A man with COPD and frequent ventricular ectopics

A 94 year old man with chonic obstructive pulmonary disease was admitted in hospital because of increasing breathlessness and cough. This was his 3rd admission in 2012 (a period of 8 months) for similar problems. At the time of his admission, his ECG showed sinus rhythm, low voltage complexes in the limb leads and most of the chest leads, frequent ventricular ectopics and ST segment depression and T wave inversion in the chest leads V2 to V6. The ventricular ectopics were no longer present two days after he was treated for his COPD with bronchodilators, glucocorticoids, antibiotics and nasal oxygen. The ST segment depression and the T wave inversion also resolved.

Discussion

What was the reason for his ventricular ectopics and ST segment and T wave changes at presentation?
Myocardial hypoxia secondary to arterial hypoxia must have been the precipitating cause for these ECG changes. It is very likely that he has underlying stable coronary artery disease.

What is the reason for the low voltage complexes in the ECG?
He has hyperinflated lungs. This must be reason for the low voltage ECG complexes.

Should this patient be treated with inhaled glucocorticoids when he is discharged?
Yes. This patient has, by definition, frequent exacerbations of COPD (more than 2 episodes in a year). He should receive long term inhaled glucocorticoids in addition to inhaled long acting beta-agonists and/or long acting anticholinergics.

Is it necessary to prescribe long term oxygen therapy for him?
Long term oxygen therapy (LTOT) is indicated only in those who have direct or indirect evidence of persistent hypoxia - for example, an arterial oxygen partial pressure of less than 56mm Hg (7.3kPa), pulmonary hypertension, cor pulmonale or secondary polycythemia. If these are not present, this patient need not be given LTOT.