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A 69-year-old gentleman is admitted with pneumonia and COPD exacerbation. The nurse calls you saying the patient has developed tachycardia and active wheezing, and his rhythm is irregular. She is worried and wants you to look at the EKG (Figure 12-1). The nurse shows you the following 12-lead EKG from the patient:

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1. What is your diagnosis and treatment plan?

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Answer

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  1. The EKG shows multifocal atrial tachycardia (MAT). The patient's underlying lung disease must have precipitated MAT. Treating the COPD exacerbation with beta-2-adrenergic agonist inhalation is the treatment of choice. Make sure to correct hypomagnesemia or hypokalemia if present.

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Multifocal Atrial Tachycardia

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Diagnosis

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MAT is an irregular SVT with a heart rate of more than 100 bpm distinguished by at least 3 p-wave morphologies (Figure 12-2). It is often associated with COPD and congestive heart failure. Therapy in patients with MAT should be aimed at treating the underlying disease.

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Figure 12-2.
Graphic Jump Location

MAT with an irregular rhythm and with at least 3 different morphological p-waves and tachycardia.

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Treatment

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Medical therapy for the tachyarrhythmia is indicated only if MAT causes a sustained rapid ventricular response that causes or worsens myocardial ischemia, heart failure, peripheral perfusion, or oxygenation. For patients with symptomatic MAT requiring ventricular rate control, we recommend therapy with verapamil or a beta-blocker.

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Wandering Atrial Pacemaker

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This disorder is similar to MAT in that there are 3 morphologically distinct p-waves but the heart rate is less than 100 bpm (Figure 12-3).

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Figure 12-3.
Graphic Jump Location

Note: Irregular rhythm with 3 morphologically distinct p-waves with a heart rate of less than 100 bpm.

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Atrial Fibrillation

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Diagnosis

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Atrial fibrillation is characterized by the absence of discrete p-waves (Figure 12-4). Rapid atrial activity can be seen as fibrillatory f waves at a rate that is generally between 350 and 600 bpm; the f waves vary in amplitude, morphology, and intervals. The RR interval shows no repetitive pattern, and is thus labeled as “irregularly irregular.” The ventricular rate usually ranges from 90 to 170 bpm.

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Figure 12-4.
Graphic Jump Location

Atrial fibrillation with an irregularly irregular rhythm with no p-waves. Note the fibrillatory or f waves.

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Treatment

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Studies have shown that rhythm control and rate control result in similar mortality and stroke rates, even in ...

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