Dr. Jeremy Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada and ARVD.
Lumps and Bumps: Can't-Miss Diagnoses in Syncope
Host: Alex Kaminsky
Guest: Jeremy Berberian, MD
EPISODE OVERVIEW
Residents are well-programmed to recognize cardiovascular emergencies such as STEMIs at a glance. However, during a busy shift it can be easy to overlook dysrhythmias and other electrophysiologic urgencies and emergencies. Syncope is a prime example of a chief complaint that may be uncovered with an EKG alone -- however, syncopal emergencies are often subtle and nuanced. Dr. Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada, ARVD and more.
KEY POINTS
Wolff-Parkinson-White (WPW)
Prevalence: 0.7 to 1.7 per 10000
Overview
Accessory Pathway Connecting the atria to the ventricle. In some instances, this can cause the accessory pathway to travel FASTER than through the AV node.
Courtesy of CardioNetworks: Free use image
Key Features:
Image: Courtesy of EMRA EKG Guide
Most common presentation is SVT. But also can present as atrial fibrillation.
Treatment
Orthodromic (Narrow): Treat like SVT
Key Point: Procainamide is the most safe chemical cardioversion in WPW as it does not directly affect the AV node. Use of AV-nodal blockers in WPW (including Amiodarone) increases the risk of VT/VF.
***Blocking the AV node in a WPW patient in Atrial Fibrillation can precipitate bad ventricular rhythms. If you see A-fib GREATER than 220 minus age -- consider WPW.***
Antidromic (Wide): Treat Like V-Tach
Brugada Syndrome
Prevalence: 5 in 10,000. Traditionally taught more common in Southeast Asian populations.
Overview
Sodium Channelopathy, which can lead to unstable dysrhythmias and ultimately cardiac death
Key Features
Diagnosis is made both by EKG and clinical criteria
Images: Courtesy of EMRA EKG Guide
Type 1:
Type 2:
Clinical Criteria (EKG Findings PLUS one or more):
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD)
Prevalence: Unknown, likely more than we thought. Mean age is 31. Also we don't have great clinical criteria to full encompass this -- yet. Multiple genes linked to disease process. Variable inheritance patterns.
Overview
Fibro-Fatty infiltration of the myocardium that replaces good "conductive" tissue with fibrinous infiltrates. Think: "Kinda like cirrhosis of the heart."
Causes paroxysmal ventricular rhythms. Can present as CHF.
Key Features
Image: Courtesy of EMRA EKG Guide
Key Resources: *If needed and/or different than references*
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