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Cardiac Case: 82-year-old Man with Syncope

by Joseph Alpert, MD

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    00:01 So he presents to the emergency department after this unexpected fainting or syncope episode in the restaurant.

    00:07 He regained consciousness quickly but he felt somewhat dizzy and light headed when sitting up.

    00:12 His physical exam with the EMTs when they arrived, the emergency medical technicians, his blood pressure was 95/45 a very low blood pressure for an 82 year old man and look at his heart rate it’s only 35 per minute that’s very slow.

    00:30 He’s awake, alert, he knows who he is and where he is and so forth but feels a little light-headed and a little dizzy and when he’s brought to the emergency room there’s nothing remarkable about his blood counts or any of his kidney or liver test.

    00:47 So what’s critical in the story here is he has a fainting episode that was unexpected, his blood pressure is quite low, his heart rate is quite low, but fortunately he doesn’t look like he’s had a stroke or anything terrible like that and here’s his electrocardiogram. Please take a look at this.

    01:13 This electrocardiogram shows complete heart block.

    01:17 There’s no relationship between the Ps and the QRSs.

    01:21 See the little normal strip there? PQRST, PQRST, PQRST, down below you have P waves randomly floating through in a very slow heart rate from a ventricular pacemaker that has taken over because there’s no impulse coming from above from the sinus node.

    01:42 The treatment for this of course is going to be a pacemaker.

    01:47 You might think, well, is this atrial fibrillation? No, because we can see the P waves so it’s not atrial fibrillation, it’s complete heart block and it certainly not ventricular tachycardia which would be much faster and it’s not ventricular fibrillation - it is complete heart block.

    02:05 Remember, atrial fibrillation would be very irregular, ventricular tachycardia would be very fast with wide complexes on the QRS complexes and ventricular fibrillation would be chaotic electrical activity, so the only diagnosis that makes sense here is a complete heart block, a failure of the conduction system which is not uncommon in an 82-year-old and the treatment is a permanent pacemaker and he should do fine with a permanent pacemaker that would set him back to having a normal heart rate and a normal heart blood pressure.


    About the Lecture

    The lecture Cardiac Case: 82-year-old Man with Syncope by Joseph Alpert, MD is from the course Cardiovascular Cases.


    Included Quiz Questions

    1. The P waves and the QRS complexes are not rhythmically associated.
    2. There is a progressive lengthening of the PR interval until a beat is skipped.
    3. The PR interval is prolonged.
    4. There is a rapid succession of identical atrial depolarization waves.
    5. There are skipped beats that are not preceded by changes in the PR interval length.
    1. Permanent pacemaker
    2. Holter monitor
    3. Antihypertensive therapy
    4. Defibrillation
    5. No treatment indicated

    Author of lecture Cardiac Case: 82-year-old Man with Syncope

     Joseph Alpert, MD

    Joseph Alpert, MD


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