Multifocal atrial tachycardia/hyperkalemia/LVH

This tracing is from 40 yo pt with h/o HTN, DM, CHF and end stage renal disease c/o of pleuritic chest pain and cough. 

 
Figure 1 - ECG case

What is the ECG interpretation?



The tracing shows an irregular narrow complex tachycardia with P waves of different morphologies (multifocal atrial tachycardia), peaked T waves in the precordial leads (esp in V3 and V4)suggestive of hyperkalemia and tall R waves in V6 and deep S in V2 (suggestive of LVH).

Lab investigation showed Hb 10, WBC - 7, PC - 200, Trop -0.2, K 8, Creatinine - 20 and CXR showed cardiomegaly and congestive heart failure worst compared to a prior study.

The case was managed as critical hyperkalemia (K-8.0). Calcium gluconate, NaHCO3, glucose-insulin was given and dialysis was eventually done. The chest pain was thought to be due to non-ischemic in nature (had a recent normal angiogram). The troponin elevation was attributed to the chronic kidney disease. Eventually discharged after a few days.


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