A 69-year-old woman, with a medical history of myocardial infarction and hypertension, visits the doctor with the following symptoms: fatigue, confusion, chest pain and syncope. These symptoms occur a few times a week. Ambulatory ECG monitoring for two weeks was indicated. During her symptoms the ECG shows the following:
ECG of patient
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Question: Which diagnosis should be considered?Correct
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A. Leemeijer & J. ten Kulve
Atrial fibrillation is not correct. Atrial Fibrillation is characterized by an increased rate of P-tops and as seen on the ECG. Not every P-top is followed by a QRS-complex. In the ECG of our patient, every P-top is followed by a QRS-complex.
Third-degree atrioventricular (AV) block is not correct. An AV block is also referred as a complete heart block, since there is no conduction through the AV node. This illustrative ECG starts with a P-top followed by a QRS-complex. Hereafter it shows a total AV block: several P-tops in a regular rate, but without a QRS-complex following.
Third-degree atrioventricular (AV) block3
Sick sinus syndrome is correct! A sick sinus syndrome (SSS), also known as the bradycardia-tachycardia syndrome, is characterized by a sinus node dysfunction. SSS consists a group of signs or symptoms that indicate the sinus node is not functioning properly. A person with SSS may have a heart rhythm that is too slow, too fast or alternates between the fast and slow rhythm.
- ECG: The rhythm is both tachycardic and bradycardic with a pause during alternation. Besides, every P-top is followed by a QRS-complex!
- Symptoms: Patients present with fatigue, syncope, pain on the chest, palpitations, slower pulse, confusion, disturbed sleep and dyspnoea. Risk factors for a SSS are older age, history of a myocardial infarction, medication for hypertension and heart surgery.
- Therapy: Risk factors are treated and, since the pacemaker cells in the sinus node are ineffective, a pacemaker is recommended to maintain a proper hearth rhythm.
Bradycardia is not correct. Bradycardia is a normal sinus rate, but with a frequency less than 60 bpm. In bradycardia, the rhythm is not altered by faster heart rhythms.
- Jer5150, ECG Guru. What is the cause of the pause. August 2012. Available here, 14 July, 2017
- Clinical Skills Education LCC. EKG Academy. Atrial Dysrhythmias – Atrial Fibrillation. 2016. Available here, 14 July, 2017
- J.S.S.G. de Jong. August 2007. ECGpedia. AV-geleiding. Available here, 14 July, 2017