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Challenges in Clinical Electrocardiography
February 18, 2019

Wide QRS Tachycardia in a Man With a Medical History of Atrial Fibrillation

Author Affiliations
  • 1Internal Medicine, PGY-2, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 2UPMC Heart and Vascular Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 3UPMC Heart and Vascular Institute, Division of Cardiac Electrophysiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
JAMA Intern Med. 2019;179(4):567-569. doi:10.1001/jamainternmed.2018.8603

A man in his 70s with stage 4 chronic kidney disease (CKD) and atrial fibrillation (AF) presented with 1 month of progressive dyspnea on exertion, orthopnea, and worsening lower extremity edema. He previously underwent ablation for AF with symptomatic recurrence 6 weeks prior to presentation. He had been treated with flecainide, 100 mg twice per day, with a recent change to 100 mg 3 times per day dosing. On initial presentation to the emergency department, the patient was alert and oriented. He had a blood pressure of 119/80 mm Hg, heart rate of 101 beats per minute, and pulse oximetry of 98% on room air. His cardiovascular examination was consistent with congestive heart failure. Initial laboratory workup revealed a creatinine level of 2.1 mg/dL (baseline, 1.3 mg/dL; to convert to µmol/L, multiply by 88.4), blood urea nitrogen levels of 45 mg/dL, serum potassium level of 4.7 mmol/L, serum lactate levels of 4.6 mmol/L, troponin levels of 0.06 ng/mL (to convert to µg/L, multiply by 1.0), and brain-type natriuretic peptide levels of 1032 pg/mL (to convert to ng/L, multiply by 1.0). His electrocardiogram (ECG) on initial presentation is shown in Figure 1 and baseline ECG in Figure 2. Transthoracic echocardiogram (TTE) demonstrated new, severe biventricular systolic dysfunction with left ventricular ejection fraction (LVEF) of 15% to 20%. The LVEF was previously 55% to 60% 6 months prior to this presentation.

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    1 Comment for this article
    Wide QRS Tachycardia in a Man With a Medical History of Atrial Fibrillation
    Daniel Sathianathan, MBBS | Private Cardiologist
    Great case highlighting Flecainide-associated toxic effects. Just having a close look at baseline ECG (figure 2) as it looks like it could be sinus rhythm with prolonged PR interval (hence trifascicular block), especially in lead II.
    CONFLICT OF INTEREST: None Reported
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