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Monday, 21 January 2013

#ECG class Case 21

#ECG Class is an educational blog which runs alongside Twitter.

A new ECG "quizz" is launched most Monday evenings, in term time. 
Cases are generally aimed at Primary Care. 
All scenarios are completely fictitious and theoretical, but based on commonly occurring presentations in General Practice. 
This is an educational site, intended for healthcare professionals and shouldn't be construed as patient advice. 

Please use the Hashtag #ECGclass on Twitter, if you want to ask the patient any questions, or request any further investigations. Alternatively, please join in discussion and leave comments below.

Remember there are no right or wrong answers!  

ECG interpretation is often open to debate, and will usually evolve and change as new information becomes available.  Everyone's opinion is valid, and useful for others, as the evolution process takes place. 
Together we will try and form an interpretation based on the trace, and information, we have in front of us. 
Don't worry if you disagree - shout up and share your thoughts - the diagnosis is often arguable on the basis of a 12 lead trace, and may only become more obvious when a longer rhythm strip is available. 

Please feel free to join in, but most important of all, have fun! :-)

#ECG Class case 21

It's the first day back in surgery, after New Year bank holiday, and a 56yrs lady presents in morning surgery with 'palpitations'. She's noticed then for the past 2 weeks.

Q1. What other factors in her history might you want to elicit?

She tells you they come on at the end of the day. Last 1-3 minutes and feel like an intermittent    irregular "thud. She has never smoked, but has partied 'quite hard' over the Christmas week! She hasn't noticed any particular triggers for the symptoms, but they are worrying her. She knows her father had an 'irregular heart problem' before he died, but she doesn't know what it was. 
She is not taking any medication, is post-menopausal, and has always been fit and well in the past. 

Q2. What investigations might you consider?

Examination is normal, but you can feel an occasional 'dropped beat' on palpating her pulse. You decide you would like  FBC and TFTs and book her in for them next day, with an ECG.

Q3. What are your thoughts on the ECG obtained below?


Palpitations are a very common presentation in General practice.  They represent an 'awareness' of heart beat. They may be entirely benign, or represent a variety of conditions.

There often seems to be an increased prevalence over the Christmas period - possibly attributed to increased consumptions of caffeine, alcohol and cigarettes - often a combination of all three over the party season! Each of these stimulants can trigger palpitations independently, but put them together...

Individuals 'awareness' of a normal heart beat is very variable.
People can report an awareness of palpitations during normal rhythm, a fast sinus rhythm or abnormal rhythm. Others with significant or frequent ectopic beats may surprisingly unaware.

Palpitations are often associated with anxiety. These more often than not occur at rest, often whilst waiting to go off to sleep, when the anxious mind is not distracted by other things.

Palpitations which occur only on exercise/activity merit further investigation.

History - Timing/frequency/duration/relationship to exercise
Social - Consumption of Caffeine, Alcohol, Nicotine, Usage of prescribed and non-prescribed drugs.
Bloods - FBC (?anaemia), Electrolytes and Thyroid function.
ECG - Basic Rhythm/ Ectopic beats/ Any signs of inherited arrhythmias?  (long QT/abnormal PR interval/ Delta Waves/Brugadas etc etc)

The ECG above shows Ventricular Bigeminy. In other words, each normal sinus beat (P-QRS complex) alternates with a Ventricular Ectopic beat. This may well be entirely benign, and depending on the history obtained, may just require reassurance, and review after any lifestyle modifications which can be made.
If there is any doubt about symptom triggers, then a 24hr ECG may be useful.

Keep reading for more about the different types of Ventricular Ectopics, and their significance, on the next post!


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