UPDATED: 7/24/2008 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER

EKG Case Presentation:
An 83-year-old male is brought to the emergency department in a private car by his son and wife. He complains that his heart is beating fast. He states that he felt this a little bit last night, but it went away spontaneously. He cannot tell you how long it lasted. There was no chest pain or other symptoms. He slept well.

This afternoon he was exercising when the feeling of a fast heart rate feeling returned. It has persisted for a "few hours." The patient took his blood pressure at home with a digital blood pressure cuff and reports that his heart rate was 170 and his systolic blood pressure (SBP) was 90. He continues to complain of a fast heart rate sensation. He denies chest pain or pressure and denies dyspnea, sweating or nausea/vomiting.

Initial Assessment:

The patient’s initial assessment is as follows:

• Awake and alert and oriented to name, day, date, month, year, location and president
• Skin is pink, warm and dry
• No respiratory distress, speaking in full sentences. Lungs clear and equal without rales or wheezes
• Heart with tachycardic apical heart sounds and strong tachycardic radial pulse. No murmur is heard
• Abdomen is soft and non-tender
• Legs without edema, swelling or evidence of deep vein thrombosis.
• He denies chest pain, pressure, tightness or discomfort
• He denies shortness of breath, nausea or vomiting, or any other complaints/concerns
• He is speaking in a jovial manner and laughing with you (or maybe at you).
• He appears younger than his stated age of 83
• BP 124/76, Pulse 180 and regular, Respirations 16 and non-labored, Temp 97.9F oral, SpO2 98 percent room air FiO2

Past Medical History:
The patient has had coronary artery bypass graft (CABG) surgeries in four vessels about 18 months ago. Reports from that time state he had presented with complaints of fast heart rate to this same ER. He was transferred to a tertiary cardiac care center 30 minutes away by ground EMS. He reports that he had an angiogram that showed "blockages," but that "stents would not work," so he had the CABG. He does not know which vessels were bypassed.

He reports that since his surgery he has done well with no episodes of chest pain or sensation of fast heart rate. He has dyslipidemia (elevated cholesterol). He still participates in cardiac rehab and that is what he was doing this afternoon when his palpitations began.

He denies any other significant past medical history. He denies prior surgeries.

Allergies:
No known drug allergies (NKDA)

Meds (generic names):
Aspirin 81mg po daily
Vytorin daily

Initial 12 Lead EKG (click for larger image):

Treatment:
The patient is placed on continuous ECG monitor, SpO2 monitor and non-invasive BP cuff. He is placed on O2 at 2lpm per nasal cannula. An IV is established in the right antecubital space with an 18 gauge angiocath and blood is drawn.

Adenosine (Adenocard) is given, 6mg rapid IVP with a rapid saline flush. There is no change in the rhythm. Adenosine (Adenocard) is repeated at 12mg. There is no change in heart rate or rhythm. The patient did complain of a flushed sensation each time.

Heart rate remained at 180-190 beats/minute. BP remained around 130/70. No chest pain or dyspnea is reported.

Cardizem (diltiazem) 20mg is given in a slow IVP with rapid conversion to the EKG shown below.

He remains pain free and no longer complains of a fast heart rate. After 30 minutes, a third EKG is obtained. It is shown below.

The T wave inversions seen in the last (third) EKG are compared to an EKG performed 18 months ago. The old EKG was normal and showed no ST or T wave changes.

The patient remains awake, alert and asymptomatic. The family is at his bedside and he is laughing and joking with them.

The labs are returned and there is an elevated Tropinin-I level, indicative of an acute myocardial injury. The rest of his labs are WNL (either "within normal limits" or "we never looked").

You present your concerns to the patient and his family: the initial tachyarrhythmia, the abnormal EKG, the elevated troponin. You inform the patient he needs to be admitted to the hospital. He refuses. He states that he will call his doctor in the morning and wishes to go home. His family sits there and stares at you, seemingly offering no support for your idea. In fact, they say very little at all.

• Now what? What is your next action?
• How will you help the patient and family understand your assessment?
  

UPDATED: 7/24/2008 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER