A frail 95-year-old patient was brought into the emergency department with poor oral intake and increasing lethargy for 5-days. She is legally blind, bed-bound for multiple years. She developed fever and cough at home and had tested positive for SARS-CoV-2 virus at the time of symptoms onset 5-days ago. On examination, she was dehydrated. She had bilateral basal crackles. SPO2 was 93% on room air. BP 120/70 HR 75 but irregular T 37.8. Lab investigations revealed
# Hb 14.5 WBC 18,700 PMN 16,600 Plts 214,000
# Cr 195 eGFR 20 Na 156 K was hemolyzed
# CRP 276
# D-Dimer 80
# Tn-T 178
Her 12-lead EKG is shown below. Why is the pulse irregular?
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I examined the P wave shape, particularly P in the inferior leads, having in mind that not all irregular pulses indicate AFib. I'd like to investigate the causes and consequences that could lead to this disease.
Because it appears to be numerous P waves, we'll name it multifocal atrial tachycardia (MAT).
I won't rush into rate control with a drug customized gift for him unless the underlying reason is addressed first. as well as a bedside ECHO (effusion, contractility, causes outside heart)
So grateful for this post, definitely a big-time learning case for all of us. It trained me in a huge way. Thanks and sincere best wishes.
Thanks again! Wandering atrial pacemaker suggests the presence of 'ectopic' foci in the atria which compete with the intrinsic sinus rhythm. Therefore, you tend to get (1) a rather 'erratic' and irregular rhythm with (2) >3 different P wave morphologies and (3) variable AV conduction time without there being ONE dominant rhythm
However, if you look carefully at the ECG above. You notice that there is a pattern that cyclically repeats itself.
Let's enlarge one of these cycles to understand what is happening. You notice that
Within any one of the cycles, there are 3 distinct P wave morphologies that repeat themselves in a predictable manner. The red arrow denotes 'ectopic/escape' atrial beat, the green arrow indicates a 'normal sinus' beat and the blue identifies an atrial beat (see how the T wave is tented due to a P wave merging at the height of the T wave) that times earlier than it is supposed to be! Let us look at them again a bit more carefully
If you analyze this segment, the cycle starts with a green sinus beat (normal P wave axis in the inferior leads) followed by a normal PR interval and QRS complex. An atrial premature beat situated on the height of the T wave and indicated by the blue arrow triggers a sinus pause! during the pause you get an escape beat with an inverted P wave. The differential is from a low atrial rhythm if the PR interval was >110 mseconds or a junctional escape beat with a retrograde conducted P wave if the PR interval was <110 mseconds. These are indicated by the red arrows. After two such beats, the sinus rhythm appears to recover only for another sinus pause to occur triggered by yet another atrial premature contracture and the cycle repeats itself. The PR interval here is clearly short favoring a junctional escape with a retrograde P wave (hence the inverted P).
This is consistent with sinus node dysfunction, which had many reasons and in this particular patient is likely multifactorial (advanced age = degenerative SN dysfunction + severe systemic illness confounded by the mild hypoxia, at least at this stage)
Thank you for your thoughtful comments! That was a nice analysis. I was hoping to get more responses, but I won't keep you waiting anymore.
Here is why I do not agree with the 'MAT' diagnosis. As the title says, have a 'closer' look ;)
You are not dealing with a tachycardia! as the estimated rate is <100 beats per min. Care to venture another guess?
and remember it is usually due to COPD and CHF if it is come out of thsese context think about possible MALIGNANCY
keeping in mind not all irregular pulse means AFib, I looked at the P wave morphology esp P in inferior leads. I wish to look into causes/complications which may precipitate this condition.
It looks like multiple different P waves hence will call it multifocal atrial tachycardia (MAT).
I will not rush into rate control by giving medications unless i treat underlying cause. and a bedside ECHO (effusion, contractility, causes outside heart)