The initial ECG ( Figure 1A) showed a very wide complex tachycardia (QRS duration of 240 ms) at 115 bpm with group beating due to intermittent failure to capture. Atrial sensed ventricular paced rhythm with intermittent failure to capture. Note, the width of the QRS complex gradually increases such that the last QRS complex before the pause is much wider than the first QRS after the pause. Electrocardiogram shows atrial sensed ventricular paced rhythm with a very wide complex tachycardia (QRS duration of 240 milliseconds) at 115 beats per minute with group beating due to intermittent failure to capture. What is the mechanism of this intermittent failure to capture?Ī: Baseline paced electrocardiogram. Her presenting electrocardiogram (ECG) showed a wide complex rhythm with intermittent loss of ventricular capture ( Figure 1A). Initial laboratory test results were pertinent to acute kidney injury, with serum bicarbonate level of 12 mmol/L (normal range 17–29 mmol/L), blood urea nitrogen level of 63 mg/dL (normal range 8–23 mg/dL), and serum creatinine concentration of 2.5 mg/dL (normal 0.5–1.0 mg/dL). She was started on doxycycline for left foot infection 4 days prior to the admission, which resulted in nausea and multiple episodes of vomiting. Her home medications included candesartan-hydrochlorothiazide (32/12.5 mg daily), flecainide (100 mg twice daily), metoprolol tartrate (25 mg twice daily), and amiodarone (200 mg daily). An 82-year-old Caucasian female patient, who had a history of hypertension, dual-chamber pacer implantation for paroxysmal atrial fibrillation, and sick sinus syndrome 3 years ago, was transferred from an outside hospital for evaluation and management of a wide complex tachycardia at 115 beats per minute (bpm).
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