Case Report: A 65-Year Old Man with Ventricular Tachycardia with Some Pattern Similar to Supraventricular Tachycardia and The Management
Author : H. Oktaviani, M. Hatta
Upload Date : 19-04-2018
Background: Ventricular Tachycardia (VT) is one of the life-threatening arrhythmias. In some cases, VT is encountered with similar pattern to Supraventricular Tachycardia (SVT). A careful analysis of the electrocardiogram (ECG) is necessary to distinguish between the two patterns, because the management and prognosis are very different between the two.
Case: A 65-year-old man presented to the cardiology clinic with palpitations, dizziness, nausea, and diaphoresis since earlier that morning. The patient already had dyspnea since a week before. He had history of cardiomegaly with hypertensive heart disease, and smoking. Family history of heart disease is unknown. In physical examination, we found extra strong pulse, 166 bpm, regular rhythm with normal blood pressure, and rhonchi in basal lungs. Electrocardiogram was performed (Fig. 1). At first glance, the pattern resembles SVT with aberrancy, but more careful examination of the pattern showed features of VT. Cardiac enzymes were at normal levels. The patient is then diagnosed as VT and admitted to the ICU.
Result: Amiodarone was administered, with the initial dose of 150mg in dextrose 10% intravenously over 20 minutes. The second dose of amiodarone was 300mg over 6 hours, and the third dose 600mg over 18 hours. After 24 hours the symptomes disappeared. Upon evaluation on the second day, ECG showed sinus rhythm with old myocard infarct patterns (Fig. 2). The patient’s complaints disappeared; he was moved to the ward after three days and discharged after seven days.
Discussion: VT is one of the life-threatening regular arrhythmias with accelerated heart rate, wide QRS complexes and some patterns of morphology that arises from improper electrical activity in the ventricles. SVT typically has narrow QRS complexes, but occasionally SVT is found with wide QRS complex due to aberrant conduction. In some cases, VT is encountered with features that may be similar to SVT with abberancy. However, there are several criterias from the ECG that directs to the diagnosis of VT (Fig 3), which are: AV dissociation, Capture/Fusion beat, Positive/Negative Concordance, Taller Left Rabbit Ear, Brugada’s/Josephson’s sign. Factors that further increase the likelihood of VT are: the patient is >35 years old, has history of ischemic heart disease and congestive heart failure. Therefore, the patient is diagnosed as and managed as VT, with SVT aberrancy as the differential diagnosis. After administration of amiodarone, the ECG pattern was that of old myocard infarct. The patient was also given furosemide, clopidogrel and fondaparinux. Clinically, the patient’s complaints receded and he was discharged after seven days.
Conclusion: Wide QRS complexes should be presumed to be VT until proven otherwise. More understanding and careful examination about the ECG criteria of VT is required to differentiate from SVT with aberrancy. When in doubt, provide VT management until proven otherwise.
KEYWORDS : Ventricular tachycardia, SVT with aberrancy, infarct myocardium
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