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iliana-schmidt

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Clinical Teaching Case
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  1. Clinical Teaching Case Anthony Battad MD, FRCPC University of Manitoba

  2. Disclosures • None

  3. The case of Ms. LM • 55 year old aboriginal female: • DM II with variable glucose control • HTN, Dyslipidemia • Femoral artery aneurysm (2003) – no sequelae • Hypothyroidism • Meds: amlodipine, metoprolol, L-thyroxine, glyburide, metformin, pioglitazone

  4. Case… • 8 Aug – presents to Pauingassi Nursing Station with “chest heaviness” • Discharged home without specific treatment • 9 Aug – unprovoked syncope with transient LOC at home • Still has 4/10 chest heaviness • EKG done and faxed to St. Boniface Hospital

  5. EKG – Aug 9

  6. Striking Features? Deep T wave inversion Prolonged QT

  7. Case… • Patient urgently transferred to St. Boniface Hospital ER • In ER, V-fib arrest: 3-4 minutes CPR  restoration of pulse, BP, sinus rhythm • Rhythm strip is not torsade de pointes

  8. EKG – Aug 9 (ER-post arrest) 594 msec Wellen’s sign

  9. Repeat EKG – Aug 10 720 msec Wellen’s sign biphasic

  10. Case… • 10 Aug – cardiac cath: no significant stenoses • 11 Aug – echo: mild LV dilation, EF = 50 – 60% • 12 Aug – cardiac MRI: normal • 12 Aug – CT Head: nil acute • 14 Aug – EP consult • 15 Aug – ICD placed

  11. Case… • 25 Aug – discharged home • Final Diagnosis: Prolonged QT, likely congenital • note normal QT on an EKG 2 years prior • Advise given for EKG screening to family members

  12. Prolonged QT • > 450 msec men • > 470 msec women • > 500 msec “very abnormal” • QTc = QT ÷ √ R-R

  13. Prolonged QT • Congenital • Jervell & Lange-Nielson Syndrome • Romano-Ward Syndrome • Idiopathic • Acquired • Metabolic: hyperkalemia, hypocalcemia, hypomagnesemia, starvation, anorexia • Anti-arrythmics: quinidine, amiodorone, sotalol • Anti-histamines: terfenadine, astemizole • Psychotropics: TCA, haloperidol • Other meds: SSRI, methadone, protease inhibitors, levofloxacin, voriconazole

  14. Top 20 Drugs Sotalol – 4.7% Cisapride Amiodorone – 0.34 % Erythromycin – 0.18 % Ibutilide Terfenadine Quinidine – 0.45 % Clarithromycin Haloperidol – 0.14 % Fluoxetine – 0.03 % Digoxin – 0.1 % Procainamide Terodiline Fluconazole Disopyramide Bepridil Furoseamide – 0.1 % Thioridazine Flecainide Loratidine Dapro (2001), Eur Heart J

  15. Clinical Features • Palpitations • Syncope • Seizures • Sudden cardiac death – Torsade de Pointes  V-fib arrest

  16. Diagnosis • Single ECG not 100 % sensitive • “average” QT • Ambulatory monitoring • Certain features for congenital QT • EP not part of routine testing

  17. Management: ACC/AHA/ECS • Lifestyle modification • Avoid QT prolonging drugs • Avoid strenuous exercise • Beta Blockers (+/-) DDD pacing to reduce QT • Implantable Cardiac Defibrillator (ICD) • Sustained VT and/or syncopal event while on β-blocker therapy