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Case 334

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A 21-year-old previously healthy male patient was admitted to the emergency department due to the sudden onset of palpitations, dyspnea and dipahoresis. Paroxysmal supraventricular tachycardia was diagnosed, a 6 mg adenosine bolus was administered and the patient developed ventricular fibrillation and cardiac arrest. Return of spontaneous circulation was achieved after the first cardiopulmonary resuscitation cycle and a 12-lead electrocardiogram was obtained (images 1, 2 and 3).

Based on the 12-lead electrocardiogram and the clinical scenario, what is the most likely diagnosis?

a) Wolff-Parkinson-White syndrome

25%

b) Brugada syndrome

25%

c) Stokes-Adams syndrome

25%

d) Lown-Ganong-Levine syndrome

25%
   

Image analysis

 

Image 1 – 12-lead electrocardiogram, leads V1 to V3, showing a delta wave (orange arrow), which appears as a result of fast ventricular activation through an acessory pathway.

 

Image 2 – 12-lead electrocardiogram, leads V1 and V2, depicting a short PR interval (< 120 ms).

 

Image 3 – 12-lead electrocardiogram, leads V1 and V2, displaying a wide QRS complex (> 120 ms) with a morphology similar to that of a right bundle branch block.

 

Highlights

– WPW is a pre-excitation syndrome which may trigger PSVT, especially atrioventricular nodal reentrant tachycardia;

– ECG: short PRi, delta wave, wide QRS complex and secondary ventricular repolarization abnormalities;

– Adenosine should be administered to patients who present to the ED with SVPT;

– If cardiac arrest occurs after administration of adenosine, WPW should be suspected;

– An electrophysiological study with ablation should be performed in symptomatic patients with WPW to prevent new arrhythmic episodes.

 

References 

– Goldwasser, G. (2009). Eletrocardiograma Orientado Para O Clinico. 3rd ed. RUBIO;

– Aehlert B. ACLS study guide. 5th ed. Elsevier; 2016;

– Page R, Joglar J, Caldwell M, Calkins H, Conti J, Deal B et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Heart Rhythm. 2016;133(4):e136-e221.

 

Authors 

Lucas de Oliveira Cantaruti Guida, 6th year medical student at UFMG.

Mail: lucas_cantaruti[at]hotmail.com

 

Leonardo Antunes Mesquita, internal medicine resident at Alberto Cavalcanti Hospital.

Mail: leonardo_a.mesquita[at]yahoo.com.br

 

Supervisor

Rosália Morais Torres, associate professor at the Department of Internal Medicine of the Faculty of Medicine of UFMG.

Mail: rmtorres[at]medicina.ufmg.br

 

 

Reviewers 

Guilherme Carvalho, Prof. José Nelson Mendes Vieira, Profa. Viviane Santuari Parisotto Marino.

 

Test question

Votorantin Municipality – Cardiologist (2010)

Concerning the Wolff-Parkinson-White syndrome, which of the following CANNOT be stated?

a) Due to the risk of sudden death, electrophysiological studies should be performed in all patients, even those who are asymptomatic.

25%

b) It may be associated with sudden death in some patients.

25%

c) The most frequent arrhythmia in patients with this syndrome is paroxysmal supraventricular tachycardia through an abnormal pathway.

25%

d) The abnormal pathway responsible for the syndrome is the Kent bundle.

25%

e)

25%
   

Commentics

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