EXTRA COPY — ECG Blog #550 - Guess the Clinical Setting — EXTRA COPY

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

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

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Acknowledgment: My appreciation to Ali Ibrahim Almfriji (from Tikrit, Iraq) for allowing me to use this case and these tracings. 

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Ali ibrahim Almfriji, Interventional cardiologist Tikrit- Iraq (9/16/2026- FB Messenger!)

I need to let Ali know if I publish this! FB Messenger!

“Guess the Clinical Setting!”

 

THE CASE:

Good day dear prof. Ken. 49 male heavy smoker, no HTN, no DM, presented to my cardiac centre (tikrit.iraq) with 8 hours anterior STEMI, LAD totally occluded proximally , primary pci was done with TIMI III flow achieved, this is attached EKG 3 hours after procedure Rhythm analysis please

MY REPLY:

Hi. Interesting tracing! RED arrows are sinus P waves. We do not have a long lead rhythm strip — but the chest leads are the continuation of the limb leads (such that there are a total of 9 beats on this tracing). Beats #8 and 9 are sinus conducted! (RED arrows with a constant and normal PR interval). The PR interval before beat #7 is too short to conduct — so this is an escape beat. There are NO P waves seen before beat #7 — but the YELLOW arrows probably reflect P waves hidden within the QRS. Note that there is NO notching seen within the QRS of beat #1 ==> so the P wave is probably completely hidden within the QRS of beat #1. Putting this all together — Beats #1-thru-6 are ventricular at a rate between 55-60 ==> AIVR (Accelerated IdioVentricular Rhythm). After beat #6 — the SA node begins to wake up and it finally achieves a rate faster than the ventricular escape rate — which is why beats #8 and 9 are sinus-conducted. Beat #7 is a FUSION beat (the PR interval is too short to completely conduct). Note that the QRS is a little smaller than beats #5 and 6 which are ventricular — and a little larger than sinus-conducted beats #8 and 9. AIVR is VERY COMMON as a reperfusion arrhythmia — so that fact that this patient had acute LAD occlusion but was reperfused with PCI means that the expected situation for developing AIVR was present. IF the patient is hemodynamically stable and asymptomatic — then NO treatment is needed! This rhythm is almost always transient (lasting hours to a day or so after reperfusion). If the patient is symptomatic — giving some Atropine may help by speeding up the sinus node. Finally — the ST-T waves in some leads (like leads I and aVL) are abnormal — probably as a result from the recent MI. If you could give me a bit more follow-up on this case — I might want to use it as an ECG Blog (if I could have your permission for this?). I hope the above is helpful — 

 

ALI REPLY: 

This is second day post pci EKG and echo study.

Nice explanation, the patient really developed continuous AIVR immediately after reperfusion on cath lab table, and was stable hemodynamically.

Im pleased if this case used as ECG blog and to mention my name dr. Ali ibrahim Almfriji , Interventional cardiologist Tikrit- Iraq.

 

MY REPLY

Thanks so much for the follow-up! I do plan to write up this case. I’ll focus on the 1sttECG — but will probably also show the 2nd tracing. This 2nd ECG shows loss of R waves in the chest leads with some residual chest lead ST elevation. There is T wave inversion in the limb leads, consistent with “reperfusion T waves”. There is also low voltage (which may be a reflection of the extensive anterior infarction. It may be a little while before I publish this case — but I will let you know when I do. THANK YOU — 