Transcript 71 year old female with generalized fatigue

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• Introductory Slide explaining purpose and
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A 71 year old female with generalized fatigue (can we add a
few more descriptors here)?
• Presents with the following ECG
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ECG # 2
Clinical Vignette
Causes
Mimickers
Management
Other similar
examples
Criteria for
major
diagnosis
Button to show answer, diagnostic
criteria, +/- teaching points
Diagnostic
criteria
index
71 year old female with generalized fatigue
Causes
Mimickers
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examples
Management
07 Sinus rhythm
21 AV junctional escape complexes
33 AV Block, 3°
Criteria for
major
diagnosis
Diagnostic
criteria
index
71 year old female with generalized fatigue
Causes
Mimickers
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examples
Management
Diagnostic Criteria: 33 AV Block, 3°
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Atrial and ventricular rhythms independent of each other (AV dissociation)
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Variable PR intervals
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Constant PP and RR intervals; A rate usually faster than V rate
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Ventricular rhythm maintained by junctional or idioventricular escape rhythm
Criteria for
major
diagnosis
Diagnostic
criteria
index
71 year old female with generalized fatigue
Causes
Mimickers
Other similar
examples
Management
Criteria for
major
diagnosis
07 Sinus rhythm
Regular Sinus Rhythm Atrial Rate 75
Notice the constant P-P intervals which are not altered by
ventricular QRS complex.
Diagnostic
criteria
index
71 year old female with generalized fatigue
Causes
Mimickers
Other similar
examples
Management
21 AV junctional escape complexes
Narrow QRS complex beats; rate usually 40-60 per minute
This is a secondary phenomenon in response to high grade AV block. There
is no relationship of the QRS complexes to the P waves.
Criteria for
major
diagnosis
Diagnostic
criteria
index
Causes
• MI
• Drug toxicity (digoxin, beta-blockers, calcium
channel blockers)
• Degeneration of conduction system
• Post-cardiac surgery
• Infiltrative diseases
• Infective endocarditis (esp aortic valve)
• Lyme disease
Mimickers
Diagnosis
Differentiating features
1st degree AV block
• Constant PR interval
2nd degree AV block- Type I
• Constant PP interval
• PR interval progressively lengthens until
one QRS complex is not conducted
(“dropped beat”)
• Appearance of “grouped beating” on
rhythm strip
2nd degree AV block – Type II
• Constant PP interval
• PR interval is constant EXCEPT for nonconducted P wave (“dropped” QRS)
AV dissociation
• Atrial and ventricular rates are different
(atrial rate may be slower or faster)
• PP intervals constant
• RR intervals constant
Management
• Continuous monitoring of heart rhythm
• Discontinue drugs with AV node blocking effect; if
taking digoxin, measure serum level
• For suspected drug toxicity, consider counter-active
medications
• If symptomatic or concern for clinical/hemodynamic
worsening, consider transcutaneous or transvenous
pacing; may temporize with dopamine, dobutamine,
isoprotenernol IV
• If congenital, evaluate response to exercise
Diagnostic criteria:
3rd Degree AV Block
• Atrial and ventricular rhythms independent of
each other (AV dissociation)
• Variable PR intervals
• Constant PP and RR intervals; A rate usually
faster than V rate
• Ventricular rhythm maintained by junctional
or idioventricular escape rhythm
Index of diagnostic criteria
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AV block, 1st degree
AV block, 2nd degree, type 1
AV block, 2nd degree, type 2
AV block, 3rd degree
AV dissociation…