Case 3

Stem: 86 year old man with a past history of hypertension, Type 1 diabetes, congestive cardiac failure, paroxysmal atrial fibrillation and aortic valve replacement. His medications include frusemide and warfarin. He presents with increasing dyspnoea. There was no chest pain preceding this presentation.

+ List the significant findings in the ECG

  • The rhythm is regular, and the ventricular rate is 125 beats per minute
  • The QRS width is at the upper limit of normal (at 120 msec) and the frontal QRS axis is leftward (at about - 13 degrees). The transition zone is in Lead V5
  • The limb lead voltages are consistent with left ventricular hypertrophy
  • There is sagging ST segment depression in Leads I and aVL. There is slight J point depression in Leads V1 to V3, and subtle horizontal ST segments in Leads V5 and V6
  • The computer calculated QTc interval is slightly prolonged at 460 msec
  • Two P waves precede each QRS complex - this is seen well in Leads I and aVL (Fig 2). The P waves have normal shape and axis. The atrial activity does not resemble that of atrial flutter. The PR interval is constant (at 168 msec). The atrial rate is about 250 beats per minute

Figure 2

+ Provide the most likely or important diagnosis

  • The underlying rhythm is atrial tachycardia with 2: 1 AV block