The following ECG is from an 81 yr old female who presented with a 4 day history of RUQ pain on a background of known gallstones.
Click to enlarge
- Mean ventricular rate 114 bpm
- No p wave visible
- QRS - Normal (90ms)
- QT - 340ms (QTc Bazette 430 ms)
- Low voltage QRS
- Flat T lead avL
- T waves in inferior leads relatively large in relation to QRS voltage
- No ST depression / elevation
Clinical Factors in Atrial Fibrillation
- Atrial fibrillation with rapid ventricular response
- Low voltage QRS
There are several features to establish on assessment of the patient in atrial fibrillation that will influence both the immediate and long-term management strategies, including:
Management Options in Atrial Fibrillation
- Onset and duration of symptoms
- Likelihood of paroxysmal episodes
- Evidence of compromise from AF
- Chest pain, cardiac failure, hypotension etc.
- Current medications
- Especially anti-coagulation and anti-arrhythmics
- Potential precipitant / cause
- E.g. sepsis, electrolyte abnormality, endocrine disease
- Suitability and contra-indications to management options
- E.g. fasting status, anaesthetic risk, drug allergy / intolerance, bleeding risk
There are several considerations in the management of AF which include:
Despite being one of the commonest arrhythmia encountered in medicine there is considerable variability in the clinical management of atrial fibrillation. There are a number of international guidelines and protocols regarding AF management, including:AF Related Calculators (links to MDCalc)Low Voltage QRS
- Rate vs. rhythm control
- Electrical vs Chemical rhythm control
- Risk vs Benefit
- Drug to use
- ? Underlying precipitant
- Infection / ischaemia / structural / endocrine / metabolic etc.
- Follow-up / disposition
- Ablation suitability
What happened ?
- Increased distance between heart and ECG leads
- Pleural effusion
- Pericardial effusion
- Inflammatory / infiltrative disease
This patient was commenced on metoprolol and digoxin for rate control as their time of onset was unknown. Their underlying cholecystitis was treated with fluids and antibiotics.
References / Further Reading
Life in the Fast LaneTextbook
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.