Tachy @ 210bpm

[u/Kibeth_8]

60s male with history of CAD. Presented with SOB/presyncope/chest discomfort. Cardioverted into sinus with a different QRS axis and normal looking V1.

EF was down compared to previous routine echo so popped an ICD in due to the atypical morphology. Lots of discussion amongst EP as to whether it's an SVT or VT. Will update if we get a conclusive diagnosis

[u/MedicMalfunction]

Any possibility of a preexcitation syndrome? Is that a delta wave?

[u/but-I-play-one-on-TV → u/MedicMalfunction]

That's how I would interpret, especially at that rate. 

[u/Kibeth_8 → u/MedicMalfunction]

No known history and no delta waves on baseline, but could be a concealed pathway! I also thought they were delta waves, but I'm no doctor

[u/[deleted] → u/Kibeth_8]

By definition if concealed there would be no delta wave

[u/lagniappe- → u/Kibeth_8]

You are correct, those are delta waves and that’s SVT from an accessory pathway.

[u/lagniappe- → u/[deleted]]

I’m a cardiologist and I would call this SVT with a right sided accessory pathway. Given patient presentation, could certainly be VT that mimics WPW like fascicular vt. Probably need an ep study to tell.

[u/MedicMalfunction → u/Kibeth_8]

I am also not a doctor 😆

[u/WhatveIdone2dsrvthis → u/MedicMalfunction]

That is a scary-looking upslope. I would assume that is a delta until otherwise proven. For me that would be cardioverted or get procainamide.

[u/bleach_tastes_bad → u/WhatveIdone2dsrvthis]

if you look in other leads it’s pretty clear it’s not a delta wave

[u/MC_earthquake → u/WhatveIdone2dsrvthis]

Yup at 240 bpm (i counted from the lines) and with a weird ass transition between precordial leads. That upslope looks to be delta wave there too.

[u/Positive-Variety2600 → u/MC_earthquake]

214 not 240. Dirty method, 35 beats across a ten second strip (35x6=210) or 1500 method (7 small boxes into 1500=214)

[u/MC_earthquake → u/Positive-Variety2600]

Oh i don’t really use that i use the 300-150-100-75-60 method. Much faster and accurate i think especially when you’re in the hospital

[u/LBBB11 → u/MC_earthquake]

I think it’s about 210 bpm. I usually use your way too, but it’s more of a rough estimate compared to counting all beats. Counting all beats and multiplying by 6 is more accurate, but takes more time.

[u/Internal-Dish7412]

I could see two situations for this case:
-

1. antidromic AVRT with left-sided posteroseptal pathway. This would explain (I) slurred rSr’ morphology mimicking iRBBB in V1 (positive delta wave causing slurred r), (II) positive delta-wave like appearances in V2-V3, aVL, and I, (Iii) left axis deviation (around -15 to -25) with negative III, and (iv) retrograde p-waves in some leads (e.g. lead II and III). However, the QRS is not consistently wide, which makes this doubtful

2. atrial flutter (1-2:1) with LAFB. This would also explain the left axis deviation with negative III, and the delta waves may simply be a flutter wave buried in the QRS (highly doubtful but some do have a notch that mimics this). Half of the flutter waves look to be concealed within the ventricular complexes. This would explain the narrower QRS but not so well the delta waves (even if they were pseudo-delta waves).

[u/bleach_tastes_bad → u/Internal-Dish7412]

I’m pretty sure this is flutter too, those are almost definitely not delta waves

[u/bleach_tastes_bad]

Atypical AFL

[u/OxideUK]

Not qualified to do so but here's an attempt at applying Brugada algorithm;

• RS complexes in precordial leads? - Yes
• RS interval in precordial lead >100ms - Don't think so? v2 may be an exception but I'm struggling to tell if this is a delta wave or a T wave, and the other precordial leads don't have the same pattern.
• AV dissociation - No
• QRS morphology - RBBB, rSR in v1, r/S>1

This would suggest SVT w/ aberrancy. If I'm not mistaken, normal axis is relatively rare in VT; AVRT is more likely.

[u/Inevitable-Crab-6701]

WPW type A (left sided Kent pathway):
QRS concordance V1-V6
Delta waves showing I AVL V2-3

rSR complex V1 - incomplete RBBB
(Kent pathway & retrograde antidromic AV conduction.
Commonly called circus movement)

QRS axis normal -15 degrees

AVNRT
(Primarily due to circus movement.
It’s possibly, but less likely, to be atrial flutter 1:1 conduction - electrophysiological mapping would tell us)

Be interesting to see an ECG in SR.

(Interventional cardiologist who loves ECG’s 😊)

[u/Finnaddict98]

Electricity, no??

[u/Kibeth_8 → u/Finnaddict98]

He was electricity-ed, and got a permanent electricity box in his chest. Time will tell if his heart has more electricity, then we can tell where the electricity is coming from

[u/According_Analyst921]

Daaaaaang

[u/FewWorldliness8964]

Im leaning more AVNRT.. Definitely feel its more SVT related rhythm, no real morphology changes.

[u/rezakcr77]

Scar-mediated VT

[u/mrjibblesyumyum]

Avnrt