Thanks to the medical team for this interesting case:
Currently admitted with a cerebellar CVA.
1.. Hypertrophic Cardiomyopathy (NOT HOCM) – diagnosed following the sudden cardiac death of his 24 year old son – diagnosis on postmortem – moderate left ventricular hypertrophy and no outflow tract obstruction and normal LV systolic function Latest
ECHO June 16: – Satisfactory percutaneous aortic valve function, severe posterior mitral annular calcification normal LV systolic function, moderate left ventricular hypertrophy although septum more severely affected Trivial mitral regurgitation, LA is moderately dilated
You are asked to review him for bradycardia and are given this ECG:
Current obs: BP 120/70, RR 16, Afebrile, HR now improved to 84, sats 97% RA.
- Interpret the ECG.
- What is your differential diagnosis?
- What is your approach to this patient if his BP decreased to 70/50?
- Regular Sinus rhythm, HR 84. Left Axis deviation. Prolonged PR interval. LBBB with no evidence of disconcordance. (New/old?)= Incomplete trifasicular block
Approach to the patient should include assessment for chest pain/ evidence from the history of an MI and comparison with an old ECG.
Clinical implications of an incomplete trifasicular block include progression to a complete heart block. Any patient presenting with syncope + incomplete trifasicular block need to be referred to cardiology as they could be having episodes of complete heart block and need consideration for a pacemaker.
- Anterior MI, Aortic stenosis, IHS, Hypertension, Hyperkalaemia, Digoxin toxicity.
- If the patient developed a syncope/ hypotension they may have developed complete heart block.
Management would include atropine, external pacing and urgent cardiology/icu review for definitive management.
Remember external pacing with the defibrillator is painful and the patient would need some sedation.
In this patient his BP remained stable; he remained in a monitored bed with regular 15 minutes obs. His drug chart was reviewed and a dose of diltiazam had been given 45 minutes previously which was then ceased. This had been given for hypertension post CVA, remembering that an acute stroke is normally followed by protective hypertension which should not be aggressively managed – tolerate up to 210/110.