EXTRA COPY — ECG Blog #537 — What is the Rhythm? — EXTRA COPY

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Figure-1: The initial ECG in today's case — obtained from XXXX. (To improve visualization — I've digitized the original ECG using PMcardio).

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Figure-2: XXXX

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Figure-3: XXXX

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Figure-4: XXXX

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Figure-5: XXXX

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Acknowledgment: My appreciation to Bashiruddin Sayeem  (from Chittagong, Bangladesh) for the case and this tracing.

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THE CASE: Dear sir, this is an EKG of a 60 years old diabetic lady presenting with SOB. Is this LVH with strain, LAHB, RBBB?

MY REPLY:

Hello Bashiruddin — This is AIVR (or "or slow VT") at ~120/minute!

 

The KEY is to look at the long lead II — and RED arrows show 2 places were we KNOW there are 2 consecutive P waves (which are upright in this long lead II, therefore 2 consecutive sinus P waves. Now set your calipers at this P-P interval (between 2 consecutive RED arrows — and the PINK arrows show partial deflections that we SEE, which we KNOW must be underlying "on time" sinus P waves. The WHITE arrows then show you where additional "on time" sinus P waves lie — telling us there is an underlying sinus tach.

 

Thus there is AV dissociation — with beat #17 being a CAPTURE beat — and beats #6,7 and 16 being FUSION beats — all of which proves that the underlying rhythm is an isorhythmic AV dissociation by "usurpation" by an AIVR at 120/minute that is slightly faster than the underlying sinus tach! (The upright R wave in V1 is not "RBBB" — but indication of the ventricular focus!)

 

Note that the QRS IS actually wide (The tracing is slanted — but the WHITE line that I drew parallel to the heavy grid line shows that what looks like "narrow" beats in the long lead II are actually WIDE (because there is an initial small, upright r wave before the deep S waves)

 

Within the dotted BLUE rectangle we see the capture beat — that shows marked LVH with very deep, symmetric (ischemic) T wave inversion in leads V5,V6 — and also in lead aVF. That said, I don't acute ST elevation in the leads in which I am able to assess — so from what I can see, probably no acute STEMI ...

 

Now this 60 yo woman presented with SOB — so the KEY is to find out WHY she is SOB (ie, heart failure, pneumonia) — and then to treat that — and possibly (hopefully) the underlying "slow VT" will resolve!

 

This would be a SUPERB CASE for an ECG Blog! May I have your permission to use this case! I will acknowledge you as I have in the past (See attached). Let me know what happens! BEST — :) Ken

 

Bashiruddin REPLY:

Thank you sir Please feel free to use it in your ECG Blog.