Download irregular pulse in a nine-year old girl

156
IRREGULAR PULSE IN A NINE-YEAR OLD GIRL
MOHAMMED IRFAN QURESHI, MD, MRCPI;
IBRAHIM H. AL-A YED, MRCP (UK), DCH;
ABDULLAH AL-JARALLAH, CABP,MBChE
./
Figure I. ECG of a 9-year old girl with an irregular pulse.
Case history
A 9-year old girl was referred to the pediatric
clinic for evaluation. She was accidentally discovered
to have an irregular and slow pulse. Clinically she
was looking well. Her blood pressure was 101/42.
Her growth parameters were normal. The one-minute
pulse was 40/minute, slow and irregular. All
peripheral pulses were palpable.
From the Departments of Pediatric Emergency and Ambulatory Care Unit
(Drs. Qureshi & AI-Ayed), and Pediatric Cardiology (Dr. AI-Jarallah), King
Khalid University Hospital, Riyadh, Saudi Arabia.
Address reprint requests and correspondence to Dr. Qureshi:
Department of Pediatric Emergency and Ambulatory Unit, King Khalid
University Hospital, P.O. Box 7805, Riyadh 11472, Saudi Arabia.
Hearing was normal.
CVS examination revealed a grade 2/6 systolic
murmur at the apex. Heart sounds were normal.
An ECG was done which is shown above:
Comment on the ECG.
What is the prognosis?
Diagnosis
Congenital Complete Heart block (Third-Degree
A V Block)
Discussion
This is a twelve-lead ECG with a rhythm strip
showing P-waves and QRS complexes having no
-
ECG QUIZ
constant relationship to each other. The QRS
complexes are narrow, suggesting the pacemaker is in
the A V node or high in the His bundle. P-waves are
more frequent than R-waves, the RR interval is fairly
regular and the atrial rate is more than the ventricular
rate. In atrioventricular dissociation, the atrial rate is
slower than the ventricular rate. I Surgically induced
or acquired third-degree heart block usually shows a
wide QRS complex.
Clinical examination may reveal prominent
peripheral pulse as a result of large ventricular stroke
volume and peripheral vasodilatation. Systolic BP is
elevated; jugular venous pulsation occur irregularly
and may be large at times (cannon waves).
Congenital complete heart block may be seen as
an isolated anomaly or may be associated with
structural defects such as L-transposition of the great
arteries. It may be associated with matemallupus
erythematosus.2 Autoimmune disease accounts for
60% to 70% of all congenital heart block and 80% of
cases with a structurally normal heart. 2
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Asymptomatic children with congenital heart block
fall into Class II of the American Heart Association
indications for pacemaker implantation and may not
require pacemaker therapy. However, prospective
studies have shown that those patients with a mean
heart rate of less than 50 beats/m were likely to
develop cardiac complications of sudden death,
episodes of dizziness with or without syncope (StokesAdams attacks) or excessive fatigue. In view of this the
implantation of a permanent cardiac pacemaker is
recommended. 3
The family was advised accordingly and we are
waiting for a decision from them. The child is stable
otherwise and is followed up in the clinic.
References
I.
Park MK, Guntheroth WG. How to read pediatric ECGs.
Mosby Year Book Inc 1992;127-28.
2. Behrman RE, Kliegman RM, Arvin AM. Nelson Textbook
of Pediatrics, 1996. 15th edition: 1342.
3. Kugler JD, Danford DA. Pacemakers in children: an
update. Am Heart J 1989; 117:665-8.