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| Figure-1: The initial ECG in today's case. (To improve visualization — I've digitized the original ECG using PMcardio). |
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Sheikh mohsin55er@gmail.com — 9/5/2026 via E-mail
— “More than one Family?” —
— Make this ANONYMOUS (Let Sheikh know by email when published! )
Thanks for your quick response. The patient had a serum K+ of 7.0 at the time of this ecg recording. I would love if you do an ecg blog on this and you have my full permission to do so. You can post it as anonymous without mentioning my name
THE CASE:
HyperK with bizarre rhythm:
Thanks’’
MY REPLY:
HI Sheikh. This is very interesting indeed. First — Was this ECG done while the patient was hyperkalemic? If so — do you know how high the serum K+ was at this time?
KEY POINT — All bets are off when you have an arrhythmia with HyperK+ — because patients “do not obey the rules” when there is HyperK — and much (most) of the time — a normal rhythm resumes once HyperK is corrected (as happened in your case!
I spent some time working on this — and from the “pretty” picture I am sending you — You might guess that I’d love to do an ECG Blog of this case. May I have your permission to do so?
I like to acknowledge colleagues who send me tracings. I’m happy to put in your name and the city and country from where you are from — OR — if you prefer, the case can be anonymous. Just let me know. If you want me to put your name — tell me how to write it (and also send me the city and country from where you are from).
There is more than 1 possible solution to this — but the simplest answer to what is going on is if there are dual AV nodal pathways. One of the pathways has faster conduction (a shorter PR interval) which I drew in PINK.
The other pathway is slower = GRAY.
In addition to dual AV nodal pathways, there is significant AV block! This may be 4:1 AV block. So you can see from the laddergram how I propose that conduction switches back and forth from one conduction pathway to the other.
We KNOW there IS conduction — because we have repetitive PR intervals. And the BEST clue to the presence of dual AV nodal pathways is when there is a big “jump” in PR interval from one beat to the next.
Again — this is clearly a result of the HyperK — with the proof of that being how normal sinus rhythm resumed after HyperK resolved.
I hope the above makes sense! Let me know if I can write this up as an ECG Blog!
THANKS — Ken
P.S. I’ve included this article on dual AV nodal physiiology — including Table-1 from this article which highlights the need to think of this when you see “2 families” of PR intervals! — :)
P.P.S. I initially thought this was dual-LEVEL AV block out of the AV node — but this does not make a “pretty” laddergram. Still could be both dual AV nodal pathways AND dual-level AV block — but that makes for a much more complicated laddergram !!!!
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