Dr Mervat Aboulmaaty Nabih

Professor of Cardiology
Ain Shams University
 Arrhythmia
How to think about arrhythmias?
• Demographic data (male vs female - age- underlying
structural heart disease)
• Context (precipitating factors) ie how did it start?
• Associated symptoms?
• How did it end? spontaneously or by DC shock?
• Was it witnessed or documented?
• Family history of similar condition or sudden cardiac
death.
 What are the various presentations of arrhythmia?
• palpitation
• syncope
• Fainting
• Cardiac arrest
• Accidentally discovered during ECG recording
• How serious (ass trauma, loss of sphincter control)
it is? and why? (complications)
• What are the main lines of investigation? and what
will they show?
• What are the main lines of treatment?
• What is your role as a general practitioner?
• Could you identify these types of arrhythmia in the
ECG:
sinus tachycardia, complete heart block, VT, VF, AF,
SVT, PVCs, A flutter, WPW syndrome
Case I
A 17 year old male patient complaining of recurrent
palpitations since the age of 12. The last attack was so
severe and was associated with syncope and
convulsions.
His family took him the hospital where an ECG was done
He was given a DC shock and he recovered his
consciousness. What is the most probable diagnosis?
What’s your management plan ?
Case II
A 27 year old medical student while standing in the
crowded section, he dropped to the floor. He was
pale, sweaty and unconscious. He regained his
consciousness immediately and vomited.
In the emergency department an ECG was done
 Tilt table test positive

What is the most probable diagnosis?

Case III
A 10 yo female child was sleeping in bed when she
heard shooting in the street. She screamed and ran in
the house and dropped dead.
A few weeks before this ECG was obtained following a seizure

What is the most probable diagnosis? Does

it impact her family members?
Case IV
A 16 year old child was born deaf mute and received a
cochlear implant. The parents noticed that he had
convulsions and recurrent syncope.
His mother‘s audiogram shows bilateral sensorineural hearing loss
What is the diagnosis? What’s your management plan?
Case V
A 25 year old male patient known to have congenital
heart disease, collapsed while playing Volley ball on
the beach.
ECG was done in the emergency department

What investigation should you order next? What do you

expect it to show?
What‘s the best
management plan?
Case VI
A 65 yo male patient known ischemic heart disease,
had syncope at home and regained his consciousness.
He used to have palpitations and chest pain.
What is the most probable diagnosis?
ECG in the emergency department is shown, DC
cardioversion was performed
An ECG later in the ward is shown, it was similar to
the ECG in the patient‘s records
What do you expect his echo to show ?
Aneurysmal dilation and hypokinesis are seen in the entire apex, distal inferoseptum, and
distal anterior wall (arrows). Other segments are hyperdynamic, EF =32%. Upper right:
Subsequentangiograp hy revealed mid-90% left anterior descending artery lesion (arrow)

What’s your subsequent management plan?

Was this VT ?
Case VII
An 83 yo female patient had recurrent syncope at
home and recovered spontaneously. Her heart rate
was 38 bpm.
What is the most probable diagnosis?
What is the most probable diagnosis? What‘s your long term management plan?
For comparison, this is trifascicular block, but the p waves are PACs not Mobitz II
Case VIII
A 70 year old male hypertensive patient had recurrent
syncope at home following a change to his
antihypertensive medication
What is the most probable diagnosis? What‘s your long term management plan?
Case IX
 A 38 year old woman with a family history of sudden
cardiac death. She complained of recurrent syncope
after exertion, she was otherwise asymptomatic.
What do you expect her echo to show?
Septal thickness 32 mm, resting LVOT gradient 50 mmHg. What‘s
your long term management plan?
Case X
37 year old man presents after a syncopal episode
while taking a shower , now asymptomatic
What does his ECG show? What‘s his long term management plan?
Case XI
67 year old man with a history of chronic atrial
fibrillation presents after a syncopal episode; he
reports a recent change in his medications
What was the possible change to his medications? What should you do
next?
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