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Internal Medicine
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Internal Medicine
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Abstract
Introduction: About 200,000 new patients each year are affected by atrial flutter. It is an abnormal cardiac rhythm characterized by rapid regular atrial depolarizations at a rate of approximately 300 beats/minute and a regular ventricle rate of about 150 beats/minute. It can go undiagnosed because it is often asymptomatic and usually diagnosed when patients are being evaluated for other health issues. This case report emphasizes the importance of thorough evaluation of symptoms suggestive of arrhythmia even if they occur intermittently.
Case Presentation: An 81-year-old lady with history of coronary artery disease, status post coronary artery bypass graft, valvular heart disease and a complete left bundle branch block, presented to the emergency department with complaints of palpitations and loose bowel movements. She denied symptoms of chest pain, shortness of breath, dizziness, or abdominal pain. Her physical examination was notable for tachycardia at 125 bpm, a respiratory rate of 30 breaths per minute, and a blood pressure of 91/60 mmHg. Initial laboratory results included an AST of 194 U/L, ALT of 323 U/L, alkaline phosphatase of 184 U/L, BUN of 49 mg/dL, creatinine of 1.51 mg/dL, and a glucose level of 96 mg/dL. Electrolytes were unremarkable, and her complete blood count was normal. Cardiac biomarkers revealed a troponin level of 208 ng/L and a BNP of 1161 pg/mL.
Her EKG revealed sinus tachycardia and complete LBBB with no acute changes. She was admitted with diagnosis of type 2 non-STEMI. Further evaluation revealed an ejection fraction of < 20% on echocardiogram. New EKG was consistent with supraventricular tachycardia and vital signs revealed tachycardia oscillating between 127-140 bpm and blood pressure of 103/62 mmHg.
Initial management with Valsalva maneuvers and metoprolol tartrate were unsuccessful. Subsequently, an intravenous push of adenosine was administered for diagnostic purposes which temporarily resolved the SVT, uncovering an underlying counterclockwise type 1 atrial flutter with 2:1 conduction and an average heart rate of 130 BPM. Given the patient's condition and high shock index, she was transferred to the ICU for a transesophageal echocardiogram and cardioversion. She improved since then, and upon follow-up in two weeks, she was noted as in sinus rhythm.
Discussion: In conclusion, this case report highlights the critical importance of a complete evaluation of patients presenting with symptoms suggestive of arrhythmia, even if intermittent, as it can often be asymptomatic or misdiagnosed. This lady with a complex cardiac history was initially diagnosed with type 2 non-STEMI secondary to sepsis, but further investigation revealed underlying atrial flutter, which was crucial for appropriate management. Prompt and accurate diagnosis followed by targeted therapeutic interventions, such as the use of adenosine and cardioversion, can significantly impact patient prognosis.
Presentation Type
Poster
Recommended Citation
Ortega, Cesar F.; Kondapavuluru, Roy; Asif, Nida; Chaglasian, Johanne; and Bello, Fatimah, "Unmasking Atrial Flutter in an Elderly Patient with Complex Cardiac History: A Case Report on Diagnostic Challenges and Effective Management" (2024). Research Colloquium. 79.
https://scholarworks.utrgv.edu/colloquium/2024/posters/79
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Unmasking Atrial Flutter in an Elderly Patient with Complex Cardiac History: A Case Report on Diagnostic Challenges and Effective Management
Introduction: About 200,000 new patients each year are affected by atrial flutter. It is an abnormal cardiac rhythm characterized by rapid regular atrial depolarizations at a rate of approximately 300 beats/minute and a regular ventricle rate of about 150 beats/minute. It can go undiagnosed because it is often asymptomatic and usually diagnosed when patients are being evaluated for other health issues. This case report emphasizes the importance of thorough evaluation of symptoms suggestive of arrhythmia even if they occur intermittently.
Case Presentation: An 81-year-old lady with history of coronary artery disease, status post coronary artery bypass graft, valvular heart disease and a complete left bundle branch block, presented to the emergency department with complaints of palpitations and loose bowel movements. She denied symptoms of chest pain, shortness of breath, dizziness, or abdominal pain. Her physical examination was notable for tachycardia at 125 bpm, a respiratory rate of 30 breaths per minute, and a blood pressure of 91/60 mmHg. Initial laboratory results included an AST of 194 U/L, ALT of 323 U/L, alkaline phosphatase of 184 U/L, BUN of 49 mg/dL, creatinine of 1.51 mg/dL, and a glucose level of 96 mg/dL. Electrolytes were unremarkable, and her complete blood count was normal. Cardiac biomarkers revealed a troponin level of 208 ng/L and a BNP of 1161 pg/mL.
Her EKG revealed sinus tachycardia and complete LBBB with no acute changes. She was admitted with diagnosis of type 2 non-STEMI. Further evaluation revealed an ejection fraction of < 20% on echocardiogram. New EKG was consistent with supraventricular tachycardia and vital signs revealed tachycardia oscillating between 127-140 bpm and blood pressure of 103/62 mmHg.
Initial management with Valsalva maneuvers and metoprolol tartrate were unsuccessful. Subsequently, an intravenous push of adenosine was administered for diagnostic purposes which temporarily resolved the SVT, uncovering an underlying counterclockwise type 1 atrial flutter with 2:1 conduction and an average heart rate of 130 BPM. Given the patient's condition and high shock index, she was transferred to the ICU for a transesophageal echocardiogram and cardioversion. She improved since then, and upon follow-up in two weeks, she was noted as in sinus rhythm.
Discussion: In conclusion, this case report highlights the critical importance of a complete evaluation of patients presenting with symptoms suggestive of arrhythmia, even if intermittent, as it can often be asymptomatic or misdiagnosed. This lady with a complex cardiac history was initially diagnosed with type 2 non-STEMI secondary to sepsis, but further investigation revealed underlying atrial flutter, which was crucial for appropriate management. Prompt and accurate diagnosis followed by targeted therapeutic interventions, such as the use of adenosine and cardioversion, can significantly impact patient prognosis.