ECG Guru - Instructor Resources - Right ventricular enlargement https://www.ecgguru.com/ecg/right-ventricular-enlargement en Atrial fibrillation and Type 2 M.I. https://www.ecgguru.com/ecg/atrial-fibrillation-and-type-2-mi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/atrial-fibrillation-and-type-2-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20channel%20page%20one.jpg" width="1800" height="1151" alt="" /></a></div><div class="field-item odd"><a href="/ecg/atrial-fibrillation-and-type-2-mi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/12%20channel%20page%202.jpg" width="1800" height="1116" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span>This excellent teaching case was donated to the ECG Guru by our friend, Sebastian Garay (who is an ECG Guru himself).<span style="mso-spacerun: yes;">&nbsp; </span>It was taken from a 33-year-old man who was complaining of chest pain and palpitations. He reported a similar episode about six months prior, but failed to follow up with cardiology. Was told by his medical care provider that he had atrial fib.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">The ECG:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>We are able in this case to provide a 12-lead ECG with each lead recorded for the entire width of the paper. This has the advantage of producing twelve ten-second rhythm strips.<span style="mso-spacerun: yes;">&nbsp; </span>Page one contains the limb leads, and page two shows us the precordial leads.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;">The rhythm</strong> is atrial fibrillation, with a heart <strong style="mso-bidi-font-weight: normal;">rate</strong> of 133 bpm and an irregularly irregular rhythm. The <strong style="mso-bidi-font-weight: normal;">QRS axis</strong> is extreme left at about -75 degrees.<span style="mso-spacerun: yes;">&nbsp; </span>This has caused Leads II, III, and aVF to be negatively deflected, and aVR and aVL to be positive. Lead I is biphasic, low voltage, and mostly positive, indicating that the axis travels almost perpendicular to Lead I, but slightly toward it.</p><p class="MsoNormal">The machine mistakenly gives us a reading for PR interval and P wave axis, even though there are no P waves.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS is on the wide side without being abnormal at .10 seconds (100 ms). The QTc is within normal limits, although it might be considered “borderline”, with 431-450 usually considered borderline.</p><p class="MsoNormal">There appears to be very <strong style="mso-bidi-font-weight: normal;">slight ST elevation</strong> in the inferior leads with no coving of the ST segment.<span style="mso-spacerun: yes;">&nbsp; </span>We see the same ST appearance in Leads V3 through V6.<span style="mso-spacerun: yes;">&nbsp; </span>The <strong style="mso-bidi-font-weight: normal;">axis in the vertical plane</strong>, as indicated by the chest, or precordial, leads, is also unusual.<span style="mso-spacerun: yes;">&nbsp; </span>It appeared the same in multiple ECGs run by different people, so lead placement is presumed to be correct.<span style="mso-spacerun: yes;">&nbsp; </span>V1 and V2 are more upright than negative, which is not normal. The most common cause of upright QRS in V1 is right bundle branch block, which is not present here. Another common cause of a dominant R wave in V1 and V2 is <strong style="mso-bidi-font-weight: normal;">right ventricular enlargement.</strong><span style="mso-spacerun: yes;">&nbsp; </span>V3, V4, V5, and V6 all look very much alike, with no R wave progression, also a sign of right ventricular enlargement.<span style="mso-spacerun: yes;">&nbsp; </span>First glance appears to show pathological Q waves in many leads, but on closer inspection, there are small “r” waves.<span style="mso-spacerun: yes;">&nbsp; </span>Other signs of right ventricular enlargement, such as the “strain pattern” (ST depression and T wave inversion in right-sided leads), are not evident here.</p><p class="MsoNormal">So, to recap, this young and symptomatic man has had intermittent bouts of atrial fibrillation and chest pain.<span style="mso-spacerun: yes;">&nbsp; </span>We do not know of other symptoms, but the ECG is abnormal in many ways, especially for a young person. His symptoms also point to serious heart disease.</p><p class="MsoNormal">The Hospital Course:<span style="mso-spacerun: yes;">&nbsp; </span><span style="mso-spacerun: yes;">&nbsp;</span><span style="mso-spacerun: yes;">&nbsp;</span>The patient presented to the Emergency Department in atrial fib with a rapid ventricular response at 140/min.<span style="mso-spacerun: yes;">&nbsp; </span>His troponin levels were all critically high at 1.230, 1.30, 1.230, and 1.250. (Normal 0.00 – 0.40). Later that day, he converted to sinus rhythm with PACs. The next day, cardiac catheterization was performed.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">Cath Findings:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span>Marked right heart pressure variations with respirations. Mild, non-obstructive coronary artery disease in a co-dominant system. Severe non-ischemic cardiomyopathy (NICM). The left ventriculogram showed global hypokinesis, with an ejection fraction of 20-25% (normal EF is 60% or greater).<span style="mso-spacerun: yes;">&nbsp; </span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">Diagnosis:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>Unspecified atrial fib and <strong style="mso-bidi-font-weight: normal;">Type 2 M.I.<span style="mso-spacerun: yes;">&nbsp; </span></strong>This is a term now being used for M.I. due to an underlying cause other than coronary artery plaque rupture and thrombosis.<span style="mso-spacerun: yes;">&nbsp; </span>In this case, loss of cardiac output due to atrial fib with RVR and NICM caused a defect in the supply-demand conditions in his heart.<span style="mso-spacerun: yes;">&nbsp; </span>Even with open coronary arteries, his heart could not keep up enough cardiac output to adequately supply the coronary arteries and the myocardium. The rapid rate increased the demand side of the equation, while not enhancing the supply side.</p><p class="MsoNormal">Patient Outcome:<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>The patient was discharged home with instructions to follow up with his primary care provider and cardiologist.<span style="mso-spacerun: yes;">&nbsp; </span>Even in the absence of heart failure symptoms, he was started on medications for failure, as well as medications for the atrial fibrillation.</p><p class="MsoNormal">&nbsp;</p><p class="MsoNormal">Our thanks to Sebastian Garay for sharing this great <strong style="mso-bidi-font-weight: normal;">non-STEMI</strong> example.<strong style="mso-bidi-font-weight: normal;"></strong></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/757/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Atrial fibrillation and Type 2 M.I. 1/5</option><option value="40">Give Atrial fibrillation and Type 2 M.I. 2/5</option><option value="60">Give Atrial fibrillation and Type 2 M.I. 3/5</option><option value="80" selected="selected">Give Atrial fibrillation and Type 2 M.I. 4/5</option><option value="100">Give Atrial fibrillation and Type 2 M.I. 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >9</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-MTe--bpYOa7siy7B0uwbYFnD7AzP1BflAeRA44FA4Bs" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/atrial-fibrillation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Atrial fibrillation</a></div><div class="field-item odd"><a href="/ecg/fib" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">A Fib</a></div><div class="field-item even"><a href="/ecg/type-2-mi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Type 2 M.I.</a></div><div class="field-item odd"><a href="/ecg/mi-non-obstructive-coronary-arteries" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">M.I. with non-obstructive coronary arteries</a></div><div class="field-item even"><a href="/ecg/nstemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">NSTEMI</a></div><div class="field-item odd"><a href="/ecg/non-stemi" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Non-STEMI</a></div><div class="field-item even"><a href="/ecg/right-ventricular-enlargement" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right ventricular enlargement</a></div><div class="field-item odd"><a href="/ecg/12-channel-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">12 channel ECG</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fatrial-fibrillation-and-type-2-mi&amp;title=Atrial%20fibrillation%20and%20Type%202%20M.I."><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Sat, 20 Jul 2019 19:41:02 +0000 Dawn 774 at https://www.ecgguru.com https://www.ecgguru.com/ecg/atrial-fibrillation-and-type-2-mi#comments