General Cardiology General Medicine

What is going on here?

A first for me: a clinical quiz.

The patient has had seventy birthdays.

He presents with shortness of breath and constant chest pressure. These symptoms began abruptly 24 hours before presenting.  He describes feeling “dreadful.”

Past history is remarkable for an implanted device 8 years ago.

A thorough physical exam is… you guessed it…normal.

Here is the ECG:

Do you know what the cause of this patient’s symptoms are?

Please feel free to post your answer in the ‘comments’ section. (If you do, it will be more fun.)

No tricks, and it is a real case.

I will post the answer in a day or so.


10 replies on “What is going on here?”

ECG shows sinus rhythm, complete heart block, VOO pacing… symptoms from the Pacemaker Syndrome due to battery death.

Looks like a complete (or third degree) heart block with an escape rhythm originating either below the AV node or more likely coming from the implanted device(note the global wide QRS complexes with P waves differing in frequency from QRS complexes). Looks like the poor fella's being kept alive and systolic only by his implanted device.

It took me a minute to figure it out, but you can enlarge the EKG by clicking on it. That helps.

Ventricular pacemaker seems to be sensing and capturing appropriately.

Subtle PR depression (if you can even call it "PR" in a paced rhythm) in I, II, and V3 suggests acute pericarditis, which would explain the clinical picture, too.

From an old CCU nurse with rusty skills, it looks more like an inferior wall infarction because of the reciprocal changes in I and AVL. Pacemaker spikes are very hard to see so wonder if battery is at the end of life. Complete block is the underlyng rhythm. Wonder why he had a ventricular pacemaker instead of dual chamber, but you didn't tell us he had a ventricular pacer, so maybe he had a dual chamber and it's not capturing appropriately.

ECG shows 3rd degree heart block, ventricular pacing at rate of ~66. The pacemaker is not sensing the atrium – not sure if it is undersensing or more likely a single chamber device.

Unusual rate for the pacer unless it is VVIR or this is an ERI/EOL rate. I don't know many people who program a base rate of 66…

Can think of lots of reasons why he could feel poorly, some bad, others not so bad. Abrupt start 24 hours ago and constant since is strange.

Maybe he had an 801 lead that snapped and stabbed through his atrium – then he could have abrupt pain and loss of atrial pacing/sensing, however, that wouldn't have been put in 8 years ago…

First thing I'd do is interrogate that device to get more info.

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