A patient in their 50s presented to the emergency department with sudden-onset, severe palpitations lasting for 2 hours. The patient experienced similar prior episodes that had terminated within minutes, either spontaneously or with deep breathing. On physical examination, the patient was in mild distress. Their blood pressure was 108/78 beats per minute (bpm) and their heart rate was 188 bpm. The 12-lead electrocardiogram (ECG) is shown in the Figure (A).
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Questions: Is there enough information in this ECG to make a definitive diagnosis? If so, what is the diagnosis?
The ECG showed a narrow complex tachycardia at 188 bpm with retrograde P waves best seen in the lead II rhythm strip. The time from the QRS to the P wave is longer than that from the P wave to the QRS, making this a long RP tachycardia. The differential diagnosis of a regular, narrow complex, long RP tachycardia includes the atypical form of atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and atrial tachycardia (AT).
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Corresponding Author: Tharian S. Cherian, MD, 320 E North Ave, Pittsburgh, PA 15212 (email@example.com).
Published Online: August 7, 2023. doi:10.1001/jamainternmed.2023.2250
Conflict of Interest Disclosures: Dr Silverstein reported personal fees from Medtronic, Biosense Webster, Volta, and Impulse Dynamics outside the submitted work. No other disclosures were reported.
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