Vetricularly Regular A-Fib... Whaa?

[sirengirl]

So here I am, just done #2 for the day. She came in EMS as a AMS/possible syncope (nursing home said she was unresponsive, lo and behold FD gets there and she's sure responsive to shouting and a good sternal rub), came in to my ER (which is a satellite ER, I am contracted to do transports out of it when necessary). Run an immediate 12-lead, and I get this:

Contact all PCPs for the pt and find somehow in 90 years of living there seems to be no prior EKG. Attending in the ER doesn't want to call a STEMI off the LBBB despite the pt being a post-menopausal diabetic female (who present different...) and runs a battery of tests. CT and X-ray come back normal, bloodwork shows negative trops and only abnormalities are RBC, HGB, and HCT are the tiniest smidge low. Nothing at all appears to be wrong with the patient. Attending admits and we get our paperwork together and get the patient and go. My initial rhythm is:

My entire transport I literally watched the monitor like I'd never seen one before. I have always been told that A Fib is "irregularly irregular" and here I am with a rhythm which clearly has an atrial rate near, oh, I don't know, Mt Everest, and a ventricular rate steady at 70. It's not atrial flutter, there's no way I can call those flutter waves, it's not SVT- it's not any kind of tachyarrhythmia- it's not really a ventricular rhythm due to the rate, it doesn't look like wandering pacemaker.... One of my other medic friends said it almost looks sinus arrhythmia, but it can't really be sinus arrhythmia with an atrial rate like that....

So I have a ventricularly regular A Fib?? :blink:

The doc called it A Fib and I wasn't going to argue. Still, I can't shake the feeling like I was missing something... Thoughts?

 

[Aidey]

Did you march it out at all or just go by what it looks like visually?

 

[sirengirl]

Did you march it out at all or just go by what it looks like visually?

No, it's all accurate. I was so confused by it I made sure to do it all manually.

 

[VFlutter]

I am not convinced it is A Fib, it may just be sinus with baseline artifact. If you at lead II you can see what appears to be consistent P waves.

What meds were they on?

Patients on various antiarrhythmics and beta blockers can have pseudo-regularized A fib at slower rates.

 

[systemet]

Not a.fib.

There's a lot of artifact, but you can see P waves for most of the QRS complexes, consider:

complex 1,2,3 : Lead II, and III (subtle, but probably there)
complex 4,5,6: Lead aVF - especially for complex 4 and 6. And look at lead II - complex
complex 7,8,9: Lead II, all the way, V3 for complex 8 and 9.
complex 10: lost in transition a little, but you can see a P wave in lead II
complex 11-12, you can see it in II, maybe in V6 if you squint and stand on your head.

 

[sirengirl]

Yeah the more I've been looking at it the more I'm convinced its a sinus with horrible artifact and some aberrancy. The 12 lead is where you can make arguments for P waves, my 3-lead on my monitor is hopeless...

If I remember correctly the patient was only on 3 meds (don't have my report in front of me at the moment) and none were blockers.

 

[Rykielz]

It's hard to say because of all the artifact. Because the QRS is regular though it can't be A-Fib. Also I wouldn't call it a STEMI. I'd be watching the patient pretty regularly and still go to the cardiac center. The patient's going to tell you a lot more then the monitor will.

 

[jwk]

Ditto - it's not A fib. That's a sinus rhythm.

 

[FLdoc2011]

That's sinus. I see p's in the II rhythm strip and V3.

May be a slight IVCD but don't think it's LBBB, doesn't look that wide, but having problems enlarging pic well on my phone.

But I agree, sinus with just some artifact.

 

[jwk]

My entire transport I literally watched the monitor like I'd never seen one before. I have always been told that A Fib is "irregularly irregular" and here I am with a rhythm which clearly has an atrial rate near, oh, I don't know, Mt Everest, and a ventricular rate steady at 70. It's not atrial flutter, there's no way I can call those flutter waves, it's not SVT- it's not any kind of tachyarrhythmia- it's not really a ventricular rhythm due to the rate, it doesn't look like wandering pacemaker.... One of my other medic friends said it almost looks sinus arrhythmia, but it can't really be sinus arrhythmia with an atrial rate like that....

So I have a ventricularly regular A Fib?? :blink:

The doc called it A Fib and I wasn't going to argue. Still, I can't shake the feeling like I was missing something... Thoughts?

There's a ton of artifact in there - and really, you should easily be able to distinguish artifact from waveform. An irregular waveform is not always fibrillation (just like a flat line isn't necessarily asystole - especially if a lead is off ), and P-waves are everywhere, and obvious in the rhythm strip from the 12 lead. This isn't even a close call, and quite honestly, I can't imagine a doc reading it as A-Fib.

Your other clue is your plethysmograph waveform. Nice and regular.

 

[Carlos Danger]

I admit I'm a little rusty on EKG's, but I know a couple things:

1) QRS's can be quite regular in A-fib. That's the point of the anti-dysrythmics that these people are on.

2) You can sometimes see normal-appearing P-waves in A-fib, as long as the rate is controlled.

 

[sirengirl]

I can't imagine a doc reading it as A-Fib.

Your other clue is your plethysmograph waveform. Nice and regular.

Yeah I thought it was strange too. I've never worked with this doc before so I wasn't gonna say anything.

I was lost until I looked at the 12 lead en route really well. It was killing me how nice and regular it was, yet to have THAT muh artifact... Yet there it is. I think the other thing too was they were calling it a fib on the Telly monitor in the ER, there was a baseline aberrancy with that on their monitor too. Who knows? Not I. I still don't understand why they weren't sending to the cath lab, they had me take to the cardiac Telly monitor floor. Alas, above my pay grade. Extremely pleasant lady, though...

 

[Rykielz]

A-Fib will not have regular QRS intervals. If they do it's not A Fib. The P waves, if present, will also be polymorphic.

 

[VFlutter]

I still don't understand why they weren't sending to the cath lab, they had me take to the cardiac Telly monitor floor. Alas, above my pay grade. Extremely pleasant lady, though...

Why would she go to the cath lab? I do not see anything that suggests a MI. Obvious STEMIs go directly to the CCL anything else gets sent to telemetry for serial trops and a work up to rule out MI and then a routine diagnostic cath with interventions if necessary. Also, she is 90 so they will most likely not aggressively treat her and just manage medically.

A-Fib will not have regular QRS intervals. If they do it's not A Fib. The P waves, if present, will also be polymorphic.

Eh, I have seen A fib get very regular. Also with complete heart block you can still have A fib as the atrial rhythm and have a completely regular ventricular rhythm.

 

[sirengirl]

Why would she go to the cath lab?

The hospitals policy is that a new onset LBBB should be treated as a STEMI until proven otherwise. Couldn't find a prior EKG to rule out being pre-existing. It's a them thing, not a universally accepted practice. I'd be interested to see if there is any outcome from the admission or not.

Besides, I've seen other hospitals send patients to a cath lab at a different hospital (owned by the same company), 20 minutes away, for chest pain x3 days that they were admitted last night for, to go directly to the cath lab, only to have them dye it up, take a look, and decide to manage the chest pain with new home medications. No lie.

 

[Carlos Danger]

A-Fib will not have regular QRS intervals. If they do it's not A Fib.

A-fib that is rate controlled with Ca+ or B blockers can actually be quite regular.

The meds effectively increase the degree of block at the AV node, which decreases the number of impulses that are transmitted. This regulates the conduction and results in regular QRS complexes.

I'm not saying that the EKG posted is A-fib - it actually looks more like artifact to me.

I'm just saying that if someone is on rate-limiting meds, you cannot use the regularity of the QRS as the defining factor in whether or not a rhythm is AF.

 

[Aidey]

The hospitals policy is that a new onset LBBB should be treated as a STEMI until proven otherwise. Couldn't find a prior EKG to rule out being pre-existing. It's a them thing, not a universally accepted practice. I'd be interested to see if there is any outcome from the admission or not.

Besides, I've seen other hospitals send patients to a cath lab at a different hospital (owned by the same company), 20 minutes away, for chest pain x3 days that they were admitted last night for, to go directly to the cath lab, only to have them dye it up, take a look, and decide to manage the chest pain with new home medications. No lie.

You might want to introduce your doctors to Sgarbossa's criteria and have them read the new guidelines. Although it sounds like the company that owns the hospital probably has some very questionable policies.

 

[FLdoc2011]

The hospitals policy is that a new onset LBBB should be treated as a STEMI until proven otherwise. Couldn't find a prior EKG to rule out being pre-existing. It's a them thing, not a universally accepted practice. I'd be interested to see if there is any outcome from the admission or not.

Besides, I've seen other hospitals send patients to a cath lab at a different hospital (owned by the same company), 20 minutes away, for chest pain x3 days that they were admitted last night for, to go directly to the cath lab, only to have them dye it up, take a look, and decide to manage the chest pain with new home medications. No lie.

It's not necessarily a LBBB. From that EKG the QRS doesn't look all that wide, hard to tell from the pic but what was the QRS duration? Could be an intraventricular conduction delay w/ left bundle morphology but not a complete block.

Also, findings of a LBBB in and of itself doesn't necessitate a trip to the cath lab. Check out the recent 3rd universal definition of myocardial infarction consensus statement. For MI/ACS you also need symptoms of ischemia along with EKG changes or positive biomarkers or a few other criteria.

 

[FLdoc2011]

Besides, I've seen other hospitals send patients to a cath lab at a different hospital (owned by the same company), 20 minutes away, for chest pain x3 days that they were admitted last night for, to go directly to the cath lab, only to have them dye it up, take a look, and decide to manage the chest pain with new home medications. No lie.

There are numerous situations where this could happen.... maybe their cardiac enzymes became significantly elevated or had new/dynamic EKG changes that warranted a cath. And not every coronary lesion is amendable to intervention. Could have been small distal vessel disease that would just need medical treatment or coronary spasm.

 

[systemet]

It's not necessarily a LBBB. From that EKG the QRS doesn't look all that wide, hard to tell from the pic but what was the QRS duration? Could be an intraventricular conduction delay w/ left bundle morphology but not a complete block.

It does meet ECG criteria for LVH (Cornell: S in V3 + R in aVL > 20mm). I'm just a paramedic, but as I understand it, there's no criteria for STEMI in the presence of LVH?

Also, a question to the group -- there's some LAD here, around - 50 degrees or so. Is this LAHB?