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April 2005 EKG Case: A 60 year old woman has a syncopal episode at home and is lethargic on ED presentation. She is cyanotic, tachypneic and has a blood pressure of 70/35 mm Hg. Immediate synchronized DC cardioversion improves her condition. What does the EKG show and what is the diagnosis? Rate: 220 EKG Diagnosis: Atrial fibrillation with aberrant conduction Clinical Diagnosis: Atrial fibrillation Wolff-Parkinson-White syndrome Practice Points: -An irregularly irregular rhythm with no p waves confirms the diagnosis of atrial fibrillation. -The QRS complexes have a distinctive slurred upstroke of the R-wave (the delta wave). -In patients without an accessory pathway, the AV node protects the ventricles from very rapid atrial discharges during atrial fibrillation. In WPW, the accessory pathway bypasses the AV node and may result in a very fast ventricular rate. This may lead to heart failure or hemodynamic compromise. The faster the ventricular rate, the greater the risk of ventricular fibrillation. -The majority of impulses are conducted via the accessory pathway and therefore a delta wave is evident. Some impulses however may be conducted normally through the AV node and will appear normal. |