COPY of ECG Blog #500 — Can You Solve this CASE?- EXTRA

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NOTE: I started my ECG Blog in 2010 — and this is my 500th ECG Blog case! The reason I saved this case for #500 — is that it is challenging — but in the spirit of the great fictional detective Sherlock Holmes — logical deduction (which is what we often need to apply when solving a complex arrhythmia) allows us to arrive at the most plausible answer. Are YOU up for the challenge?

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The ECG in Figure-1 is from an older patient who reports 2 syncopal episodes, but no chest pain. He is on a ß-blocker and a calcium-channel blocking agent.

QUESTIONS:

• What is the rhythm in Figure-1?
• What is the cause of this rhythm?
• What is the recommended treatment?

• Extra Credit: Can you explain each of the 10 beats?

Figure-1: The initial ECG in today's case — from an older patient with syncope, but no chest pain. (To improve visualization — I've digitized the original ECG using PMcardio).

My Initial Thoughts:

The history — and a 2-second look at this tracing gets us started!

• The patient is "older" — he/she presents with an obviously slow and not completely regular rhythm (overall heart rate under 50/minute) — and he/she is on rate-slowing medication ( = the ß-blocker — and perhaps also verapamil or diltiazem, which are the main rate-slowing calcium blocker medications).
• 
  
• PEARL #1: Given this history — if the very slow heart rate is not the result of rate-slowing medication — and acute ischemia/infarction, hypothyroidism and sleep apnea are not factors — then a component of SSS (Sick Sinus Syndrome) is probably operative (See ECG Video below in the ADDENDUM for review of the features of SSS). 

As to the Rhythm ...

The reason this case is so challenging — is that the P waves are tiny!

Take Another LOOK at the ECG in Figure-1:

• Focus on lead II — because this is the best lead to use when searching for sinus P waves (ie, If we see an upright P wave in lead II with similar P wave morphology in a number of beats — this probably reflects an underlying sinus rhythm).
• Are there any of the 10 beats in this tracing that we know are preceded by upright P waves in this lead II?
• Are there any P waves that we think may be conducting?
• Are there any P waves that we know are not conducting?
• 
  
• PEARL #2: The Sherlock Holmes principle that we apply for complex arrhythmia interpretation is simple: Start with what you know to be true. After this is established — we can work our way toward assessing those aspects of this complex tracing that we are not yet certain about.

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What I Immediately Knew to be True:

Although tiny — I was quickly able in Figure-1 to identify a number of P waves. I have labeled what I quickly saw in Figure-2:

• The last 4 RED arrows in lead II are clearly highlighting sinus P waves (ie, Despite being of extremely low amplitude — all 4 of these P waves are upright and manifest the same P wave morphology).
• The PR interval preceding beats #7,8,9 is decreasing and different for each of these beats. We know the PR interval preceding beat #9 is too short to conduct.
• In addition — it is clear that the last RED arrow P wave in lead II can not be conducting, because it occurs after beat #10.
• Given that the PR interval preceding beats #7 and 8 is different (ie, The PR interval before beat #8 being a little bit shorter than the PR interval before beat #7) — this means that at most — only one of these P waves can be conducting (depending on what the “normal” PR interval for conduction is for this patient).

Armed with the knowledge that today’s ECG ends with 4 fairly regular sinus P waves ( = the last 4 RED arrows) — it seems logical to suspect that underlying sinus P waves may be present throughout this tracing. This puts us to the task of testing this hypothesis, keeping in mind how small sinus P waves are in this tracing.

• KEY Point: There is virtually no artifact on this tracing. As a result — even minor differences in morphology are most probably "real" — and likely to represent hidden atrial activity.
• With this in mind, as we look at the beginning of ECG #1 — it should be clear that the 1st RED arrow in lead II highlights a sinus P wave, albeit with a PR interval too short to conduct.
• 
  
• PEARL #3: Knowing what the P-P interval is from the last 4 RED arrow P waves in lead II — tells us approximately where to look for additional sinus P waves in the beginning of the lead II rhythm strip.
• For this reason — I thought the tiny distortion in the baseline seen immediately after beat #2 in lead II (ie, between the 2 RED arrows right after beat #2) most probably represents the 2nd sinus P wave in this tracing (albeit this P wave is partially hidden within the last part of the QRS complex before it).
• 
  
• PEARL #4: This is where the use of simultaneously-recorded leads is so useful for confirming our suspicion of additional atrial activity. Use of this concept allows me to confirm that the small upright deflection seen right after the QRS of beat #3 in lead II ( = the 3rd RED arrow in this lead) is real — because the vertical BLUE timeline below it highlights comparable small deflections at the same point in the cycle just after beat #3 in simultaneously-recorded leads V4,V5,V6.
• 
  
• An especially subtle distortion then appears near the beginning of the T wave of beat #4 in lead II (ie, between the 2 light BLUE arrows in this lead). Referral to the 2nd vertical BLUE timeline confirms that this subtle distortion of the T wave of beat #4 in lead II is indeed the 4th sinus P wave (because a comparable subtle distortion of the T wave of beat #4 occurs at the same point in lead V4).
• All that remains for us to do at this point — is to confirm where the 5th sinus P wave in lead II occurs (and the vertical RED timeline does this by highlighting a similar T wave distortion at the same point after beat #5 in lead V3).

Figure-2: I have labeled the sinus P waves that we have identified.

Which Beat in Figure-2 Occurs Earlier than Expected?

Now STEP BACK for a moment. Take a look at what we've established in Figure-2?

• We know that the rhythm is supraventricular (because the QRS is narrow in all leads throughout this tracing).
• There is a fairly regular atrial rhythm ( = the colored P waves in the lead II rhythm strip).
• Most of the 10 beats in this rhythm are not sinus-conducted. They can't be — because the PR intervals before beats #1 and #9 are too short to conduct — and the P waves closest to beats #2,3,4,5 and #10 all occur after the QRS. 
• This tells us: i) That there is AV dissociation for at least part of this tracing — because the P waves nearest to beats #1,2,3,4,5 and #9,10 are not related to their neighboring QRS complex; — and, ii) That these 7 beats (#1,2,3,4,5; and #9,10) — are all junctional escape beats occurring at an appropriate junctional escape rate of between 40-50/minute.
• Finally (as we step back a bit from this tracing) — We can see that the ventricular rhythm in Figure-2 is almost regular — with the exception of one beat.

QUESTION:

• Which beat in Figure-2 occurs earlier-than-expected?
• Why does this beat occur early?

ANSWER:

• Beat #6 in lead II clearly occurs earlier-than-expected. 
• 
  
• PEARL #5: When there is an underlying regular (or at least fairly regular) sinus rhythm, such that all sinus P waves are "on time" (as shown by the colored P wave arrows in Figure-2) — the finding of a beat that occurs earlier-than-expected strongly suggests that this beat is conducted. This tells us that beat #6 in Figure-2 is a "capture" beat that is being conducted by the "on time" sinus P wave in front of it!

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Let's Magnify the Lead II Rhythm Strip:

At this point in our analysis — I'm going to magnify the lead II rhythm strip that we have been focusing on, as this will greatly facilitate our observations.

• I have done this in Figure-3 — in which I break up the 10-beat tracing from Figure-2 into 2 parts.

Figure-3: I've magnified the lead II rhythm strip from Figure-2.

Orient yourself to the rhythm in Figure-3:

• RED arrows highlight the underlying sinus bradycardia, with slight sinus arrhythmia.
• As described earlier — beats #1,2,3,4,5 are all junctional escape beats at a rate in the 40s — and, beat #6 represents a sinus-capture beat.
• The rhythm strip ends with 2 additional junctional escape beats ( = beats #9,10).
• This leaves us with beats #7,8 that we have not yet defined.

PEARL #6: If your goal is to confidently interpret complex arrhythmias — then the use of calipers is essential!

• Escape rhythms are usually regular (or at least almost regular). Awareness of this truism holds the key for determining which of the 2 remaining beats (#7 or #8) is sinus-conducted.

I illustrate this concept in Figure-4 — in which I show my measurements of each of the R-R intervals in today's tracing.

• QUESTION: What do these R-R interval measurements tell you about beats #7 and 8?

Figure-4: I've measured R-R intervals from Figure-3.

ANSWER:

• Note that the R-R interval preceding each of the junctional escape beats in Figure-4 is constant at 1480 milliseconds, with the exception of the slight variation (to 1460 msec.) preceding junctional beat #9.
• KEY Point: The R-R interval preceding beat #7 is shorter-than-expected ( = 1430 msec. — instead of 1480 msec.). This tells us that beat #7 is sinus-conducted — whereas beat #8 (which manifests a slightly shorter PR interval) is another junctional escape beat.

I illustrate the above findings schematically in Figure-5 — in which RED arrow P waves indicate sinus-conducted beats.

• YELLOW arrow P waves highlight "on-time" P waves that are not conducting.
• Note in Figure-5 that the PR interval preceding beat #7 is slightly more than 1 large box in duration — which tells us that there is 1st-degree AV block for this one "on-time" sinus P wave that is normally conducted to the ventricles.

Figure-5: RED arrows indicate sinus-conducted beats. YELLOW arrows highlight "on-time" P waves that are not conducting.

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Laddergram Illustration:

For clarity of the above relationships — I add in Figure-6 my proposed laddergrams for today's tracing:

• XXXX

Figure-6: My proposed laddergrams for today's case.

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So the reason that the P-P interval is not as regular as a "normal sinus rhythm" would be — is that we have sinus bradycardia and arrhythmia. Clinically — your patient is on 2 medications (ß-block and verapamil or diltiazem) that may each cause sinus brady and arrhythmia. Since your patient is 70 years old — we need to assess for SSS ( = Sick Sinus Syndrome) — but in order to diagnose SSS — we need to RULE OUT that the brady rhythm is being causes by rate-slowing medications — so we need to see the effect of tapering and stopping these to meds. You can only diagnose SSS after you rule out potentially other "fixable" causes of bradycardia — so rule out recent ischemia/infarction — hypothyroidism — sleep apnea — electrolyte disturbance — and rate-slowing medication. And if this degree of symptomatic bradycardia (Your patient is having syncopal episodes) — then a permanent pacemaker is needed. But it is possible that if you stop ß-blockers and Ca-blockers — that he will resume having a normal heart rate.

Now the "incubation period" for SSS is often very long (up to a decade or more! ) — and your patient might have subtle (preclinical) SSS that is being exacerbated by the drugs. So we would just have to see what happens when the drugs are slowly withdrawn (whether this may or may not be safe to do as an out-patient vs as an in-patient).

So the above is the clinical part of this case. The rhythm is VERY interesting — and a GREAT teaching case! 

To facilitate seeing the P waves — My Figure-5 magnifies leads I and II (the 2 lines here are continuous — as I broke them up to be able to magnify what we are looking at). Once you know where the P waves are — We can measure the preceding R-R intervals — which I have done in milliseconds. We know beats #1,2,3,4,9 and 10 are not conducted — because the P wave does not occur at a point where it can possibly conduct. Note that the R-R interval preceding all of these beats (except beat #9) by the identical preceding R-R interval of 1480 msec. — so this is the R-R interval of junctional escape beats. The R-R preceding beat #9 is close to this (1460 msec.) — and you can have slight variation in the junctional escape rate — but beat #7 is sinus-conducted (as the preceding R-R is less = 1430 msec. and the PR interval is longer than for all other beats except for the PR interval before beat #6.

But in my Figure-7 (which is the laddergram) — We can see that the reason the PR interval preceding beat #6 is longer than the PR interval before beat #7 is that junctional escape beat #5 exerts some degree of retrograde conduction, which delays sinus-conducted beat #6 a little (thereby resulting in a slightly longer PR interval by "concealed" conduction). 

BOTTOM LINE — The this rhythm is marked sinus bradycardia and arrhythmia — with resultant appropriate junctional escape. This is an "escape-capture" rhythm (with beats #6 and 7 being "captured" sinus conduction). And again — given symptoms of syncopal episodes — if discontinuing the ß-blocker and Ca-blocker does not result in normalization of the rate — then the patient will need a pacemaker.

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abdallah sbai sassi <dr.abdallahsbaisassi@gmail.com>

Thanks for your insights regarding this EKG. Of course, you can use it for your blog — it would be my pleasure. My full name is Abdallah Sbai Sassi, from Rabat, Morocco — thank u again for your time.

Non-dihydropyridine (non-DHP) calcium channel blockers, specifically verapamil and diltiazem, are the primary calcium blockers that cause bradycardia by slowing the heart rate. While some dihydropyridine CCBs like amlodipine have been linked to bradycardia in rare cases, they are more often associated with reflex sinus tachycardia because they are more vascular-selective than dihydropyridines.

MY REPLY:

The reason this case is so challenging — is that the P waves are tiny. But if you use all 12 leads (as I show here in my Figure-2) — you can figure out where all of the P waves are (ie, the BLUE vertical lines show that in leads V3,V4 — there are in fact P waves in lead II at this precise moment). So if you look at lead II in this figure — you can see there is a fairly regular atrial rate — except for the early beat #6 (which as you correctly say is a "capture" beat = that is sinus-conducted).

So the reason that the P-P interval is not as regular as a "normal sinus rhythm" would be — is that we have sinus bradycardia and arrhythmia. Clinically — your patient is on 2 medications (ß-block and verapamil or diltiazem) that may each cause sinus brady and arrhythmia. Since your patient is 70 years old — we need to assess for SSS ( = Sick Sinus Syndrome) — but in order to diagnose SSS — we need to RULE OUT that the brady rhythm is being causes by rate-slowing medications — so we need to see the effect of tapering and stopping these to meds. You can only diagnose SSS after you rule out potentially other "fixable" causes of bradycardia — so rule out recent ischemia/infarction — hypothyroidism — sleep apnea — electrolyte disturbance — and rate-slowing medication. And if this degree of symptomatic bradycardia (Your patient is having syncopal episodes) — then a permanent pacemaker is needed. But it is possible that if you stop ß-blockers and Ca-blockers — that he will resume having a normal heart rate.

Now the "incubation period" for SSS is often very long (up to a decade or more! ) — and your patient might have subtle (preclinical) SSS that is being exacerbated by the drugs. So we would just have to see what happens when the drugs are slowly withdrawn (whether this may or may not be safe to do as an out-patient vs as an in-patient).

So the above is the clinical part of this case. The rhythm is VERY interesting — and a GREAT teaching case! 

To facilitate seeing the P waves — My Figure-5 magnifies leads I and II (the 2 lines here are continuous — as I broke them up to be able to magnify what we are looking at). Once you know where the P waves are — We can measure the preceding R-R intervals — which I have done in milliseconds. We know beats #1,2,3,4,9 and 10 are not conducted — because the P wave does not occur at a point where it can possibly conduct. Note that the R-R interval preceding all of these beats (except beat #9) by the identical preceding R-R interval of 1480 msec. — so this is the R-R interval of junctional escape beats. The R-R preceding beat #9 is close to this (1460 msec.) — and you can have slight variation in the junctional escape rate — but beat #7 is sinus-conducted (as the preceding R-R is less = 1430 msec. and the PR interval is longer than for all other beats except for the PR interval before beat #6.

But in my Figure-7 (which is the laddergram) — We can see that the reason the PR interval preceding beat #6 is longer than the PR interval before beat #7 is that junctional escape beat #5 exerts some degree of retrograde conduction, which delays sinus-conducted beat #6 a little (thereby resulting in a slightly longer PR interval by "concealed" conduction). 

BOTTOM LINE — The this rhythm is marked sinus bradycardia and arrhythmia — with resultant appropriate junctional escape. This is an "escape-capture" rhythm (with beats #6 and 7 being "captured" sinus conduction). And again — given symptoms of syncopal episodes — if discontinuing the ß-blocker and Ca-blocker does not result in normalization of the rate — then the patient will need a pacemaker.

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Acknowledgment: My appreciation to Abdallah Sbai Sassi (from Rabat, Morocco) for the case and this tracing.

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Additional Relevant ECG Blog Posts to Today’s Case:

• ECG Blog #185 — Review of the Ps, Qs, 3R Approach for systematic rhythm interpretation.
• ECG Blog #188 — Reviews how to read and draw Laddergrams (with LINKS to more than 100 laddergram cases — many with step-by-step sequential illustration) — See the quick access LINK in the upper Menu on top of every page in this Blog!
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• ECG Blog #256 — Escape-Capture Bigeminy (with junctional escape and "capture" from retrograde conduction — with AUDIO Pearls on "Escape-Capture" and on "Sick Sinus Syndrome" plus Step-by-Step Laddergram).

Other Post with "Escape-Capture" Rhythms: 

• ECG Blog #349 — another example of Escape-Capture with Step-by-Step Laddergrams.

• ECG Blog #163 — Escape-Capture Bigeminy (with sinus bradycardia and resultant junctional escape — and possibly also with SA block).
• ECG Blog #315 — Escape-Capture Bigeminy (from marked sinus bradycardia).
• ECG Blog #144 — Escape-Capture Bigeminy (from 2nd-degree AV block of uncertain severity).

ADDENDUM:

• These 2 ECG Videos cover KEY concepts in today's case:

—  —

ECG Media PEARL #68 (6:15 minutes Audio) — Reviews the meaning of the term, "Escape-Capture" (this being a special form of bigeminal rhythm).

—  —

ECG Media PEARL #69 (2:45 minutes Audio) — Reviews the ECG findings of SSS = Sick Sinus Syndrome (excerpted from the Audio Pearl presented in Blog #252).