie i vendeg urmalm mde beeleA tiltbpevwemle, Ao gleceetleril vareleetart we chelesterolhrpemat thin e pite die mi thledletic marde behaniehl, hielot ee bg.Zls pidt weak a trgieam a hathyipetes ef tvn kmt qr liat paieddebeplga mom edree t weedaloftpearf. viwe telnwertan. udisrs eelpated weegmie.. Er a gee _edere brlelb velwe latle t temi kaetles gvea mt thiuldA dieretica: Alohol, DeYoi_b Wmm iele kae -Mi l we celwelpebarswhn, corti, hslem berbltawt, eacks, atie 1v, bcAbaeliue, ia eamalde, ACTH, iIIaigOelmWe, beidrabeebee.A MWee% eI -Apt1fdaA skbeltplamlaxetre, e g z er hlgotme. mild' ee we wajgade ede c_A _ ,m hi wes de totI wean ergl_.h pb odglewr oW aar! w bdee ulechitseia"" t:brebee mile 6e. Be tIbhcIaetle van bijwebnineneve" bie"blgeem bQ tdlmlaa ege viaea v mletale.Bijsm. udege.ile ateileeme rehlbemet ieethe w gen dleul gewmlbej bebmbg I inklas Ofe reg Wleiiheld, Impoeebarweedweeaaa W de Imtleveslimlsauteewebpdleluee indie imabli pie nala, vow gl,ee, hvecllsh,sc_maa edawegltectl Zeal: bi eA-do tIe, eipije Ippeellm, _-eeblireml * w _ r gaw_ wele-a a es gPMi. aWaP 40 21 blftn. _0aU: rl|h mgmg 8 1wbl mg111 vPi b .enI om 41 E W1lJ10 so m eWl0 U.R. Rogmpb_ e40 80 me tebliten mg ma N mg w __swbU 3u12,5mg"we El1/214OO7. hiU V&- iar p , Zie W t_ Ver waleidge prWect-i4farmatis t dA 18-tkstt op w_ vi wrgar ble asweag beschlikbar. Baw B.V. llHeIC, Phoemaceetlca, Energlaweg 1, Mljrecht 3641 R. Tl.: 0297-280666. S ure 2003. MSAmJ CUMdi 1971;273346 Fme 1. SBlb WK.H.CardI&Actusel 2001 6*2.k ataal.Thei W. CSn 3. R H at it. J CNII. Epim 109 3-M763 * SeW M1ha. (leg 2001L61(10:1501-1529 * 5. McGIJB eLt * 7.SlgIarJieal.J Ced Phemeel 2001;36672-U5s Tbar2601a23,33-S5S * LtNeAitmaL Am J 1IW161-166 * PkAm)Jcbl 9.iwit &. MCde.NJMOdi11mL OMgs 1NS11IS033-1044 18M19M7K-12N
PRUS: 'Coa50 n'CozarOD wwoldenvotedig vargoed binn hot GVS. Mompnr zie KNMP-tmm jan Riadpa d viledig productinformatie l(IB-tkatvoor mr infonnatie over 'Coz5ar Oen 'Coza 10
2003
1. Dialhf B., .a.: Cardiovascular morbidiy and mortaty in th Losafln Intrwvantion For Endpoint raducdt in ihwtmion udy (LlFEk a randomised trial agminst atalol. 7he Lancer359: 995 - 1003,2002
4
l3arindisaarft dbalWin. diet vrgelifnd sta usen losartan 50-100 nmg ( HGZ indian nodiqj en aiMnol 50-100 mg 1+ tM indion nod) bij 9193 patint mat Imparnie an LVH. De studu bidhop n anCVAI Ujerwhaeindpuntw asmgcwminerdeCV-xml aniddhtdi -rnombIcbft(CV-staftaMI Vardare informatis over LIFE staat oor u op: www.mijn-artenpagina.nl COZAAR is un gerogistird handilsmerk van E.l. du Pont Nemous and Company, Wilmington, Deiaw1rI. USA
50 mg /100 mg. O
MMS Postus 581, 2003 PC Haarlem, Telefoon 023 - 5153153, www.msd.nl
Nethd
Heare Joual, Votume 11, Number 10, October 2003
i
Voor uledp bhemetl ower hM geelidld kistcuetet opeemee met: Bawr.V. HsllbfCars,' Pbhwaretlcals, Pesh. 80, 3640 AS Mjdrecbt
KHJZAL M0
n Bayer HealthCare
435
______________________ II
41
A patient with chest pain An 81 -year-old male was referred to the emergency ward because ofchest pam radiating to the left arm, and nausea. He had no palpitations. The | arterial blood pressure was 130/90 mmHg. His ECG on admission is shown in figure 1. He had a history a large anteroseptal myocardfial ~~~~~~~~~~of infarction in 1976, leaving a large
v
aneurysm and a markedly reduced
-.
.9
a
:
I
ventricular ejection fraction of ,A,, Tleft 19%. A recent ECG (figure 2)
-
showed sinus rhythm with a normal PR interval (0.20 sec), QRS duration
of 0.14 sec, left heart axis', and left bundle branch block (BBB) cona_:S__|.@d_".,l._|.
.
are visible figuration; Qwaves
_____________________________________________________
Figur
I and aVL.
1. Mr,
i
in leads
Scintigraphy performed
recently showed slight pen-infarction ischaemria. His clinical status had been
stable until now. The patient underwent electrical cardloversion with 50 J resulting in sinus rhythm with relief of symptoms. A recurrent myocardial
infarction
N
a [ 110111 E211a f H r-f i
;_
was excluded; no acute myocardial ischaemia was detected.
What would your diagnosis and Answer
N 2
M
You wil find the answer on page 435.
Figure 2 J.M.E van Den. LVA. Bow_a. PJ. van Haveldt E.F.D. Wever. Departrnent of Cardiology, Heart Lung Centre Utrecht, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein. Address for correspondence: E.F.D. Wever. E-mail: [email protected]
418
Netheriands Heart Journal, Volume II, Number 10, October 2003
Anwwr to rhythm puzzle (peg 416) The patient's symptoms were not catued by an acute coronary syndrome but by a wide-QRS tachycardia (QRS duration, 0.14 sec, figure 1). The diffcrential diagnosis of a wide-QRS tachycardia is as follows: 1. Ventricular tachycardia (VT); 2. Supraventricular tachycardia (SVT) with either functional or preexstent BBB or IV conduction delay; 3. Atrioventicular reentry tachyardia with anterograde conduction over an accessory bypass (WolffParkdnson-White syndrome). Carotid sinus massage and intravnous administraton of adenosine may be of help in settling the diagnosis. Figure 1 shows VA disocation befirc the first, fifth, ninth, and twelfth QRS complexes (see leads I, 11, and V1). The fiffh QRS complex is preceded by thre QRS complexes, the first two ofwhich show VA conduction with slightlyincreasing VAduration (see leads I and V1). Between the fifth and sixth, the ninth and tenth, and the
twcelfi and tiirteentl QRS complexes, no atral activity is seen. Thus, the VA ratio is >1. This rules out the diagnosis of antidromic circus movement tachycardia during which a 1:1 AV ratio is obligatory. Also, atal tachycardia is excluded (AVratio 1). The QRS complex in V1 was positive, thus, the tachycardia had a RBBB morphology. The electrical heart axs was orientated to a superior direction, more leftward when compared with the ECG during sinus rhythm. The R/S nadir interval (V3) is about 0.10 sec. Considering these tatures, the diagnosis must be set at VT. If the hacmodynamic saituation is stable during VT, the patient may be treated with intravenousadministraton of an antiarrhythmic drug (e.g. procainamide): For firther differentiation (VT versus SVT), electrical cardioversion using low energy (5 or 10 J) may be useful. Successftl low-energy cardioversion points to the diagnosis of VTI.
Productinformatle van de in dit tijdschrift opgenomen advertenties
Productinformatie COZAARO 50 en COZAA*R 10
Kinzalmonos 40/80 - Kimalkomb 80
SAMENSTELLING: Cs 50bvpartaet5mg bkmim ng_en'COZa 100obaprWtbtl00 kmgkmksarw. INDICATES: Essamntil hnne. Tw2diabsdci mstprotdhunAtervwgin*gvndprograsm van nmia dmps. mdion nsodl kiand damming wordinwdoogd niijidn. DOSERING: Hp se. 50 mrmnmal damp 100 mg. TWpe2-d*icimW taphar. Galknalijs amivangpdeamr is 50 mg mml -. Deddoss ke wordinwe r*ar 100 mammal dp. C ' mWn mtand"mantdyaown, mat Wio-_ kuvllne a indira vamlgmknilina 1wogI~caamias woedmn gacmbms bdl indn itintgroapmnwwordtvarwannearde 9-tt DNTRA-HIECAS: gohvooru mvandebmtV d vnvan diproict. a hp nlactate.WAASUMNENEN : Awcoqpw nsii pidintI mat ilrbwisculalm volwmdaplatie, psilnt e w lpov nanvanhrtaan t_mp*lwt lm gaitiosrdardfumctie. mnst.nom,gestoondlav rncda,irradUmpnWmomanhmmakima rN*mnoup Idnuri g d1Uggbiuvn kfllumapaandidurica of kmlhnmuppnasnn.84 dt vanvn ton mos hat aunI'ium zog20di wordn gcotr d. Gmuink bij anirn: 'Cs is niat bij mndnr ondmrmoct EBwEN: aBkignaijnondermw.rduizdiptaidkinortoa tNdohlmSnen l (amnmkd>m5jnmolt Nadein.toducieavnhetgmnmuI zijnondmrndarazarnemgmllnvanovergwi*i mt* Mnift mactl. ani-oadm warnr zestling wo de b-r anglat. mat aoh ontofkn mld. VERGOEDINO EN -Wol hahlb_hsrctl en/of swelling van hatugaat de l,m. phwynn
_mumduUIq~ 40 mg, 80 mg tlmlaxnt of 80 mg telmisartan on 12,5 mg hydrochothleide per tablet. l _mtiegeet. laila: Eseotft bhprtensle. Bij petinten aluee pop DAgie wbe -mare tdrts asim, It eimaib geiadtwd. _werla warbij ie Miidhmk wavedeeaiewelem Aepme beerek to brlken kan I tabli, sma iags. Om doirgms fltlw dewegi Uiegt 40 .g. d we SO g. W borti d dosis .ed gi ar - m stIkbt tat mtlg eeeffkiiate is wanwrlefleatl B w A serleg mt eliat eebkd paning ve de pate ldiWteawt bedreagi: A maximal. Ip iwedg 40m6g. OirectwertaWes we m_mrap ioa*rveetgeembksati wan tdierteawbpdrochloethlazieaulida reelgMi VWe iu de maaaer .weesge. Ae.pssleeatvAAe.dega-iataMtiftgbljdmaAe. g e, astep bwr- of u e1ig_lbhtedd van hot PmIt zagersebap a hi g vanoIN&ih eba Vsrwechtighid -tbg -----S. u sleflasufkltlsa. e.eIkNb clial Is gbode in A wldpAb gedee rvnle pbgeteeeI alerraaaiplaetatle. intrFieveecmire un erbebcadiempepath M wetemaApI-, A mmdWisem, dea-e.Adtmne.hima ihhpereMink, 1wsdaft, #tw mg- of demme d g hea aemAae w wip eadftin met btj,ti bei leew leWsne-de *em. iz h gplhilg gIk ws. stmlbewei as tamlawlee ong.eeAn dIe As hallemepigele oeelagee, aesgeel dft magIi e ie i vendeg urmalm mde beeleA tiltbpevwemle, Ao gleceetleril vareleetart we chelesterolhrpemat thin e pite die mi thledletic marde behaniehl, hielot ee bg.Zls pidt weak a trgieam a hathyipetes ef tvn kmt qr liat paieddebeplga mom edree t weedaloftpearf. viwe telnwertan. udisrs eelpated weegmie.. Er a gee _edere brlelb velwe latle t temi kaetles gvea mt thiuldA dieretica: Alohol, DeYoi_b Wmm iele kae -Mi l we celwelpebarswhn, corti, hslem berbltawt, eacks, atie 1v, bcAbaeliue, ia eamalde, ACTH, iIIaigOelmWe, beidrabeebee.A MWee% eI -Apt1fdaA skbeltplamlaxetre, e g z er hlgotme. mild' ee we wajgade ede c_A _ ,m hi wes de totI wean ergl_.h pb odglewr oW aar! w bdee ulechitseia"" t:brebee mile 6e. Be tIbhcIaetle van bijwebnineneve" bie"blgeem bQ tdlmlaa ege viaea v mletale.Bijsm. udege.ile ateileeme rehlbemet ieethe w gen dleul gewmlbej bebmbg I inklas Ofe reg Wleiiheld, Impoeebarweedweeaaa W de Imtleveslimlsauteewebpdleluee indie imabli pie nala, vow gl,ee, hvecllsh,sc_maa edawegltectl Zeal: bi eA-do tIe, eipije Ippeellm, _-eeblireml * w _ r gaw_ wele-a a es gPMi. aWaP 40 21 blftn. _0aU: rl|h mgmg 8 1wbl mg111 vPi b .enI om 41 E W1lJ10 so m eWl0 U.R. Rogmpb_ e40 80 me tebliten mg ma N mg w __swbU 3u12,5mg"we El1/214OO7. hiU V&- iar p , Zie W t_ Ver waleidge prWect-i4farmatis t dA 18-tkstt op w_ vi wrgar ble asweag beschlikbar. Baw B.V. llHeIC, Phoemaceetlca, Energlaweg 1, Mljrecht 3641 R. Tl.: 0297-280666. S ure 2003. MSAmJ CUMdi 1971;273346 Fme 1. SBlb WK.H.CardI&Actusel 2001 6*2.k ataal.Thei W. CSn 3. R H at it. J CNII. Epim 109 3-M763 * SeW M1ha. (leg 2001L61(10:1501-1529 * 5. McGIJB eLt * 7.SlgIarJieal.J Ced Phemeel 2001;36672-U5s Tbar2601a23,33-S5S * LtNeAitmaL Am J 1IW161-166 * PkAm)Jcbl 9.iwit &. MCde.NJMOdi11mL OMgs 1NS11IS033-1044 18M19M7K-12N
PRUS: 'Coa50 n'CozarOD wwoldenvotedig vargoed binn hot GVS. Mompnr zie KNMP-tmm jan Riadpa d viledig productinformatie l(IB-tkatvoor mr infonnatie over 'Coz5ar Oen 'Coza 10
2003
1. Dialhf B., .a.: Cardiovascular morbidiy and mortaty in th Losafln Intrwvantion For Endpoint raducdt in ihwtmion udy (LlFEk a randomised trial agminst atalol. 7he Lancer359: 995 - 1003,2002
4
l3arindisaarft dbalWin. diet vrgelifnd sta usen losartan 50-100 nmg ( HGZ indian nodiqj en aiMnol 50-100 mg 1+ tM indion nod) bij 9193 patint mat Imparnie an LVH. De studu bidhop n anCVAI Ujerwhaeindpuntw asmgcwminerdeCV-xml aniddhtdi -rnombIcbft(CV-staftaMI Vardare informatis over LIFE staat oor u op: www.mijn-artenpagina.nl COZAAR is un gerogistird handilsmerk van E.l. du Pont Nemous and Company, Wilmington, Deiaw1rI. USA
50 mg /100 mg. O
MMS Postus 581, 2003 PC Haarlem, Telefoon 023 - 5153153, www.msd.nl
Nethd
Heare Joual, Votume 11, Number 10, October 2003
i
Voor uledp bhemetl ower hM geelidld kistcuetet opeemee met: Bawr.V. HsllbfCars,' Pbhwaretlcals, Pesh. 80, 3640 AS Mjdrecbt
KHJZAL M0
n Bayer HealthCare
435
