Haven't read the initial case presentation? Read: Case 15: But I Want to Go Home!

EKG Case Presentation:
An 83-year-old male is brought to the emergency department by private car. He complains that his heart is beating fast. He states that he felt this a little bit last night, but it went away spontaneously. There was no chest pain or other symptoms.

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.

You transport him to the hospital where 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.

Learning Objectives:

• Basic: Identify a supraventricular tachyarrhythmia
• Intermediate: Classify the patient as stable or unstable per clinical presentation
• Advanced: Identify risk factors for serious underlying conditions warranting further monitoring and/or treatment

Expert Panel Discussion of the Case:
Although this case unfolds in a hospital's emergency room, EMS providers often encounter the same scenario out in the field of having to help patients understand transport and treatment decisions. All healthcare providers are called to be "patient advocates" by keeping the patient's best interests above all other concerns. Although fully competent patients are capable of making a decision regarding their own health treatments, it is often necessary to properly inform the patient of what may be occurring in order facilitate an informed decision.

While urban systems may be able to afford the luxury of transport times on the realm of single digits, rural EMS providers often need to divert to tertiary centers at considerable distances in order to provide adequate care to patients with concerning clinical scenarios.

Initial EKG (click for larger image): 

This patient's initial EKG showed a supraventricular tachycardia at 160 bpm. Vital signs remained normal and no signs of clinical deterioration due to the tachycardia were evident, therefore there was no need to do a synchronized cardioversion if pharmacological therapy was available.

Second EKG: 

After pharmacological cardioversion, the second EKG showed an irregular normal sinus rhythm at 85 bpm with polymorphic premature ventricular contractions and premature atrial contractions, pathological Q-waves in leads V1-V3 (presumably from an old infarction), lateral T-wave abnormalities in leads I, aVL, V5 and V6, and left atrial enlargement.

Third EKG:

The third EKG showed resolution of the polymorphic PVC and PACs, but still showed monomorphic premature ventricular contractions.

Although troponin levels could remain elevated for months after an acute myocardial infarction, we do not know the status of this patient’s troponins after his CABG. This patient does have several high risk factors for an acute myocardial infarction. Primarily, he had a myocardial infarction 18 months ago. The clinical scenario back then was similar to the current case. At both instances, the patient referred no chest pain. He suffered from high cholesterol level, and recently suffered at least one recorded episode of sustained supraventricular tachycardia.

This patient should at least get a second set of cardiac markers, including troponin and CK-MB, and a CT angio or cath lab for further evaluation.

Case Author: Andrew Bowman, RN EMT-P

Case Discussion: Gustavo E. Flores, MS4 EMT-P

References

• Eggers KM et al. Persistent cardiac troponin I elevation in stabilized patients after an episode of acute coronary syndrome predicts long-term mortality. Circulation 2007 Oct 23; 116:1907.