#ECG #Medicine
Que. An otherwise healthy woman in her 20's with no past medical history presented with tachycardia. She had experienced palpitations and called 911. Prehospital rhythm strips were at a rate of at least 200 (unavailable) and the medics gave adenosine at both 6 mg and 12 mg with no effect. She was stable, with no Chest pain, SOB, hypotension or evidence of shock. Initial ECG at ED was recorded. Her charts revealed 3 previous visits for palpitations, and in all cases the ECG was interpreted as normal. After dialing up the esmolol, the patient spontaneously converted to Normal Sinus Rhythm and another ECG was recorded.
What is your diagnosis ?
Answer: Diagnosis. Atrial Fibrillation in the setting of Wolf Parkinson White(WPW) Syndrome
Fig 1 shows HR ~200 bom, Irregularly irregular rhythm, Wide QRS complex and Very short RR interval ~ 240ms. The complexes look bizarre and multiform. They are not uniform, as they would be with simple aberrancy. Thus, these represent differentially pre-excited ventricular myocardium.
Fig 2 shows Sinus rhythm with short PR interval and large delta waves, seen best in precordial leads, and confirming Wolff Parkinson White (WPW) syndrome of pre-excitation down an accessory pathway.
Fig 3 shows very subtle delta waves
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