1. Intern Case Report
May 29, 2015
Sarah Andry D.O.

2. 30 year old obese male CC: dyspnea HPI:
Started the AM after a night of binge drinking
Typically occurs after drinking
More frequent
“Feels bad” for 2-3 days afterwards
Palpitations, no CP
No PND/orthopnea/swelling/cough

3. Medical hx
Social hx
Unknown
Tobacco- 1ppd x 5 years
Reported hx abnormal EKG
EtOH- binge drinking several times monthly
Drugs- denies
Medications
None
Surgical hx
NKDA
- None
Family hx
MI/CVA
Father- pacemaker/defibrillator in his 40s

4. Vitals Physical exam 128/85 171 20 98.3 100% RA Gen: A&Ox3, NAD
HEENT: NC/AT, EOMI, MMM
Neck: Supple, trachea midline, no JVD
CV: Tachycardic, irregularly irregular, no murmurs
Lungs: Breathing comfortably on RA, no conversational dyspnea, CTAB
Abd: Obese, normoactive bowel sounds, soft, nontender
Ext: Radial, DP, PT pulses +2/4, no edema or cyanosis
Neuro: CNII-XII grossly intact, normal coordination, normal gait

5. Labs
135
4.1 11
1.63 92
102 26
7.9
14.6
219
AST 67
ALT 56
Alk phos 53
Mag 1.99
UDS
(+)THC
(+)cocaine
(+)opiates

9. Adenosine 12mg
Diltiazem gtt 20mg/hr
Lopressor 10mg
Amiodarone 150mg
Diltiazem 10mg

12. Atrioventricular Reciprocating Tachycardia
Reentrant circuit (bypass pathway) + AV node

13. Wolff-Parkinson-White
Preexcitation of accessory pathway that bypasses the AV node
WPW syndrome when EKG changes + symptomatic tachycardia
3.4% with WPW have 1st degree relative with preexcitation syndrome
Autosomal dominant inheritance (PRKAG2 gene, γ2 subunit of AMP- activated protein kinase)
Delta wave
Initial ventricular activation is slurred due to slow muscle fiber-to-muscle fiber conduction
Wider QRS when greater amount myocardium depolarized via accessory pathway causing delay in ventricular contraction

14. Wolff-Parkinson-White with Atrial Fibrillation
Hemodynamically unstable - cardioversion AV nodal blockers contraindicated May increase conduction down accessory pathway
Drug
Mechanism
Verapamil
MOST DANGEROUS; ↑AV node refractory period, ↓myocardial contractility and SVR, reflex ↑ sympathetic tone, ↓ accessory pathway refractoriness - VF
Adenosine
Blocks AV nodal conduction
Beta Blockers
intrinsic antegrade refractory period that was initially competing with the AV node could then become the dominant route for rapid, antegrade conduction
Amiodarone
 has beta blocking properties, may ↑ conduction via the accessory pathway
Digoxin
Vagomimetic; ↑ AV node refractoriness and ↓ concealed retrograde conduction into the accessory pathway

15. Wolff-Parkinson-White with Atrial Fibrillation
Initial treatment is procainamide mg/min Monitor BP q5-10 min until: - termination of arrhythmia - patient becomes hypotensive - QRS lengthens by 50% - total of 17mg/kg has been given

16. Wolff-Parkinson-White with Atrial Fibrillation
- Radiofrequency catheter ablation when accessory pathway + tachyarrhythmia (orthodromic/antidromic AVRT, preexcited afib/aflutter)
- Cryoenergy as an alternative when accessory pathway is close to AV node/bundle of His
Antiarrhythmics: flecainide, propafenone

17. References
DiBiase L. Wolff-Parkinson-White. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
Alguire, P. C., Epstein, P. E., & American College of Physicians. (2006). MKSAP 16: Medical knowledge self-assessment program. Philadelphia, PA: American College of Physicians.
Pappano, Achilles J. Cardiovascular Physiology 10th Ed. Elsevier/Mosby, 2013.
Peter K, Pavel V, Gebauer RA,  Materna O, Janousek J. Electrophysiologic Profile and Results of Invasive Risk Stratification in Asymptomatic Children and Adolescents With the Wolff–Parkinson–White Electrocardiographic Pattern. Circ Arrhythm Electrophysiol. 2014;7: , published online Jan 2014.