Diagnosis on Sight: “I have a rapid heart rate”

A 31-year-old male presented to the emergency department with palpitations. The patient stated that he thinks his symptoms began “last night” and felt like he had “a rapid heart rate.” He said that prior to last night he felt fine. He did admit to drinking alcohol with his friends 2 nights prior. The patient estimated that he “must have drunk about 30 beers.” On review of systems, he reported feeling anxious. He denied illicit drug use, headache, chest pain, cough, shortness of breath, fevers, nausea, vomiting, abdominal pain, dysuria, or increased urinary frequency. He reported that he was unaware of any family history of early heart disease or sudden death. His initial EKG is shown below. After consultation with cardiology, the decision was made to cardiovert the patient given the wide complex tachycardia.  After cardioversion, the resulting EKG is shown below: On review of previous records, the patient had a recent ED visit 2 months ago with the EKG shown below: What is the diagnosis? Preexcited atrial fibrillation with underlying Wolf-Parkinson-White syndrome Explanation: Wolf-Parkinson-White (WPW) syndrome and the WPW pattern on EKG are rare disorders. Only 0.13 – 0.25% of the population have a WPW pattern on EKG [1,2]. However, only a small fraction of these people will develop WPW syndrome. WPW syndrome is defined as a symptomatic arrhythmia with a WPW pattern on EKG. The patient’s initial EKG showed a wide complex tachycardia that was ultimately determined to be preexcited rapid atrial fibrillation. After cardioversion, the patient’s underlying baseline EKG tracing showed findings of Wolf-Parkinson-White with: A shortened PR interval Widened QRS complex Delta wave: Slurred upstroke of the QRS complex The most common arrhythmias associated with WPW syndrome are: AV Reentrant Tachycardia (AVRT): … Continue reading Diagnosis on Sight: “I have a rapid heart rate”