ECG: Interpolated VPCs & Fusion Beat

1. ECG OF THE WEEK DR.P.VIJAYARAGHAVAN’S UNIT DR.C.R.RAJAKUMAR

2. 65 YRS old male came OPD C/O shortness of breath, palpitation Known DM,SHT on regular treatment O/E Pts GC fair Pulse - 94/min, irregularly irregular BP- 100/70 mmHg CVS - S1S2 Heard ,no murmurs RS - NVBS , no added sounds P/A – Soft, no organomegaly CNS- NFND

3. ; Rate- 100/min Axis lt axis -30 sinus beat interspersed with broad QRS complexes SINUS BEAT; P-wave predominently negative component in V1 PR interval-0.16 seconds QRS duration 0.12 seconds ST depression T –inversion in L1,AVL,V5-V6 Tall R wave in V5-V6[>20mm]

4. BROAD QRS COMPLEXES BROAD ,BIZZARE COMPLEXES[0.16 SECS] Varying morphology RBBB Pattern Constant coupling interval for most of the complexes No compensatory pause Secondary ST-T changes present

5. INFERENCE; LAE [ lt atrial enlargement] LVH [Lt ventricular enlargement] VPC[ventricular pre mature complexes] Possible site of origin [ lt ventricle] Multifocal Interpolated VPC TRIPLETS

6. VPC [ventricular pre mature complexes] Characterized by the pre mature occurance of a QRS complex that is abnormal in shape and has a duration usually exceeding the dominent QRS complex generally >120 milliseconds T wave is commonly large and opposite in direction to the major deflexion of the QRS Fully compensatory pause usually follows a VPC Interval between the P wave of the sinus impulse immediately before the vpc and the first sinus p wave after the vpc equal to twice of the sinus cycle length

7. VPC MAY OCCUR Bigeminy -every sinus beat is followed by a VPC Trigeminy -every 2 sinus beats are followed by a VPC Quatrigeminy -every 3 sinus beats followed by a VPC 2 successive vpcs - COUPLET or PAIR 3 successive vpcs - TRIPLET INTERPOLATED VPC- is an extra systole which is, so to speak ,sandwiched between two conducted sinus beats 3-5 consecutive impulse - SALVOS 3 or more successive vpc s at a rate of 120 or more lasting 30 seconds or more - VT from 6 consecutive ectopic impulses to runs lasting upto 30 seconds - NON SUSTAINED VT

8. VPC with identical contour and coupling –single focus initiated by reentry VPC with identical contour but varying coupling- parasystolic ventricular focus or reentry when there is delay in the reentry pathway VPC with Variable contour but fixed coupling- single focus but transmitted variably through ventricles VPC with variable contour and coupling- more then one focus

9. CLINICAL FEAUTERS; Palpitation , chest discomfort, neck pain, hypotension, heart failure Prevalance of the VPC INCRESED BY Age , male sex, hypokalemia , infection, ischemic or inflamed myocardium, Hypoxia,anasthesia,surgery

10. MANAGEMENT Absence of heart disease – reassurance and avoidance of potentially aggravating factors [ coffee,tobcco,environmental stress or stimulants] -Mild anxiolytic drugs,or beta blockers VPC with slow rate- atropine,isoproterenol,or pacing Vpc with fast rate- slowing heart rate May be treated with IV lidocaine , procainamide , propronolal,iv magnesium

11. Thank you