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Clinical Image: A 69 year-old woman with chest pain and syncope

A 69 year-old woman with chest pain and syncope

[headline_subtitle subtitle=”Can you come up with the proper diagnosis?”]
Presentation

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

Question about chest pain and syncope.

A. Leemeijer & J. ten Kulve

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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.

Atrial fibrillation2

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.

  1. Jer5150, ECG Guru. What is the cause of the pause. August 2012. Available here, 14 July, 2017
  2. Clinical Skills Education LCC. EKG Academy. Atrial Dysrhythmias – Atrial Fibrillation. 2016. Available here, 14 July, 2017
  3. J.S.S.G. de Jong. August 2007. ECGpedia. AV-geleiding. Available here, 14 July, 2017

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