Question 23.1

An 85-year-old male presents to the Emergency Department following a collapse. There was no loss of consciousness. His ECG (ECG 23.1) is shown on page 9.

[it shown here. This page 9.] 

ECG

a)    List the major abnormalities.    (5% marks)

b)    List the likely aetiologies for these abnormalities.    (20% marks)

c)    List the potential cardiac complication is this patient.    (5% marks)
 

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College answer

Not available.

Discussion

The college answer, let alone the ECG image, are not available at the time of writing, making this a hilarious exercise in trying to guess what the examiners were thinking. What condition has "major abnormalities" on ECG, causes octogenarians to collapse without passing out, has several possible aetiological causes and is associated with cardiac complications?

Well, reader, that could be damn near anything. The list could include:

  • Conduction abnormalities, eg. complete heart block
  • Ischaemia
  • Arrhythmias, eg. AF or VT
  • Implantable device malfunction
  • Electrolyte disturbance

It probably would not include inherited channelopathies and weird conduction disorders like WPW syndrome or arrhythmogenic RV cardiomyopathy, because the patient is 85. 

Fortunately, Kate Wagner from Jonathan Begley's study group found the exact ECG 

that was used for this paper, in Wikipedia of all places. It was apparently this Mobitz Type II block. That means this elderly man had a Stokes-Adams attack. Thank you, Wagner et al. If Deranged Physiology had merch, some would have been sent your way.

Thus:

a) Major abnormalities: 

  • RBBB
  • Mobitz Type II AV block
  • Tachycardia (sinus rate is ~ 100)

b) Likely etiologies:

  • Ischaemic heart disease
  • Anterior MI
  • Age-related degenerative change (Lenègre-Lev disease)
  • Cardiac surgery, eg. mitral valve repair

c) Cardiac complications:

  • Sudden P-wave asystole
  • Progression to complete heart block

References