Intended for healthcare professionals

Endgames Picture Quiz

ECG leads to a quick diagnosis

BMJ 2008; 337 doi: (Published 10 September 2008) Cite this as: BMJ 2008;337:a1030
  1. J Bhar-Amato, specialist registrar in cardiology
  1. 1Manchester Royal Infirmary
  1. jb.amato{at}

    A 19 year old man presented to the emergency department with a two hour history of palpitations and chest discomfort. He had no important medical history and took diphenhydramine occasionally for hay fever. He denied smoking, drinking alcohol excessively, and using drugs. On examination he seemed breathless, his pulse was irregular at 140 beats per minute and his blood pressure was 145/60. On further examination of his cardiovascular, respiratory, and abdominal systems no abnormality was detected.

    His 12 lead electrocardiogram is shown in the top half of figure 1.

    The next day this patient was reviewed on the post take ward round on the coronary care unit. His 12 lead electrocardiogram is shown in the lower half of figure 1.

    Figure 1


    • 1. What do the electrocardiograms show?

    • 2. How would you treat this patient in the short term?

    • 3. What long term treatment would you offer?


    Short answers

    • 1. Pre-excited atrial fibrillation.

    • 2. Intravenous flecainide is preferable, and the drug most often used for this purpose in the United Kingdom. Other options include intravenous sotalol, amiodarone, procainamide, or ibutilide. If at any time the patient becomes haemodynamically unstable, electrical cardioversion should be performed immediately.

    • 3. Referral to a cardiologist for accessory pathway ablation in Wolff-Parkinson-White syndrome. Oral drugs like flecainide, sotalol, amiodarone, procainamide, and disopyramide are available, but should be given at the discretion of the specialist.

    Long answers

    1. What the electrocardiogram shows

    The electrocardiogram in the top half of figure 1 shows an irregular rhythm with QRS complexes of varying morphology. Some complexes are narrow and others are broad with a slurred upstroke (the “delta wave,” best seen in the lateral leads in figure …

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