Figure 1: ECG during palpitation.
Online Clinical Case Study (March 2009)
The
content of the Office Cardiology Series is provided by:
Dr.
TAM Chi Ming
MBBS (HK), MRCP (UK), FHKCP, FHKAM (Med), Specialist in Cardiology
Dr.
LI Siu Lung, Steven
FHKAM (Med), FRCP (Glasg), FRCP (Edin), FRCP (Lond), Specialist in Cardiology
Dr.
WONG Shou Pang, Alexander
FRCP, FHKAM (Med.), FHKCP, Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙譚志明醫生、李少隆醫生及王壽鵬醫生提供。
A 61-year-old lady presented to the A&E department for sudden onset fast palpitations. She has been suffering from worsening effort intolerance with intermittent fast palpitations. There was no history of syncope. Figure 1 shows her ECG during palpitation.
Her arrhythmia was controlled with IV amiodarone and she was put on low-dose beta-blocker for maintenance therapy. Since then she has had no more fast palpitations, but experienced postural giddiness and worsening exertional shortness of breath. Her pulse rate remained at 40–50 while she was on a minimal dose of betablocker. The beta-blocker was thus stopped for 2 weeks and a treadmill test was performed (Figure 2).
Figure 1: ECG during palpitation.
Figure 2. Treadmill test.
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What is the diagnosis (Figure
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What is the diagnosis (Figure
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This lady suffers from sick sinus syndrome with tachyand brady-arrhythmia. Her tachy-arrhythmia manifests as paroxysmal atrial fibrillation while her brady-arrhythmia manifests as sinus bradycardia with chronotropic incompetence. Sick sinus syndrome sometimes causes a management dilemma as medical treatment is effective against tachy-arrhythmia but not brady-arrhythmia. Effective rate limiting drugs can further aggravate bradycardia while the patient’s sinus node fails to respond to rate demand. This patient has very sick sinus node pacemaker and her exercise capacity was limited by her slow heart rate (chronotropic incompetence). Her heart rate could barely rise to 100/min (65% target, normal >85%) to achieve a maximum workload of 5.8 METS. The patient subsequently received a rate adaptive dual chamber pacemaker. Her beta-blockade was thus increased to suppress her paroxysmal atrial fibrillation with the pacemaker as back-up. Anti-coagulation is indicated if subsequent Holter strips show high atrial fibrillation load (Figure 3).
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A 45-year-old lady with a rash on the ankle
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content of the Dermatology Series is provided by: Dr. CHAN Hau-ngai, Kingsley, Dr. TANG Yuk-ming, William, Dr. CHAN Loi-yuen & Dr. MAK Kam-har Specialists in Dermatology & Venereology 皮膚科病例研究之內容誠蒙陳厚毅醫生、鄧旭明醫生、陳來源醫生及麥錦霞醫生提供。 |
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