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A 55-Year-Old Man With Acute Myocardial Infarction Develops Tachycardia Following Balloon Angioplasty* FREE TO VIEW

E. William Hancock, MD, FCCP
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*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, FCCP. For additional information about the ACCP-SEEK program, phone 1-847-498-1400.

Chest. 1999;116(1):243-244. doi:10.1378/chest.116.1.243
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A 55-year-old man was admitted to the ICU with an acute myocardial infarction. He was managed with immediate cardiac catheterization and balloon angioplasty of a totally occluded right coronary artery, leaving a 30% residual stenosis. The creatine kinase level was 2,200 U/L (17% MB fraction) 6 h after the procedure. At this time, frequent runs of tachycardia begin to occur (Fig 1). The patient is not aware of these, and is free of chest discomfort. Which of the following therapies is most appropriate?

A. Lidocaine

B. Procainamide

C. Digoxin

D. Esmolol

E. Diltiazem

The ECG shows a basic sinus rhythm at 75 beats/min, with a 12-beat run of tachycardia that is slightly irregular at a mean rate of 128 beats/min. The QRS complexes during the tachycardia are not extremely wide, but have a duration of 0.12 s. The initial vector is different from that of the sinus-conducted complexes. The most important point that favors a diagnosis of ventricular tachycardia, however, is that the P waves continue through the tachycardia at a rate of approximately 75 beats/min, with atrioventricular dissociation. In the setting of acute myocardial infarction, a wide-complex tachycardia has a particularly high likelihood of being ventricular tachycardia.

Lidocaine has been widely favored for many years as the drug of choice for treating ventricular tachycardia in patients with acute myocardial infarction. Procainamide is the second choice, and should be used if lidocaine fails. However, lidocaine has the advantage of easy adjustability of the blood level and relative freedom from myocardial depression and proarrhythmic risk. Its most frequent side effect is the precipitation of mental status changes and sometimes seizures, especially in elderly patients. Prophylactic lidocaine, given routinely in acute myocardial infarction even though ventricular tachycardia has not occurred, is not beneficial and it has the added risk of the bradyarrhythmia that it causes.

Digoxin, esmolol, and diltiazem are drugs that might be considered for various types of atrial arrhythmia, including fibrillation, flutter, or multifocal atrial tachycardia. They are not useful in ventricular tachycardia, and would not be considered if the ECG is correctly interpreted.

Akhtar M, Shenasa M, Jasayeri M, et al. Wide QRS complex tachycardia: reappraisal of a common clinical problem. Ann Intern Med 1988; 109:905–912

Berger PB, Ruocco NA, Ryan TJ, et al. Incidence and significance of ventricular tachycardia and fibrillation in the absence of hypotension or heart failure in acute myocardial infarction treated with recombinant-tissue-type plasminogen activator: results from the Thrombolysis in Myocardial Infarction (TIMI) phase II trial. J Am Coll Cardiol 1993; 22:1773–1779

Eldar M, Sievner Z, Goldbourt U, et al. Primary ventricular tachycardia in acute myocardial infarction: clinical characteristics and mortality. Ann Intern Med 1992; 117:31–36

Hine LK, Laird N, Hewitt P, et al. Meta-analytic evidence against prophylactic use of lidocaine in acute myocardial infarction. Arch Intern Med 1989; 149:2694–2698



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