35 year old male presents to the !re station complaining of an irregular heart beat. The patient states that he walked up to the top of the lighthouse earlier in the day and started to feel palpitations.

He is on vacation and has been “drinking a lot” all week. He denies chest pain or shortness of breath although he appears anxious. Past medical history: Healthy Medications: None Allergies: NKDA Vital signs are assessed. RR: 18 HR: 54 (irregular) NIBP: 130/84 SpO2: 99 RA

The cardiac monitor is attached.

A 12 lead ECG is acquired.

Breath sounds are clear bilaterally. The patient is adamant that he does not want to be transported to the hospital. He states that he just wants a printout of the 12 lead ECG to show his private physician. What is your interpretation of this ECG?

How would you explain to this patient the risk of refusing care/transport? Discussion This ECG shows atrial fibrillation and early repolarization. There are notched J-points with upwardly concave ST-segments and prominent T-waves in the inferior leads (II, III, aVF) and the left precordial leads (V4-V6).

Although the atrial fibrillation is concerning, the early repolarization pattern is probably normal for a 35 year old male. Having said that, it would be nice to have an “old” ECG for comparison. It can be scary when there is coincidental T-wave inversion in lead aVL with early repolarization since we often rely on a reciprocal change in lead aVL to rule-in acute inferior STEMI!

This can sometimes happen when the QRS complex is negative in lead aVL and the frontal plane axis is nearly vertical. See another example at Dr. Ken Grauer’s ECG Review #47.

In 1978 Ettinger et al. coined the term “holiday heart” to describe abnormal heart rhythms (typically atrial fibrillation) in otherwise healthy individuals following excessive alcohol consumption. It is usually temporary and resolves within 24 hours.

Atrial Fibrillation is a risk factor for stroke. The risk increases with age, hypertension, diabetes, and underlying cardiovascular disease, including heart failure. This patient’s risk is relatively low, but the issue should be brought to the patient’s attention. As Stephen Smith, M.D. points out in the comments, Holiday Heart Syndrome typically has a rapid ventricular response. It is possible this patient has AV nodal disease unless we can attribute the slow ventricular response to good health and increased vagal tone. In this case paramedics contacted online medical control, the risks of refusing care were discussed with the patient, and he signed a refusal against medical advice.

References Ettinger P, Wu C, De La Cruz C, Weisse A, Ahmed S, Regan T. Arrhythmias and the “Holiday Heart”: alcohol-associated cardiac rhythm disorders. Am. Heart J. 1978;95(5):555–62. doi:10.1016/0002- 8703(78)90296-X.

Wolf P, Abbott R, Kannel W. Atrial !brillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983-988. doi:10.1161/01.str.22.8.983. EMS 12-Lead Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation JEMS Talk: Google Hangout EMS Today 201