Palpitations
Try out this cardiology case and test your clinical knowledge. The answers are at the bottom.
Questions
You are an FY1 in A&E in a district general hospital. A 76 year-old gentleman with a history of a previous myocardial infarction presents with 8 hours of palpitations and breathlessness. He has no chest pain.
He currently takes Aspirin 75mg OD, bisoprolol 2.5mg OD, Ramipril 2.5mg OD, spironolactone 25mg OD.
Observations:
Saturations: 96% on room air
BP: 102/60
HR: 146 bpm
Temp: 36.9
RR: 20/min
On examination the patient is tachycardic with no other significant findings. He is attached to a cardiac monitor and the ECG rhythm strip is shown below
VBG:
pH 7.31
pO2 10.6
pCO2 5.2
lactate 2.1
HCO3- 22
K+ 4.7
Na+ 136
Q1: What rhythm is shown below?
The nursing staff attach the patient to a defibrillator and have put out a peri-arrest call and hence the on-call medical team are on their way but are delayed at a cardiac arrest elsewhere in the hospital. The patient has large-bore IV access.
Q2: What is the most appropriate next step in management?
The patient’s blood pressure drops to 80/50 mmHg and he becomes confused. The amiodarone infusion has only been running for 5 minutes.
Q3: What is the next most appropriate step in management?
After the previous management step, the patient returns to sinus rhythm at 85 bpm. The cardiology team will review him in the morning.
Q4: What medication could you write up or change to reduce the likelihood of recurrent VT overnight?
BONUS QUESTION: Which additional investigation will this patient likely require and what would it show?
Answers
Reveal the Answers
This is a regular, broad-complex tachycardia. It is most likely Ventricular Tachycardia (VT) – mainly due to the history of ischaemic heart disease leaving scarred areas of myocardium that are pro-arrhythmic.
There is also a hint of atrio-ventricular dissociation, seen most clearly in the 7th complex from the left.
Infuse amiodarone 300mg over 30 minutes. The patient has been in VT for several hours and is haemodynamically stable with no overt signs of heart failure. Therefore, the next most appropriate step is to administer amiodarone via a slow IV infusion.
Ideally this should be done through a central line but can also be given through a large peripheral cannula when there will likely be a delay in gaining central access.
Defibrillation with a synchronised shock. The patient now has signs of haemodynamic compromise and therefore requires defibrillation. Ideally anaesthetic support should be summoned to sedate the patient if he is still conscious, but if there is an unacceptable delay then it is not mandatory.
The two most important changes would be to increase his bisoprolol (initially to 5mg daily) and finish the amiodarone infusion – once 300mg has been given, a further 900mg IV is usually given over 23 hours.
After the loading of 1200mg over the first 24 hours, amiodarone is often given as a loading regime of 200mg TDS for a week, then 200mg BD for a week and then 200mg OD thereafter.
BONUS QUESTION ANSWER
This patient requires an echocardiogram to assess his left ventricular function, although his drug regime suggests that he has severe LV impairment. He will likely require an implantable cardioverter-defibrillator (ICD) before discharge as this VT episode was unprovoked, although he is approaching the upper end of the age-range when ICDs are usually considered.
To get more information about the conditions mentioned in this case including diagnosis and management, have a look at our free cardiology notes on In2Med. Written by medical students, we have pitched them just at the right level to help you ace your exams.
Dr Alexander Tindale
Cardiology SpR
Cardiology SpR
About The Author
This clinical case is written by Dr Alexander Tindale, a cardiology registrar at Royal Brompton & Harefield NHS Foundation Trust.
Disclaimer
The intended purpose of this website is to be used as a resource for revision for exams. It should not be used as a guideline or reference for clinical practice/decision making or by patients looking for medical information or advice. In2Med takes no responsibility for any loss or damaged resulting from the use of information from this website.
