CME INDIA Case Presentation by Dr Narendra Kumar, Cardiologist Physician, Godda, Jharkhand.

CME INDIA Case Study

Male aged 55 yrs., pulseless with severe pain chest and breathlessness

[Na-123, K-4.8, Cl-107]

What does this ECG point?

CME INDIA Discussion:

Dr Ranjeet Ramgarh: Acute MI… Idioventricular rhythm.

Dr Harish Dalra, Mysore: Rule out hypothermia. And Dr Raju Sharma, Jamshedpur told to do calcium

Dr Vivek Gumber, Resident Smbt Medical College, Nashik: Idioventricular rhythm

Dr N.K. Singh, Admin: An idioventricular rhythm is very similar to VT except the ventricular rate is less than 60 beats per minute. All other characteristics of VT apply; this includes the presence of atrioventricular dissociation. When the ventricular rate is between 60 and 100 bpm, it is referred to as an accelerated idioventricular rhythm. This is a hemodynamically stable rhythm that occurs commonly after myocardial infarction and no treatment is needed.

Dr Varun Kumar, DM Card, Ranchi: Sinusoidal pattern resulting in PEA… (Pulseless electrical activity). Reasons may be cardiovascular or metabolic…but as pt c/o chest pain so most probably post MI… this ECGS pattern is just prior to cardiac arrest…. patient wouldn’t have survived….

Dr Sandeep, Khshi Nagar, UP: Idioventricular rhythm qrbb with st elevation in v1, qv2 suggestive of Acute AWMI with proximal LAD occlusion

Dr D.P. Khaitan, Gaya: We should look at the history – Pulseless with severe chest pain and breathlessness. Definitely we should think of ECG suggestive of Pulseless electrical activity I missed to see the history. D/D Slow VT.

Dr Raj Ashwini, Rims, Ranchi: Post MI – Free wall Rupture can cause PEA and SCA

Dr Varun Kumar, DM Card, Ranchi: Slow VT @ 50 bpm??

Dr D.P. Khaitan, Gaya: Sir please see the range. I do appreciate you. To my knowledge this is also known as accelerated idioventricular rhythm, sometimes referred as Slow VT – usually in between 50-100 bpm (Page 169 -Goldberger’s Clinical Electrocardiography (First South Asia Edition)

Deepak Gupta, DM Card Pulse Hospital, Ranchi:

Recommend nomenclatures:

  • Classical VT usual rate more than 150/min
  • Slow VT– 1OO to 150/min
  • Wide complex QRS Rhythm with all brugada criteria of VT except Rate less than 100 is called AIVR (some also call it Slow VT)
  • Idioventricular rhythm not accelerated has heart rate less than 60

ECG showing Sine wave pattern usually seen in Hyperkalemia but can be seen in any advanced conduction delay like severe acidosis due to any cause, Class 1 Antiarrhythmic drug mainly sodium channel blocker and alson in Class 1c drug like Flecanide . They are basically terminal waves and may be seen in Large Acute MI damaging conduction system. This type of rhythm if not treated urgently can lead to death of patient.

Dr D.P. Khaitan Gaya: ECG Diagnosis: Accelerated Idioventricular Rhythm. Electrocardiogram characteristics of AIVR include a regular rhythm, 3 or more ventricular complexes with QRS complex > 120 milliseconds, a ventricular rate between 50 beats/min and 110 beats/min, and occasional fusion or capture beats. But I do agree that quoted ECG favours more “Pulseless Electrical activity” (Electromechanical Dissociation). I congrat Dr Varun Kumar for the same.

The points in favour of ‘Pulseless Electrical Activity’ with pertinent positive findings:

  1. Regular rhythm with vent. rate 50/mt
  2. Wide QRS complex (more than 0.20s) merging with T Inscribing Sinusoidal pattern
  3. The presence of Discordant T almost throughout including a VR
  4. In most of the leads are T taller / or deeply inverted
  5. ST elevation in lead V1

CME INDIA Further Discussion:

  • There is the history – Male aged 55yrs in a pulseless condition with breathlessness
  • The pattern of wide QRS pattern suggests idioventricular rhythm
  • The sinusoidal pattern might indicate Hyperkalemia (But Serum potassium as mentioned in the report is normal – 4.8)
  • Discordant T points towards diffuse coronary insufficiency and the presence of the same in aVR further strengthens ischamic repolarization. Such Discordant T points is a risk marker of Sudden cardiac arrest.
  • More widened QRS complex might be due to slower muscle to muscle:
  1. Transmission associated
  2. Purkinje dysfunction
  3. Hyponatremia (serum Na being 127 as reported) etc.

All these findings in the presence of being pulseless condition strongly point to the diagnosis of “Pulseless Electrical Activity”

The patient is having cardiac electrical activity but insufficient pumping activity resulting in pulseless status – also known as eletromechanical dissociation (EMD)

This is a syndrome:

– Might have so many conditions, but mainly are metabolic and cardiac ones so to say.

– Pulseless electrical activity. most likely attributed to diffuse coronary insufficiency here.

Dr Varun Kumar: Sir, terms are self-explanatory… tachycardia by definition is heart rate more than 100 bpm whether SVT or VT….now idioventricular rhythm is heart rate between 20-50 bpm depending upon site of origin in ventricle. Accelerated idioventricular rhythm is heart rate usually between 60-100 but some authors consider it from 50-120 & even 130…when it is more than 100 then it is sometimes referred as slow VT…. AIVR is mostly considered benign condition & it is a welcome sign post reperfusion in AMI pts. Treatment usually is treating underlying problem. Slow VT is usually considered as heart rate between 100-150, & fast VT is heart rate more than 150, as described by Dr Dipak. VT with heart rate more than 250 is considered as ventricular flutter.

CME INDIA Learning Points:

  • PEA is a clinical condition characterized by unresponsiveness and the lack of a palpable pulse in the presence of organized cardiac electrical activity.
  • Pulseless electrical activity has been known as electromechanical dissociation (EMD) in past.
  • PEA does not mean mechanical quiescence. Patients may have weak ventricular contractions and recordable aortic pressure (“pseudo-PEA”).
  • True PEA is a condition in which cardiac contractions are absent in the presence of coordinated electrical activity. PEA encompasses a number of organized cardiac rhythms.
  • Mnemonic of “Hs and Ts” favored by the American Heart Association (AHA) and European Resuscitation Council (ERC):
  1. Hypovolemia
  2. Hypoxia
  3. Hydrogen ion (acidosis)
  4. Hypokalemia/ hyperkalemia
  5. Hypoglycemia
  6. Hypothermia
  7. Toxins
  8. Cardiac tamponade
  9. Tension pneumothorax
  10. Thrombosis (coronary or pulmonary)
  11. Trauma

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