ECG Case of the Month: Wide-QRS Rhythm in a Man with a Clotted Dialysis Fistula.

A 57-year-old man with diabetes mellitus, systemic arterial hypertension, and end-stage kidney disease came to the hospital because his arteriovenous fistula used for hemodialysis had clotted. His blood hemoglobin level was 12.8 g/dL (reference, 13.5-17.5); and serum chemistry levels were creatinine 6.7 mg/dL (0.7-1.3), sodium 132 mEq/L (136-146), potassium 4.0 mEq/L (3.5-5.1), chloride 94 mEq/L (98-106), carbon dioxide 24 mEQ/L (23-29), calcium 9.1 mg/dL (8.4-10.2), and phosphorus 9.1 mg/dL (2.7-4.5). An electrocardiogram was recorded (Figure 1).

Clinical case of the month. A 29-year-old man with acute onset blurry vision, weakness, and gait abnormality. Stroke.

A 29-year-old man, with no significant past medical history, was in his usual state of health until the afternoon of admission. The patient was seated at work eating lunch when he suddenly noticed that his vision became blurry. He covered his right eye and had no visual difficulty but noted blurry vision upon covering his left eye. At this point, the patient tried to stand up, but had difficulty walking and noticed he was "falling toward his left." Facial asymmetry when smiling was also appreciated. The patient denied any alteration in mental status, confusion, antecedent or current headaches, aura, chest pains, or shortness of breath. He was not taking any prescribed medications and had no known allergies. The patient denied any prior hospitalization or surgery. He denied use of tobacco, alcohol, or illicit drugs, and worked as a maintenance worker in a hotel. His family history is remarkable for his father who died of pancreatic cancer in his 50s and his mother who died of an unknown heart condition in her late 40s. Vital signs on presentation to the emergency department included temperature of 97.6 degrees F; respiratory rate of 18 per minute; pulse of 68 per minute; blood pressure of 124/84 mmHg; pulse oximetry of 99% on ambient air. His body mass index was 24 and he was complaining of no pain. The patient had no carotid bruits and no significant jugular venous distention. Cardiovascular exam revealed a regular rate and rhythm with no murmurs. Neurological exam revealed left-sided facial weakness, dysarthria, and preserved visual fields. He was able to furrow his brow. Gait deviation to the left was present, and Romberg sign was negative. Deep tendon reflexes were 2+ throughout, and no other focal neurological deficit was present. The patient was admitted to the hospital with a diagnosis of stroke. Electrocardiogram, fasting lipid profile, computed tomography (CT) scan of head, magnetic resonance imaging (MRI) of head and neck, and transthoracic echo with bubble study were ordered. The initial head CT did not reveal bleeding. He was started on aspirin (ASA). On the second hospital day, the symptoms improved with resolution of dysarthria. His ataxia had also improved. Fasting lipid profile revealed mildly elevated low-density lipoprotein and total cholesterol. His head MRI revealed an acute right thalamic stroke. Echocardiography was significant only for a patent foramen ovale (PFO) with transit of agitated saline "bubbles" from right atrium to left heart within three cardiac cycles (Figure). Doppler ultrasound of extremities revealed no evidence of deep venous thrombosis. A complete resolution of symptoms occurred by the third hospital day. The patient was discharged on full dose aspirin and a statin and was referred for consideration of enrollment in a PFO closure versus medical management trial.

Electrocardiograms Recorded After Asystolic Cardiac Arrest.

A man with a history of drug abuse was found down at home and was asystolic. Following restoration of sinus rhythm, a hypothermia protocol brought his temperature to 32.5°C (90.5°F), and large Osborn waves appeared on his electrocardiogram. With rewarming the electrocardiographic signs of hypothermia diminished. Due to hypoxic brain injury during the arrest, the patient remained unresponsive and died on the fourth hospital day.

Type I Second Degree Atrioventricular Block in a Woman With Remote Repair of a Ventricular Septal Defect.

In a 45-year-old woman with syncope, an electrocardiogram revealed intermittent asymptomatic type I second degree atrioventricular block, right bundle branch block and left anterior fascicular block. An echocardiogram documented concentric left ventricular hypertrophy and right ventricular dilatation and hypokinesia. Because the patient did not have second degree atrioventricular block at the time of an electrophysiological study, the atrioventricular node, the left posterior fascicle, and the His bundle all remain potential sites for the type I second degree atrioventricular block on her initial electrocardiogram.

Lower Extremity Paralysis.

Severe hypokalemia in the absence of other electrolyte abnormalities, the result of diarrhea, caused striking electrocardiographic changes, generalized weakness, flaccid paralysis of the lower extremities, and biochemical evidence of mild skeletal and cardiac rhabdomyolysis in a 33-year-old man. Repletion of potassium reversed all abnormalities in 24 hours.

Management of acute ST-segment elevation myocardial infarction. II. Beyond reperfusion.

The last issue of the Journal contains a continuing medical education article on reperfusion therapy in acute ST-segment elevation myocardial infarction (STEMI), and this article completes the sequence by discussing other aspects of the management of acute STEMI.