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The ECG reveals atrial flutter with a nonspecific T-wave abnormality. The atrial rate is 300 beats/min. The ventricular rate is 84 beats/min; hence the atrial flutter occurs in a 4:1 pattern. (This is best seen in lead V1, where one of the atrial beats is “hidden” in the QRS complex.) The PR interval of 208 ms on the computerized analysis is misleading and illustrates the risk of relying on the computer for a diagnosis. The nonspecific T-wave abnormalities are best seen in leads V2 and V3 and are of no consequence.
While there are no definitive studies that prove that combining energy drinks containing taurine with beverages containing caffeine increases the risk for arrhythmias, there are several anecdotal case reports. In addition to consumption of taurine- and caffeine-containing beverages, this patient is under a significant amount of stress, producing a large catecholaminergic response.
The patient has no prior cardiac history of arrhythmias and no prior cardiac workup. He underwent synchronized cardioversion to restore normal sinus rhythm and was scheduled for an outpatient workup for structural heart disease.
ANSWER
The ECG reveals atrial flutter with a nonspecific T-wave abnormality. The atrial rate is 300 beats/min. The ventricular rate is 84 beats/min; hence the atrial flutter occurs in a 4:1 pattern. (This is best seen in lead V1, where one of the atrial beats is “hidden” in the QRS complex.) The PR interval of 208 ms on the computerized analysis is misleading and illustrates the risk of relying on the computer for a diagnosis. The nonspecific T-wave abnormalities are best seen in leads V2 and V3 and are of no consequence.
While there are no definitive studies that prove that combining energy drinks containing taurine with beverages containing caffeine increases the risk for arrhythmias, there are several anecdotal case reports. In addition to consumption of taurine- and caffeine-containing beverages, this patient is under a significant amount of stress, producing a large catecholaminergic response.
The patient has no prior cardiac history of arrhythmias and no prior cardiac workup. He underwent synchronized cardioversion to restore normal sinus rhythm and was scheduled for an outpatient workup for structural heart disease.
ANSWER
The ECG reveals atrial flutter with a nonspecific T-wave abnormality. The atrial rate is 300 beats/min. The ventricular rate is 84 beats/min; hence the atrial flutter occurs in a 4:1 pattern. (This is best seen in lead V1, where one of the atrial beats is “hidden” in the QRS complex.) The PR interval of 208 ms on the computerized analysis is misleading and illustrates the risk of relying on the computer for a diagnosis. The nonspecific T-wave abnormalities are best seen in leads V2 and V3 and are of no consequence.
While there are no definitive studies that prove that combining energy drinks containing taurine with beverages containing caffeine increases the risk for arrhythmias, there are several anecdotal case reports. In addition to consumption of taurine- and caffeine-containing beverages, this patient is under a significant amount of stress, producing a large catecholaminergic response.
The patient has no prior cardiac history of arrhythmias and no prior cardiac workup. He underwent synchronized cardioversion to restore normal sinus rhythm and was scheduled for an outpatient workup for structural heart disease.
A business professional, age 39, presents with shortness of breath that abruptly began two hours ago. He states he has been under a significant amount of stress at work during the past six months. He is approaching a deadline on a very important contract, which he says will “make or break” his career. As a result, he has been working long hours and often consumes eight to 10 cups of coffee as well as three to five energy drinks per day. After getting only three hours of sleep last night, he had two cups of coffee with a “two–energy-drink chaser.” About one hour after his last energy drink, he felt several palpitations and abruptly became short of breath. There is no history of pulmonary or cardiac illness. The patient’s medical history is unremarkable, with the exception of childhood cases of chickenpox and mumps. He has never had a surgical procedure. He takes ibuprofen on occasion after playing sports and has no known drug allergies. During college, he smoked one pack of cigarettes per day, ceasing at graduation. In response to work-related stress, he has started smoking again and is up to half a pack per day. His alcohol consumption consists of two cocktails in the evening and a 12-pack of beer on the weekends. He denies illicit drug use. The review of systems is remarkable for heartburn, bloating, and frequent indigestion. He denies nausea, vomiting, diarrhea, or constipation. The physical examination reveals a well-developed, anxious male in mild distress. His weight is 174 lb and his height is 74 in. Vital signs include a blood pressure of 90/58 mm Hg; pulse, 88 beats/min; respiratory rate, 18 breaths/min; and temperature, 98°F. His O2 saturation is 99% on room air. The HEENT exam is normal. There is no thyromegaly. The mucous membranes are pink and moist. The chest is clear to auscultation in all lung fields with excellent diaphragmatic excursion. The pulse is regular. There are no murmurs, rubs, clicks, or extra heart sounds. The abdomen is soft and nontender. The liver and spleen are not palpable. The pulses are equal and strong bilaterally. The neurologic exam is unremarkable. A chest x-ray, blood chemistry, complete blood count, and electrocardiogram are ordered. You are handed an ECG tracing that reveals the following: a ventricular rate of 84 beats/min; PR interval, 208 ms; QRS duration, 102 ms; QT/QTc interval, 358/423 ms; R axis, 20°; and T axis, 29°. What is your interpretation of this ECG?
