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Clinical Opal - Makoa presents with palpitations & dizziness

22 January 2024 - Grace Larson

Makoa is a 67 year old male who has come in for review as he has been experiencing some dizziness, fatigue and palpitations. 

He is treated for hyperlipidaemia and hypertension that was diagnosed 5 years ago and is on Atorvastatin 10 mg and Lisinopril 10 mg. 

His blood pressure is currently 124/80 and heart rate 128 and irregular. His lungs are clear, and other physical examinations are non- concerning. 

He denies fatigue, chest pain, palpitations or shortness of breath and continues to work as a bus driver. 

Makoa has an ECG performed.

https://en.wikipedia.org/wiki/Atrial_fibrillation#/media/File:ECG_Atrial_Fibrillation.jpg

 

Question

What are the key features seen in Makoa’s ECG and your interpretation based on Rate, Regularity, Waves & Complexes, Intervals & Segments?

Interpretation

Rate -  132

Regularity - Irregulary

Waves & Complexes - P waves absent/fibrillatory, QRS complex present and normal, T waves present and normal

Intervals - PR interval absent, ST segment normal, QT interval normal

Interpretation - Rapid Atrial Fibrillation (AF)

Causes and Risk Factors

AF occurs when action potentials fire rapidly within the pulmonary veins or atrium and cause a fast atrial rate of 400-600 beats per minute. P waves are difficult to spot due to the fast rate and low amplitude, but can on occasion be seen. The AV node becomes intermittently refractory so wont let all the action potentials be conducted through to the ventricles, hence the different ventricular rate. Key causes include hypertension, coronary artery disease, heart failure, valve diseases, thyroid disorders, and chronic lung diseases. Lifestyle factors such as obesity, alcohol consumption, and smoking can elevate the risk of AF.

Complications

AF is a common recurrent arrhythmia in adults and is independently associated with stroke, heart failure and all cause death. It can present without symptoms in some individuals with 10% of ischemic strokes associated with an unknown diagnosis of AF. 

Management and Treatment

Treatment focuses on rate control, rhythm control, and stoke prevention. Beta-blockers and calcium channel blockers are commonly used for rate control. Antiarrhythmic drugs or cardioversion may be employed for rhythm control. Anticoagulation is crucial for stroke prevention, especially in patients with elevated stroke risk (assessed by CHA2DS2-VASc score https://www.mdcalc.com/calc/801/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk).

Management for patients like Makoa should include lifestyle modifications alongside pharmacological interventions. Regular follow-up and coordination with cardiologists are key for optimal patient outcomes.

Related Courses

Further Reading

Non-adherence to thromboprophylaxis prescribing in general practice – the views of GPs

References

https://www1.racgp.org.au/ajgp/2019/october/atrial-fibrillation

https://www.racgp.org.au/getattachment/58b7d6f1-80a2-41fa-ab1c-26d44832555d/200707kistler2.pdf

https://www.nps.org.au/australian-prescriber/articles/atrial-fibrillation-an-update-on-management

 

Grace Larson
Grace Larson

Grace Larson, RN, BN, CertIV(TAE), GradDipClinNurs(PaedCritCare), MAdNursPrac(PaedCritCare), has extensive experience in paediatric nursing, with 13 years in Paediatric Intensive Care Units (PICU). She’s published journal articles in the specialty area of pain and sedation in PICU, and has presented at national and international conferences on the area of pain and sedation in paediatrics. Grace has previously worked with the ACCCN delivering Paediatric Advanced Life Support in Victoria, bringing a wealth of experience into her clinical teaching on paediatric resuscitation. She has also consulted with NSW Health on quality and safety delivering within PICU, and has been contracted with the ANMF to develop nursing programs for nurses who require additional education as part of their practice requirements.

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