WPW and AFIB!

Poaching from Moffitt at VA report. Mini case of a young patient presenting with palpitations with the 1st EKG above.

Several things: Notice the extremely fast rate (>200 BPM!), wide complex, irregularly irregular rhythm, and variable QRS amplitudes and morphologies.

AFIB w/ BBB is certainly on the differential, as is VT (more commonly regular, but can look irregular with fusion/capture beats making their way down the AVN). However, notice how the QRS morphology changes. This makes AFIB w/ BBB less likely. Polymorphic VT is also less likely given that the axis of the QRS complexes does not change with this different beats!

This is a case of AFIB w/ a WPW bypass tract! Treatment of choice? Procainamide which preferentially slows the fast conduction down the bypass tract.

In this case, procainamide failed and cardioversion resulted in the second EKG. Notice the clear delta-waves  in the precordial leads! (Also RBBB morphology that may have been leading to some of the QRS morphology variability in the 1st EKG).

AFIB w/ WPW is a dangerous rhythm that may degenerate into VF.

It is important to recognize as nodal blocking agents should be avoided since it would result in conduction only down the fast bypass pathway and an unstable rhythm!

 


Filed under: Morning Report

WPW and AFIB!

Poaching from Moffitt at VA report. Mini case of a young patient presenting with palpitations with the 1st EKG above.

Several things: Notice the extremely fast rate (>200 BPM!), wide complex, irregularly irregular rhythm, and variable QRS amplitudes and morphologies.

AFIB w/ BBB is certainly on the differential, as is VT (more commonly regular, but can look irregular with fusion/capture beats making their way down the AVN). However, notice how the QRS morphology changes. This makes AFIB w/ BBB less likely. Polymorphic VT is also less likely given that the axis of the QRS complexes does not change with this different beats!

This is a case of AFIB w/ a WPW bypass tract! Treatment of choice? Procainamide which preferentially slows the fast conduction down the bypass tract.

In this case, procainamide failed and cardioversion resulted in the second EKG. Notice the clear delta-waves  in the precordial leads! (Also RBBB morphology that may have been leading to some of the QRS morphology variability in the 1st EKG).

AFIB w/ WPW is a dangerous rhythm that may degenerate into VF.

It is important to recognize as nodal blocking agents should be avoided since it would result in conduction only down the fast bypass pathway and an unstable rhythm!

 


Filed under: Morning Report

Long-term effects of PPV on heart failure outcomes

PPV clearly has a role in the treatment of acute HF exacerbations by helping reduce preload and afterload thereby improving cardiac output, but are there long-term benefits to PPV on HF specific outcomes? We know that HF can be worsened by sleep disordered breathing from both obstructive/restrictive and central etiologies so it is reasonable to hypothesize that PPV could improve mortality in these patients.

A recent meta-analysis looked at this question.

Subjects: Subjects with chronic HF who may or may not have had sleep disordered breathing.

Methods: 19 Controlled trials from lit review looking at standard HF medical therapy +/- sham PPV vs. standard HF medical therapy + PPV. 843 patients in total.

Outcomes: Mortality, LVEF, BNP

Results: PPV was associated with improvement in LVEF, BNP but NOT with mortality.

We’ve made huge strides in improving HF mortality in the last 30 years, but routine PPV does not seem to be part of our arsenal in improving HF related mortality.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116333/


Filed under: Morning Report