Week 27
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Quiz 27 Context:
A 78-year-old female presents with minor injuries sustained because of a fall. The patient reports she was in her usual state of health when she suffered an abrupt witnessed loss of consciousness and fell to the ground. Their were no prodrome symptoms. She did not require CPR during this event. The patient does not recall any similar events in the past.
The patient reports a past history of hypertension, coronary artery disease, previous myocardial infarction, and peripheral vascular disease. She takes medications regularly including aspirin, a B-blocker, and a diuretic, all of which have been at stable doses. She remains physically active and does not smoke or drink alcohol.
Physical examination reveals a female patient in no acute distress. Vital signs reveal a temperature of 37.6 degrees Celsius, heart rate 65 bpm, blood pressure 130/70 mmHg. The exam is most notable for scattered abrasions consisted with minor trauma. There is a soft systolic murmur. The lungs, abdomen, and extremity exam is otherwise unremarkable.
As part of the evaluation, an EKG is done and, subsequently, a holter monitor is placed. The key findings on analysis of the holter monitor is shown above.
Sorry, that is not the most likely answer. Try Again.
a. Excellent!
This image is of a Holter monitor demonstrating intermittent complete heart block in patient with syncope.
You have correctly identified this week's Image of the Week. Now test your knowledge of other aspects of arrythmias. Do you know…
… the usual age of onset of atrioventricular nodal re-entry tachycardia? How common is it relative to other supraventricular tachycardias? What heart rates does it present with? Does it respond to vagal maneuvers? Does it respond to adedosine? Is there any role for radiofrequency ablation therapy in these patients?
… what is the "rule of thumb" regarding the diagnosis of a sustained or non-sustained wide-complex tachycardia in a patient with known coronary artery disease or previous myocardial infarction? What is the initial therapeutic approach to such a patient with sustained wide-complex tachycardia and hemodynamic instability? And if the same patient was hemodynamically stable? Is there any utility to using adenosine in these patients? Is there any significant risk to its use?
… when working up a patient with symptoms suspected to represent cardiac arrhythmia, when should a holter monitor be used? What are the advantages to event recording monitoring systems, also called loop recorders, compared with holter monitors? Is there any utility to the signal-averaged EKG and, if so, when is it useful?
The answers to these questions, and a concise review of the pathogenesis, diagnosis, and treatment of arrhythmia, can be found here within the Cleveland Clinic Disease Management Project.
This history, examination, and monitor data are most consistent with which of the following possibilities as a cause for the syncope:
- Complete heart block
- Wenckebach 2nd degree block
- Neurocardiogenic syncope
- Atrial fibrillation with
slow ventricular response
- Atrioventricular
nodal re-entry tachycardia
