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Wolf-Parkinson-White alternans diagnosis unveiled by adenosine stress test
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Journal of Electrocardiology 43 (2010) 144 – 145 www.jecgonline.com
Wolf-Parkinson-White alternans diagnosis unveiled by adenosine stress test Rami N. Khouzam, MD, FACC, FACP, FASNC⁎ Division of Cardiovascular Diseases, Farmington Heart Center, Farmington, NM, USA Received 24 August 2009
Abstract
The case of a 41-year-old woman who presented to her primary care physician with atypical chest pain was reported. An electrocardiogram (ECG) was performed in his office and the patient was told she had left bundle-branch block and an old infarct. The patient was very concerned and referred to cardiology for further evaluation/testing. An ECG at the cardiologist's office was normal. The cardiologist however suspected the ECG performed at the primary care physician office to be preexcitation (Wolf-Parkinson-White). During an adenosine nuclear stress test, intermittent preexcited beats occurred transiently to confirm the diagnosis of Wolf-Parkinson-White. WolfParkinson-White can mimic multiple other ECG changes including a pseudoinfarct pattern and hence be misleading. The figure of the unique ECG, during the adenosine stress test, of intermittent preexcited (preexcitation alternans) complexes is included. © 2010 Elsevier Inc. All rights reserved.
A 41-year-old woman who has hypertension, diabetes, and dyslipidemia presented to her primary care physician with atypical chest pain. An electrocardiogram (ECG) was performed in his office and the patient was told she had left bundle-branch block and an old inferior infarct. The patient was very concerned and referred to cardiology for further evaluation/testing. An ECG at the cardiologist's office was normal. The cardiologist however suspected the ECG performed at the primary care physician's office was preexcitation. A 24-hour Holter monitor showed sinus rhythm and failed to reveal any preexcitation or supraventricular tachycardia. During an adenosine nuclear stress test, intermittent preexcited beats in a bigeminal pattern occurred transiently to confirm the diagnosis of midseptal Wolf-Parkinson-White (WPW) syndrome (Fig. 1). The nuclear images were negative for ischemia, and left ventricular systolic function was normal by gated pictures as well as echocardiogram. The WPW syndrome can mimic different ECG changes including a pseudoinfarct pattern and hence be misleading. Preexcitation alternans is a form of intermittent preexcitation in which a QRS complex manifesting a delta wave alternates with a normal QRS complex. We assume that adenosine inducing an atrioventricular nodal blocking effect helped in unmasking the anomalous pathway causing WPW syndrome.
⁎ 92 Fleet Place, Mineola, NY 11501, USA. E-mail address: [email protected] 0022-0736/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jelectrocard.2009.09.002
In general, adenosine infusion should not be administered in patients with known and confirmed preexcitation because it could potentially induce atrial fibrillation and simultaneously cause atrioventricular block. However, the fact that the effect of adenosine is very short-lived makes it safe to be used even in wide QRS tachycardia of unknown origin. The diagnostic effect of adenosine can be used in sinus rhythm too if latent preexcitation or ventricular parasystole is suspected.1 Administration of adenosine triphosphate during sinus rhythm has been described as possible useful bedside test for identifying patients with concealed accessory pathway who are prone to atrioventricular reenterant tachycardia and those with associated dual AV node pathways.2 Adenosine can cause conduction block in about 20% of nondecremental accessory pathways. Along with atrial activation mapping, adenosine may help differentiate retrograde AV node conduction vs residual accessory pathway conduction after radiofrequency catheter ablation.3 References 1. Tomcsányi J, Tenczer J, Gattyán A, et al. The use of adenosine in the diagnosis and treatment of cardiac arrhythmias. Orv Hetil 1997;138:3037. 2. Belhassen B, Fish R, Viskin S, Glick A, Glikson M, Eldar M. Adenosine5′-triphosphate test for the noninvasive diagnosis of concealed accessory pathway. J Am Coll Cardiol 2000;36:803. 3. Fishberger SB, Saul JP, Triedman JK, Epstein MR, Walsh EP. Use of adenosine-sensitive nondecremental accessory pathways in assessing the results of radiofrequency catheter ablation. Am J Cardiol 1995;75:1278.
R.N. Khouzam / Journal of Electrocardiology 43 (2010) 144–145
145
Fig. 1. Twelve-lead ECG, showing intermittent preexcited QRS complexes with short PR interval and a delta wave in the upslope of the QRS, in a bigeminal pattern (preexcitation alternans).
Journal of Electrocardiology 43 (2010) 144 – 145 www.jecgonline.com
Wolf-Parkinson-White alternans diagnosis unveiled by adenosine stress test Rami N. Khouzam, MD, FACC, FACP, FASNC⁎ Division of Cardiovascular Diseases, Farmington Heart Center, Farmington, NM, USA Received 24 August 2009
Abstract
The case of a 41-year-old woman who presented to her primary care physician with atypical chest pain was reported. An electrocardiogram (ECG) was performed in his office and the patient was told she had left bundle-branch block and an old infarct. The patient was very concerned and referred to cardiology for further evaluation/testing. An ECG at the cardiologist's office was normal. The cardiologist however suspected the ECG performed at the primary care physician office to be preexcitation (Wolf-Parkinson-White). During an adenosine nuclear stress test, intermittent preexcited beats occurred transiently to confirm the diagnosis of Wolf-Parkinson-White. WolfParkinson-White can mimic multiple other ECG changes including a pseudoinfarct pattern and hence be misleading. The figure of the unique ECG, during the adenosine stress test, of intermittent preexcited (preexcitation alternans) complexes is included. © 2010 Elsevier Inc. All rights reserved.
A 41-year-old woman who has hypertension, diabetes, and dyslipidemia presented to her primary care physician with atypical chest pain. An electrocardiogram (ECG) was performed in his office and the patient was told she had left bundle-branch block and an old inferior infarct. The patient was very concerned and referred to cardiology for further evaluation/testing. An ECG at the cardiologist's office was normal. The cardiologist however suspected the ECG performed at the primary care physician's office was preexcitation. A 24-hour Holter monitor showed sinus rhythm and failed to reveal any preexcitation or supraventricular tachycardia. During an adenosine nuclear stress test, intermittent preexcited beats in a bigeminal pattern occurred transiently to confirm the diagnosis of midseptal Wolf-Parkinson-White (WPW) syndrome (Fig. 1). The nuclear images were negative for ischemia, and left ventricular systolic function was normal by gated pictures as well as echocardiogram. The WPW syndrome can mimic different ECG changes including a pseudoinfarct pattern and hence be misleading. Preexcitation alternans is a form of intermittent preexcitation in which a QRS complex manifesting a delta wave alternates with a normal QRS complex. We assume that adenosine inducing an atrioventricular nodal blocking effect helped in unmasking the anomalous pathway causing WPW syndrome.
⁎ 92 Fleet Place, Mineola, NY 11501, USA. E-mail address: [email protected] 0022-0736/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jelectrocard.2009.09.002
In general, adenosine infusion should not be administered in patients with known and confirmed preexcitation because it could potentially induce atrial fibrillation and simultaneously cause atrioventricular block. However, the fact that the effect of adenosine is very short-lived makes it safe to be used even in wide QRS tachycardia of unknown origin. The diagnostic effect of adenosine can be used in sinus rhythm too if latent preexcitation or ventricular parasystole is suspected.1 Administration of adenosine triphosphate during sinus rhythm has been described as possible useful bedside test for identifying patients with concealed accessory pathway who are prone to atrioventricular reenterant tachycardia and those with associated dual AV node pathways.2 Adenosine can cause conduction block in about 20% of nondecremental accessory pathways. Along with atrial activation mapping, adenosine may help differentiate retrograde AV node conduction vs residual accessory pathway conduction after radiofrequency catheter ablation.3 References 1. Tomcsányi J, Tenczer J, Gattyán A, et al. The use of adenosine in the diagnosis and treatment of cardiac arrhythmias. Orv Hetil 1997;138:3037. 2. Belhassen B, Fish R, Viskin S, Glick A, Glikson M, Eldar M. Adenosine5′-triphosphate test for the noninvasive diagnosis of concealed accessory pathway. J Am Coll Cardiol 2000;36:803. 3. Fishberger SB, Saul JP, Triedman JK, Epstein MR, Walsh EP. Use of adenosine-sensitive nondecremental accessory pathways in assessing the results of radiofrequency catheter ablation. Am J Cardiol 1995;75:1278.
R.N. Khouzam / Journal of Electrocardiology 43 (2010) 144–145
145
Fig. 1. Twelve-lead ECG, showing intermittent preexcited QRS complexes with short PR interval and a delta wave in the upslope of the QRS, in a bigeminal pattern (preexcitation alternans).