Would You Cardiovert this Patient?

A 90 yo patient with multiple co-morbidities and mild dementia presents with chest pain.
The patient is haemodynamically stable.

The ECG is shown below:

What does the ECG show?

The patient has been given Magnesium, with nil response. You are called to give advice.

What's your diagnosis?

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ANSWER

This is an 'imposter'. It simply shows artefact. Here's how to tell.

• Look at lead III. This is the underlying rhythm in place. One lead cannot refuse to go into an arrhythmia. The arrhythmia will show in all leads.
• The rate is important to look at. It is > 300 bpm and probably closer to 500 bpm.
  • If this was a real rate, the patient would now be in VF arrest. The ventricle cannot tolerate fast rates (>300 bpm) for any period of time.
  • If this was in fact the rate, the patient would not be stable as the diastolic filling time is so decreased that the blood pressure would drop significantly.

The cause of this imposter can be:

• Underlying patient tremor, such as with Parkinsons Disease
• A lead malfunction

What to do about it

Redo the ecg, either after having replaced the leads, otherwise you could ask the patient to sit on their hands, to stop any tremor readings and redo the ecg. If it still continues, think of electrical interference and see what can be turned off and the effect that has.