CASE PRESENTATION

Dr. ADEEL AHMAD.

PGR WMW.

Name Sobia

Age 35 years

Sex Female

Resident Faisal Abad

Presented

“Palpitation and SOB 6 hours”.

Patient HTN+ 3 months (on regular medication) nonDMpresented in emergency with H/O palpitation that started 6hrs back. She complains of such a palpitation for last 3 months on and off, palpitation can occur any time that have no relation to exercise or work load.She, along with palpitation, also complains of SOB for up to a similiarperiod. SOB can occur any time,no diurnal variation,noseasonal history. There is no H/O orthopnea and PND.

Past History: Except HTN not significant

Personal History: Not significant

Family History: She is married and living a happy life.

Treatment History:

She was on

Losartan 50 mg 1 po OD and

Tenormin 50 mg BD

VitalsBP 170/100 mmHg

Pulse 120 beat/m

RR 20/M

Fever A/F

Pallor -ve Cyanosis -ve Clubbing -ve Koilonychia -ve S /hemorrhage -ve Osler nodes absent Heberden nodes absent Boucard nodes absent Palmer erythema -ve Dupuytren contrature -ve Skin rash -ve Axillary nodes not palpable JVP not raised Thyroid normal Ankle edema absent Sign of dehyration -ve

GPE

CVSOn inspection; Shape of chest is normal.

On palpation; Apex beat in 5th intercostal space just medial to mid clavicular line,no other sound is palpable,no thrill,no murmur.

On auscultation; Both sound normal,no thrill,nomurmur.

Respiratory system

On inspection; Rate 20/m thoraco abdominal.

On palpation; Trachea is central,apex beat in 5th

medial to midclavicular line,chest movement and expansion within normal range,no vocal fremitus.

On purcussion; upper border of liver is in 5th

intercostal space.

On auscultation; Breath sounds are normal,noronchi,no crepts.

GIT

On Inspection; Oral hygiene is good,

On Palpation; Not done

On Purcusion; Not done.

On Auscultation; B/S are audible,no bruit is present.

CNS

HMF Normal.

Speech Normal

Cranial nerves Intact.

Motor Intact

Sensory Intact

Cerebellar Intact

Diagnostic criteria:The QRS complex duration is >0.11 second; in

approximately 20% of individuals, the QRS complex may not be >0.11 second.

PR is <0.12 second.

A delta wave is prominent, often in V3 through V6,

In type A WPW syndrome, a tall R wave present in V1

In type B WPW , the QRS complex is predominately negative in V1 through V3 and upright in V5 and V6.

HistoryIn 1930, Wolff, Parkinson and White described a

distinct (ECG) pattern in healthy young people with short bursts of tachycardia.

In 1944, doctors confirmed the presence of extra pathways

Prevalence:WPW is a congenital heart abnormality

WPW occurs randomly in the general population

1 to 3 per 1,000 persons.

Men have a higher incidence of WPW than women.

Some cases of WPW are inherited.

7 to 20 percent of patients with WPW also have congenital defects within the heart.

Symptoms of WPWAny age, from infancy to adult years.

Heart palpitations

Racing feeling in your chest

Dizziness

Shortness of breath (dyspnea)

Anxiety

Rarely, cardiac arrest (sudden death)

Some people have WPW without any symptoms at all.

Types of WPWPractical concept is that a negative delta wave usually

signals where the AP is:

A negative delta wave in a left-side, I and aVLindicates a left-side AP.

A negative delta in a right-side lead such as V1 predicts a right-side AP.

A negative delta in the inferior leads (II, III, and aVF) indicates a posteroseptal AP.

A positive delta in the inferior leads predicts an anteroseptal AP.

An isoelectric delta in V1 predicts an anteroseptal AP.

Left lateral wall - Negative delta waves in lead I

and aVL; positive or isoelectric in II, III, aVF and V1-4; and negative or isoelectric delta waves in V5-6

Right free wall - Positive delta waves in I and II,

negative delta waves in aVR, isoelectric or negative delta wave in aVF, isoelectric delta wave in V1, isoelectric or positive delta waves in V2-3, and positive delta waves in V4-6

Left posterior free wall - Positive delta waves in lead I and aVL; negative delta waves in II, III, and aVF; positive delta waves in V1-5; and negative or isoelectric delta wave in V6

Posteroseptal - Positive delta waves in lead I and aVLwith negative delta waves in II, III, and aVF; isoelectricwaves in V1; and positive delta waves in the rest of the precordial leads

Left anteroseptal - Positive delta waves in I, II, and aVF; negative delta wave in aVR; isoelectric or positive delta wave in V1; and positive delta waves in V2-6

Right anteroseptal - Positive delta waves in I, II, and aVF; negative delta wave in aVR; negative or isoelectricdelta waves in V1-3; and positive delta waves in V4-6

TreatmentDDAVNRT

Orthodromic AVRT

Antidromic AVRT

Narrow complex

Orthodromic AVRT and AVNRT blocking AV node conduction

Vagal maneuvers (eg, Valsalva maneuver, carotid sinus massage, splashing cold water or ice water on the face)

IV adenosine 6-12 mg via a large-bore

IV verapamil 5-10 mg or diltiazem 10 mg

Wide complex

Antidromic AVRT

Procainamide or

Amiodarone or

Flecainide if wide-complex tachycardia is present, if patient hemodynamically stable

Ibutilide

Unstable patient

Synchronized electrical cardioversion,

A level of 100 J initially

If necessary, a second shock with higher energy (200 J or 360 J)

Pregnancy Sotalol

Radiofrequency Ablation Indication

Patients with symptomatic AVRT

Patients with AF

Patients with AVRT or AF with rapid ventricular rates found incidentally during EPS,RR interval during AF <250 ms

Asymptomatic patients who would endanger the public safety

Patients with WPW and a family history of sudden cardiac death

RFAIn RF ablation, platinum-tipped 3.5- to 8-mm

steerable multielectrode catheters are advanced via the femoral artery or vein to locate and ablate the AP by delivering thermal RF energy

Surgical treatmentSurgical treatment is replaced by RFA

Patients in whom RF catheter ablation (with repeated attempts) fails

Patients undergoing concomitant cardiac surgery

Long-term antiarrhythmic therapyOral medication is the mainstay of therapy in patients

not undergoing RFA. Choices include the following:

Dual-drug therapy (eg, procainamide and verapamil[class Ia and IV])

Class Ic drugs (eg, flecainide, propafenone), typically used with an AV nodal blocking agent

Class III drugs (eg, amiodarone, sotalol)

In pregnancy, sotalol (class B) or flecainide (class C)

WHAT IS DIAGNOSIS

WHAT IS DIAGNOSIS

WHAT IS DIAGNOSIS

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