ECG Blog #428, 429 (4-16.1-2024)- PUBLISH JUST FOR PRACTICE!

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Acknowledgment: My appreciation to Chun-Hung Chen = 陳俊宏 (from Taichung City, Taiwan) for the case and this tracing.

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Related ECG Blog Posts to Today’s Case:

• ECG Blog #205 — Reviews my Systematic Approach to 12-lead ECG Interpretation.
• ECG Blog #185 — Reviews the Ps, Qs, 3R Approach to Rhythm Interpretation.
• ECG Blog #188 — Reviews how to read and draw Laddergrams (with LINKS to more than 80 laddergram cases — many with step-by-step sequential illustration).
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• ECG Blog #128 and ECG Blog #129 — Review Fusion Beats.
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• ECG Blog #366 — MAT explained.
• ECG Blog #199 — More on MAT.
• ECG Blog #65 — for an example of MAT in a patient with chronic pulmonary disease (plus more on the differential diagnosis of MAT).
• ECG Blog #200 — for an example of Wandering Atrial Pacemaker.

I link to 2 additional illustrative Cases taken from Dr. Smith’s ECG Blog. For each of these posts — Please scroll down to the bottom of the page to see My Comment. These cases provide insight to assessment for MAT:

• The January 5, 2020 post in Dr. Smith’s ECG Blog — for an example of MAT.
• The September 30, 2019 post in Dr. Smith’s ECG Blog — for an example of “MAT”, but without the tachycardia ...

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ADDENDUM (XXX/XX/2024):

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ECG recognition of MAT (3:20 minutes Video).

 

Figure-3: Summary of KEY points related to MAT.

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Chun-Hung Chen, M.D.  — EMAIL (3/20/2024)
Emergency Department,
China Medical University Hospital 
2 Yuh-Der Road,Taichung City Taiwan 40447
Tel:  0975681472
drumbeater1978@gmail.com

 

This patient is 92 years old with a history of arrhythmia and hypertension. The electrocardiogram (ECG) was conducted as a routine examination, and the patient did not report any discomfort at the time. The ECG is as follows:

 

The first 4 QRS complexes are junctional rhythm. Afterwards, there are numerous Premature Atrial Contractions (PACs) and Premature Ventricular Contractions (PVCs). Is this interpretation correct?

MY REPLY:

GREAT CASE — and at some point I'll make an ECG Blog of this! I'll acknowledge you and let you know when I do — but it may be a while, as I have a bunch of others to go before.

 

Beats #1,2,3,4; and 11; and 15,16 are ALL of the same etiology !!! These beats have a QRS that is no more than borderline prolonged — with marked left axis (as seen for beats 1,2,3,4 in leads I,II,III) — and incomplete RBBB morphology (beat #11 in V1 — with wide terminal S wave in V6 for beats #15,16) — so I think these are FASCICULAR beats from the LPH (left posterior hemifascicle) because of their incomplete RBBB/LAHB morphology.

 

GREEN arrows show retrograde P waves from these ventricular beats (#1,2,3,4) — but when these fascicular beats occur later — they are PRECEDED by P waves, and therefore do NOT conduct retrograde.

 

RED arrows show that there IS an "underlying" sinus rhythm — but along the way, in addition to the accelerated fasciular focus (which is ~100/minute — whereas it should only be ~20-50/minute) — there are PACs from multiple ( = BLUE lines showing lots of different P wave morphologies).

 

There is NO single specific classification for this particular rhythm! As I emphasize in Blog #366 — MAT is part of a spectrum. At the other end of the spectrum is sinus rhythm with PACs — and in your case, in this asymptomatic 92yo man — there is also an accelerated fascicular rhythm!

 

Since the patient is 92 and asymptomatic — we do not want to "do too much to him" (because it is "hard to make an asymptomatic patient feel better" !!!!). But it's good to appreciate that this rhythm "behaves" as MAT — which means we should look for simple potentially "fixable" exacerbating factors such as electrolyte imbalance (Check K+ and Mg++ ) — hypoxemia (Check O2 sats) — heart failure, sleep apnea, dehydration, etc. If nothing turns up abnormal — it may be that this 92 yo man has been in this rhythm for YEARS .... and we may then want to leave him alone ..

Please see ECG Blog #366 (https://tinyurl.com/KG-Blog-366 ) that reviews MAT.