AF-misdiagnosed? ECG & 2DEchocardiogram

[Carol911]

My mom,71, diagnosed of AF during a recent (5/2009) hospitalization due to HTN medication (methyldopa ) induced cholestasis.  Has history of HTN & on beta-blocker.
No dyspnea  (SOB) & Paroxysmal nocturnal dyspnea.
2DE result: normal LV size & systolic function. No RWMA. LVEF 59%, Normal PASP 26mmHg.  Trivial aortic & tricuspid regurgitation”
Chest AP/sitting results: .. heart size .. appeared to be slightly enlarged.

14 days into the Wafarin treatment, she fell for no obvious reason and hit back of her head.  Warfarin caused major CNS bleed. Took 3 weeks to recover from an almost paralyze situation.

ECG/EKG taken right after the CNS bleed
1. Measurements: all others are in spec.
H Rate= 53 {is the low HR due to BP medications ??}
QRSD = 102
QTc = 455

2. Waves:
sinus rhythm looks regular: PR=176 ( measured : 2.5 mm consistently on all leads).

”Abnormal ECG, unconfirmed diagnosis, sinus rhythm, non-specific T abnormalities, anterior leads” is the only observation mention in her ECG.  I found low-amplitude T waves at VR and inverted T waves (pointing down) at V4, V2, V3.

P waves seem to have low amplitude (about 1mm), duration about & less than 0.12s &  single notch P wave in all leads with the inter-peak duration about 0.04s.  I suspect it is LAE.
No AF symptom.  Heart rate very low & tired easily.

Blood test done at the Cardiologist’s office on 9/15:
Haematology & Biochemistry: all within range or non clinical significant.

Questions:
1. Should I look for evidence in this ECG taken right after the CNS bleed to confirm her AF?
2. Does it looks like that she has AF?
3. I’ve asked her to get another ECG done in a different clinic to verify her AF.  She is back on Wafarin, will Warfarin affect the ECG results?

[Carol911]

Hello,

I updated my post adding more details.  I am still trying to post this question in the Expert Forums, I started from 5 am (PST) & the "Heart Disease" Forum is still not accepting question. Thank you.

The updated post:
My mom,71, diagnosed of AF during a recent (5/2009) hospitalization due to HTN medication (methyldopa) induced cholestasis.  Has history of HTN ,on beta-blocker & various medications (she doesn’t have record of what they are) for HTN.

Hospital’s report:
No dyspnea  (SOB) & Paroxysmal nocturnal dyspnea.
2DE result: normal LV size & systolic function. No RWMA. LVEF 59%, Normal PASP 26mmHg.  Trivial aortic & tricuspid regurgitation”
Chest AP/sitting results: .. heart size .. appeared to be slightly enlarged.

14 days into the Wafarin treatment, she fell for no obvious reason and hit back of her head.  Warfarin caused major CNS bleed. Almost paralyze, took 3 weeks to recover.

Data from ECG/EKG taken right after the CNS bleed while in the hospital:
“H Rate= 53
PR = 176 (I measured it, it is 2.5 mm consistently on all leads).
QRSD = 102  
QT = 484
Qtc = 455  
--AXIS—
P = 28
QRS = 5
T = 39

Sinus rhythm
non-specific T abnormalities, anterior leads
Abnormal ECG, unconfirmed diagnosis,”

My observations: (for reference, I used my 14 yr old son’s normal ECG & http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson1/index.html)

P waves: In all leads except in V2, 4, 5 and all sections in line III, the amplitude is 1mm, duration is 0.12s, with a single notch and the inter-peak duration is about 0.04s. In V2, 4, 5 and all sections in line III, duration is 0.04s or less.

T waves: Inverted (pointing down) in V4, V2 (in V2, T wave is also at the same direction as the QRS), V3 with amplitude of about 1 mm. Low-amplitude (less than 0.5 mm) in all other leads.

S & ST segment: almost undetectable except in V1, 2, 3, 4, & 5.

QRS: Amplitude ranges from 3 mm (II, V5. III, V6, & II - the bottom line) except in aVF, in which all waves forms are almost undetectable. Inverted (pointing down) in lead III.

U waves: undetectable.

My mom has no AF symptom.  She gets tired easily, could it be the HTN medications?

Blood test done at the Cardiologist’s office on 9/15:
Haematology & Biochemistry: all within range or non clinical significant.  TSH (Thyroid) & T4 within limits.

Questions:
1. Is the ECG taken right after the CNS bleed appropriate to use to confirm her AF? If not, why not and what would be appropriate?
2. Upon reviewing my description of the subject ECG, do you believe the ECG demonstrates medical evidence to support the conclusion she has AF?
3. I’ve asked her to get another ECG done in a different clinic to verify her AF.  She is back on Wafarin, and her current HTN medications are: Amlodipine Besylate  (Ca Channel B.), Lisinopril (ACE inhibitors), & Atenolol (BB). Will these medicines affect the ECG results? If so, how would they affect it?
4. Does she have LAE (her father die of enlarged heart related problem at 50+ yr old)?

[grendslori]

I was really curious as to where you were getting your information from. There is nothing that you described that says there was A-Fib or A-Flutter. Both would have registered on the EKG computer readout. The baseline is not normal in either of those problems, it is not a part of the normal P,Q,R,S,T complex. U Waves are very rare. It could be that your mother still has either of those problems and that those arrhythmias were not 'active' at the time the EKG was run. You really cannot compare the EKG of your son as EKGs are different in young people as opposed to full adults. All of your mother's tests appear to be normal except the T-Wave which would be abnormal if the heart is enlarged. It is usally depressed and can be seriously depressed which is known as 'Strain'.In strain, the S wave basically disappears; the R- wave basically drops down into the T-wave. A heart rate in the 50s is not bad; it is alittle slow, however certainly not slow enough to warrent a pacemaker (usually rates of 40- bpm). Heart medicines are probably the cause of her bradycardia. Her Ejection Fraction is perfect. If her echo is normal, I would disregard the enlagement shown on an x-ray; just turning the body a fraction of an inch can make it appear to have an enlarged heart. Why do you think your mother has an enlarged Atrium. Things that cause problems there, would generally origionate from an enlarged left ventricle; something your mother doesn't appear to have.  

[Carol911]

Hi grendslori,

Thank you very much for your comments. It is of most value.

The same doctor diagnosed the AF while she is hospitalized in 5/'09 recruited her into his clinical trial for some new AF drug immediately. We were not provided with any more info on her diagnosis except for the hospital discharged reports (both the 5/'09 & the 8/'09 hospitalization due to Warfarin) in which I based my whole research on.

I spent days learning & analysing my mom's ecg & AF.  I compared my mom's ecg with lots of other references found in the net.  The main one is :
http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson1/index.html
And I am still learning. I appreciate your comments.

I need to correct this in my post:
PR = 176
RR intervals are consistently 2.5 to 2.6 mm on all leads

Regarding Strain:
What do you mean by "R- wave basically drops down into the T-wave"? In her ecg, R wave looks normal (tall) & S & ST segment: almost undetectable except in V1, 2, 3, 4, & 5.

I suspect that the cause of her current bradycardia is caused by Beta Blocker.

She has no AF symptom (I understand some AF patient has no symptom) & no lone AF.  If she has AF "incident", she would have know the racing heart rate, wouldn't she? She told me she does not have such experience.

Per my request, she obtained another ecg from a different Dr. (not a Cardiologist, just a walk-in clinic) yesterday & the Dr. said everything is normal.  I have not seen this ecg report yet.  I had made arrangement for her to see another Cardiologist.  She was hospitalized in 5/'09 due to doctor's error to prescribed her the methyldopa  (the doctor did apologize for this mistake).  I need to be more careful in reviewing her medical findings & hence I need help from all of you.

I can't conclude that she has AF, instead I question if she has LAE or LBBB (LBBB - I am greatful that another forum member alerted me of such on my "AF & Warfarin bleeding problem" post).  

I have another post named "AF & Warfarin bleeding problem" in which I attached her ecg (unfortunately, by mistake, I didn't attache her ecg in this post & I don't know how to fix it).

With your permission, I'd love to email you a pdf file of the detail findings of her ecg in which I based my questions on.

Again, I am thankful.

[grendslori]

Hello Carol. I have to hand it to you for the care and concern that you are sharing with your mother! You are referring to AF; my question is are you saying your mother has Atrial Flutter or Atrial Fibrillation? A lot of people seem to connect the two even though they are somewhat different. I am taking it you are sure this is Atrial Flutter. In Atrial Flutter there is a classic Saw-toothed baseline. Sometimes it's referred to as F waves. Normal P-waves are absent from the baseline, you see flutter waves instead. If you think of two normal complexes in between those two complexes there are what looks like a sawtooth 'bumps' between the two complexes. What should be the P-wave is often times elevated up on the R-wave. The rates of this arrhythmia are generally between 250-350 bpm; in A-Fib the rates are generally over 350. There are a lot of people who have A-Flutter and don't have a clue so it really is possible for a person to not know they are in this type of arrhythmia. If your mother had LBBB, that would have shown up on her EKG.
I can't really explain what I mean by the strain on the T=wave. If you want to try and send me something, go ahead. I will try and help you to understand it more.

[Carol911]

OK, case closed.  My mom got an ECG done 2 days ago in a regular clinic. I finally got a copy of this ECG a few hours ago.  It is a clear case of A Fib : No p wave, hence no PR data.  RR intervals irregular.

[grendslori]

That's good that you have that EKG to look at, Carol, just for future reference, be careful on trying to read EKGs with the way you are doing it. EKGs can be VERY misleading in what they are telling you. My own daughter  (before her transplant) had an EKG that was absolutely classic of WPW which she had had surgically ablated (as in an open heart surgery, not an ablation done in the cath lab). One month after that surgery her classic WPW complex returned; several EP Studies proved she did NOT have WPW. She had a short P-R interval due to the surgery and a wide QRS due to a LBBB and an inverted T wave with strain due to her Hypertrophic Cardiomyopathy. EKGs can be very misleading if the underlying heart has a combination of issues.

[Carol911]

The 2 ECG looks very different.  I think my mom's underlaying heart problem (causes the A Fib) is still showing up in both ECG. Except that the one (first one) taken right after the CNS bleed affected her sinus rhythm (became regular).  The newest one is classic A Fib except that her heart rate is 70 (may be is the beta blocker, Ca-channel, etc. HTN drugs).  So to answer my own questions (based on observations only, no medical explanation):
1. No.
2. 1st ECG may be, 2rd ECG absolutely.
3. I don't think so.

Next step is to find a Cardiologist to evaluate her stroke risk level & the appropriate treatment.  I will ask the Cardio about TEE.

Thanks again grendslori.