Cardiology 7.

Arrhythmias and conduction disturbances

V – 4.

I. INITIAL QUESTIONS
1. General approach to treatment bradyarrhythmias?
2. Diagnostic strategy in case of tachyarrhythmias?
3. Give indications, contraindications, side effects of potassium channel blocker?

II. CLINICAL CASE.

A 23-year-old male with no previous medical history was transferred to our clinic for
out of hospital cardiac arrest. In the pre-hospital setting successful electrical
cardioversion was performed with an estimated no-flow period of 8 min and low-
flow period of 11 min. 
In the emergency department the patient was comatose and mechanically ventilated
but hemodynamically stable. Cardiopulmonary examination was normal and there
were no signs suggestive of drug abuse. 
The ECG demonstrated sinus rhythm with narrow QRS complexes and T wave
abnormalities in the precordial leads. Urgent coronary angiography showed normal
coronary arteries, while pulmonary angio-CT came back negative for pulmonary
embolism. Lab exams were in normal range, including a complete electrolyte panel
and TSH. Seventy-two hours later, he was successfully waned off mechanical
ventilation and the ECG tracings now demonstrated large QRS complexes with signs
of ventricular preexcitation. 
An ETT was performed and demonstrated a normal size, diffusely hypokinetic LV
with a LVEF of 47%, with an unusual aspect of the myocardium at the level of the
inferolateral wall with what appeared to be excessive trabeculation.
An electrophysiological study was performed and a malignant right anterolateral
accessory pathway was identified and successfully ablated, with no inducible atrial
fibrillation (AF) following the provocation maneuvers
Because the echocardiographical findings were considered indeterminate with mild
systolic dysfunction having been described after prolonged cardiac arrest and
hypertrabeculation of the myocardium being a common finding among young men of
African descent, we performed gadolinium enhanced CMR.
 1. What is your diagnosis?
2. What is your management strategy, next step?
III. INTERPRET THE RESULT OF THE INVESTIGATION
A 64-year-old woman with known renal failure on thrice-weekly dialysis comes to
your office feeling poorly. She has missed her last two dialysis sessions because she
had a sore throat and cold symptoms. You check her pulse and find it to be slightly
rapid. Her blood pressure is about her usual at 145/88 mm Hg. You obtain an
electrocardiogram (ECG). What is the most likely diagnosis?

IV. PRESCRIPTIONS
1. Prescribe Metaprolol to patient with atrial fibrilation.
2. Prescribe Verapamil to patient with SVT.