Cardioversion Conundrum

Author: Paul Watson / Editor: Jason M Kendall / Reviewer: Nadarajah Prasanna, Phil Delbridge / Codes: A1, CC1 / Published: 16/11/2023

A 48-year-old gentleman presents at 3am to the emergency department (ED) having woken at 2am with palpitations. He has known intermittent arrhythmias, with 6 episodes over the last 2 years. His last attendance was 1 month ago. He underwent electrophysiology at that time, and has been booked for ablation therapy in 3 days time. In preparation for this, his usual bisoprolol was stopped 4 days ago, as he must be free of any anti-arrhythmics for one week prior to the procedure.

On previous occasions attempts at cardioversion with adenosine have been unsuccessful; treatment with verapamil and electrical cardioversion have both been successful.

He has mild chest pain (3/10 severity), and is warm and sweaty. He had no dyspnoea or nausea.

He has no other previous medical history, and apart from his bisoprolol, has no other medications. He is a non-smoker.

His heart rate is 180 with a BP of 127/85.

He is keen to stress that he does not want any attempt at chemical cardioversion, as he does not want to jeopardise his forthcoming ablation therapy.

A nurse presents you with the following ECG:

Cardioversion Conundrum

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