This ECG was recorded from a 60-year-old woman with rheumatic heart disease. She had been in heart failure, but this had been treated and she was no longer breathless.
What does the ECG show and what question might you ask her?
The ECG shows:
• Atrial fibrillation with a ventricular rate of 60-65/min
• Normal axis
• Normal QRS complexes
• Prominent U wave in lead V2
• Downward-sloping ST segments, best seen in leads V5-V6
Clinical interpretation
The downward-sloping ST segments (the 'reverse tick') indicate that digoxin has been given. The
ventricular rate seems well-controlled. The prominent U waves in lead V2 could indicate hypokalaemia.
Diagnosis
Atriat fibrillation with digoxin effect
What to do
Ask the patient about her appetite: the earliest symptom of digoxin toxicity is appetite loss, followed by nausea and vomiting. If the patient is being treated with diuretics, check the serum potassium level - a low potassium level potentiates the effects of digoxin. If in doubt, the serum digoxin level is easily measured.
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