Concluded Case

Palpitations---- ECG?

68 years old female with history of palpitations. On Examination- Irregular Pulse .and normotensive Comments on ECG welcomed


Concluded answer

Ecg shows sinus tachycardia. Only isolated t inversion in evidence any arrhythmia. Pl go for 2d echo.could be anxiety state

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It's a very interesting ECG Clinically irregular pulse is felt not ECG is showing normal sinus rhythm - how can it be possible??? Please read on This ECG has few interesting finding Each QRS complex is preceded by P wave - therefore it is sinus rhythm Most important if these is as follows If one were to look at P waves carefully, the amplitude of P waves in lead II, III and aVF is about 3 mm, it satisfies the criteria for right atrial enlargement The criteria is as follows - Right atrial enlargement produces a peaked P wave (P pulmonale) with amplitude: > 2.5 mm in the inferior leads (II, III and AVF) > 1.5 mm in V1 and V2 But there is one more finding - P waves are not peaked as described classically in P pulmonale, but P waves show gentle curve and duration of P wave is also prolonged - this finding indicates that there is little bit left atrial enlargement as well There is one more finding about P wave, is amplitude is reduced in lead I and its is showing Negative deflection of P wave in lead aVL, This indicate that there is gross enlargement of atrium causing change of axis of depolarisation This once again point to some severe pathology affecting the heart Tall T waves are generally insignificant, they can be seen after exercise, in stained heart or can also be seen in hyperkalemia Now coming to the question - why there is irregular pulse on palpation of radial artery - but ECG is showing sinus rhythm? The answer is as follows. We have just concluded that there is severe pathology affecting heart - possibility of valvular heart disease such as severe and chronic mitral regurgitation It is because heart is working excessively for long time to maintain blood circulation in spite of regurgitation, it is showing some signs of fatigue. And every time heart pumps there is differential filling of heart because of breathing. Expiration increases left atrial filling and inspiration decreases left atrial filling. This usually is not having any visible effect. But in this case it has a significant effect on pulse pressure. Some times heart contact with lesser force - at that time radial pulse is weak and not felt. Some times heart contracts with greater force, at that time radial pulse of strong and well felt Therefore, when one is checking radial pulse, one feels that there is irregular pulse But if one were to feel brachial pulse, this false irregularity of radial pulse will not be felt at brachial pulse. At brachial artery, every contraction of heart will be well felt, and the pulse at brachial artery will always be regular in this case Hope this explanation helps

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Sinus tachycardia LAD P pulmonale RR interval is constant in every lead and P followed by qrs complex Hyperacute T wave show possibility of MI R/0 by Cardiac Marker Right atrial enlargement d/t PAH /chronic lung disease / Cor pulmonale

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Except tall T wave following ? Electrolyte imbalances , i can not see any abnormality and following this pulse rate is high. Pl.any additional finding share with us Dr.Praveenji .

Sir - on examination- pulse is irregular which doesn't co- relate with ECG - That is why I wanted a cardiologist opinion in this case . Thanks for your valuable opinion

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NSR Sinus tachycardia Acute repolarisation in all chest leads L2 T inversion in avl Hyperkalemia

Thanx dr Dinesh Gupta

NSR , Sinus tachycardia ,border line 1st degree block P Pulmonale , + left atrial hypertrophy ( biatrial hypertrophy) LAD ? Cor pulmonale / valvular heart disease

Sir ecg is WNL except for tall T waves,look for s potassium

Ecg shows sinus tachycardia. Only isolated t inversion in evidence any arrhythmia. Pl go for 2d echo.could be anxiety state


AF st segment elevation bundle branch block is dds

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