A 78-year-old woman with congestive heart failure (CHF) (EF, 25%), chronic atrial fibrillation (AFib), gastroesophageal reflux disease, HTN, hyperlipidemia, diabetes, and osteoporosis takes 12 different pills. At the recent senior citizen day at the local church, a nurse told her that she does not need to take digoxin because she is on amiodarone. She wants to eliminate digoxin from her medication regimen, and she wants to know why you put her on it in the first place.
What is your answer?
Digoxin reduces hospitalization. In the large Digitalis Investigation Group study, digitalis only improved hospitalization. It had no effect on survival.
The ECG in the figure below:
is suggestive of:
Left Anterior Fascicular Block. Here, there is a normal sinus rhythm and marked left axis deviation. There are small Q waves in leads I and aVL with a slight activation delay in aVL. This is anterior hemiblock. Anterior hemiblock produces small Q waves in the right precordial leads. The QRS pattern seen in V2 is often very suggestive of anteroseptal infarction, but the specificity is much less in the presence of anterior fascicular block.
A 25-year-old man attends the ED because of palpitations of 1 hour in duration. They occurred suddenly when he was watching TV. He says his heart feels as if it is racing extremely fast. The patient has never had similar symptoms before. He denies chest pain or shortness of breath. He has had no loss of consciousness. Vital signs: Temperature 98.6° F (37.0° C), pulse 205 beats/min, BP 110/80 mm Hg, RR 17 breaths/min. Additional history: No medical history. No use of drugs, tobacco, or alcohol.
What is the most likely cause of his palpitations?
Technically, SVT refers to any tachycardia that originates above the bundle of His (although it most commonly refers to AV nodal reentrant tachycardia [AVNRT]). AVNRT usually occurs spontaneously, although it may be triggered by stimulants, exercise, or alcohol. The most common presenting symptom is palpitations. Other symptoms such as chest pain and loss of consciousness represent unstable tachycardia and warrant a more aggressive approach. Because the patient is stable, vagal maneuvers such as the Valsalva maneuver can be attempted. If these fail, adenosine should be used to attempt to convert the heart to a sinus rhythm. Adenosine administration can be repeated three times. Adenosine is successful in inducing cardioversion in most cases. If it fails, however, an AV nodal blocking agent can be used such as a nondihydropyridine calcium channel blocker (diltiazem) or a beta-blocker (metoprolol). If at any point the patient becomes unstable (chest pain, hypotension, loss of consciousness), adenosine administration may be tried, but you should proceed quickly to synchronized cardioversion. A repeat ECG after the episode has resolved can screen for underlying dysrhythmias such as the preexcitation seen in Wolff-Parkinson-White syndrome. Patients with a single episode of well-tolerated AVNRT may not require any further treatment. Diltiazem and metoprolol are usually first-line agents for chronic suppressive therapy. In patients with poorly tolerated SVT, definitive management with catheter ablation should be considered. These decisions should be made in conjunction with a cardiologist. Patients with uncomplicated AVNRT without significant comorbidities may be discharged home with close cardiology follow-up. Poorly tolerated AVNRT or the presence of significant comorbidities probably warrants admission for monitoring.
An 80-year-old man with severe AS is turned down for surgical AVR due to significant comorbidities. He is referred to you for consideration for transcatheter AVR.
Which of the following findings is considered a contraindication for this procedure?
Life expectancy <1 year. Life expectancy of <1 year, despite treatment of AS, is an absolute contraindication for TAVR. Severe peripheral artery disease precludes a transfemoral approach; however, the procedure may be done via a transapical approach, a transsubclavian approach, and even a transaortic approach. Severe pulmonary disease and an inaccessible apex preclude a transapical approach but the other approaches remain available. Active endocarditis is a contraindication to the procedure. The available valves are suitable for annular sizes between 19 and 29 mm.
ST- and/or T-wave changes suggesting myocardial injury. In this patient, there are symmetric, prominent T waves that are upright. These are seen in the inferolateral leads and are associated with ST depression in leads V1 , V2 , and V3 . There are no Q waves so this is not an acute infarct, but it is an acute current of injury. The rhythm is sinus.
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