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VT or SVT? Here, Both!

Complex ECGs like this one have to be approached systematically. Firstly, we can see a normal sinus rhythm. A is the first beat of a wide complex tachycardia. This must be a ventricular tachycardia. Although there is a P-wave before the first beat of the tachycardia, it is not premature. Therefore, there is no SVT with aberrant conduction. The first beat of the tachycardia looks different from the subsequent beats because there is a fusion beat present. The VT conducts 1:1 back to the atria (a small negative P-wave can be seen at the end of the QRS complex in V1).

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Long QT Syndrome,Look Closely and Do Not Trust the ECG-Computer

ST-elevation V2/V3, why? The patient never had chest pain, echocardiography inconspicious. History of several syncopal episodes. But, there is something wrong with the ECG. We observe a sinus rhythm ECG, at first glance, there are ST-elevations in leads V2-V4. No ST-depressions are visible. Upon closer examination, a prominent T-wave is noted, starting immediately after the QRS complex. The ECG computer erroneously indicates a significantly shortened QT and QTc interval.

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Ventricular Tachycardia After Inferior Myocardial Infarction

76-year-old man, with a history of inferior wall myocardial infarction. He experiences recurrent episodes of brief palpitations, often lasting only 5-15 seconds. In this ECG, at the beginning, the last part of a wide-complex tachycardia is visible. After 2 sinus beats, another wide-complex tachycardia begins (with the same QRS configuration).

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Non-respiratory Sinus Arrhythmia

This is the ECG of an 81-year-old man with hypertension. Currently, he has no complaints: no palpitations, no shortness of breath, no syncope, no chest pain. The rhythm is irregular, but all P-waves have the same shape. There is a non-respiratory sinus arrhythmia present, which is essentially the minimal variant of a sick sinus syndrome. There are no consequences for the patient resulting from this diagnosis.

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Sudden Shortness of Breath - Pulmonary Embolism

ECG 1 is from a 57-year-old male with no prior cardiac disease. He reports acute shortness of breath for 2 days. We see a sinus rhythm with left anterior fascicular block (LAFB) and conspicuous T-wave inversions in the inferior leads and in V1-V6. These are typical ECG changes that may indicate a pulmonary embolism. ECG 2 was taken from the same patient 1 year earlier. The patient has an acute pulmonary embolism. Sinus tachycardia may be present in acute pulmonary embolism. However, as in this example, the heart rate can also be completely normal.

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Why is this not second degree AVB Type II and no high grade AVB

(Image 1) Why is there no second-degree AVB  Mobitz type II and no high-grade AV block? To the first question: Basically, second-degree AV block Mobitz type II is rare. The two ECG patterns that can easily be confused with Type II Mobitz block are: blocked/non-conducted PACs and second-degree AVB Mobitz type I (Wenckebach). (Image 2) You have to compare the PR duration before the pause and after it. With the naked eye, the difference is often difficult to recognize, a pair of calipers does a good job here.

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Atypical Atrial Flutter

Why is this left atrial atypical atrial flutter (ECG 1)? Atrial fibrillation can be excluded because nice flutter waves (all look the same) can be clearly identified. With typical right atrial flutter, the reentry circle runs counterclockwise and we see typical saw tooth patterns in the inferior leads (negative flutter waves). The flutter waves are positive in V1 (ECG 2). With typical right atrial flutter with a clockwise reentry circle, the flutter waves in the inferior leads are positive.

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Junctional Escape Rhythm, Very Slow

This ECG comes from a 75 yo man who had 2 syncopes in the past few weeks. The 12-lead-EKG at the family doctor showed an inconspicuous finding. Here you can see a section of the patients Holter ECG. There is a very slow junctional escape rhythm. How can this be recognized?

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AIVR - Accelerated Idioventricular Rhythm

This Holter-ECG comes from a 70-year-old physician with coronary artery disease. He is twelve months after PCI (RCA, RCX). Currently no symptoms (no dyspnea, no chestpain, no palpitations). You can see that an overview/section from a Holter- EKG, 3 channels are shown, strip width is 30 seconds. First you can see a sinus rhythm with frequent PVCs, then there is a transition to an accelerated idioventricular rhythm (AIVR) that lasts almost a minute in total. 

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Second-degree AV Block with Left Bundle Branch Block & Lead Reversal

This ECG shows second-degree AV block, Mobitz Type II and an interventricular conduction delay, probably left bundle branch block. The QRS width is about 130 ms, or .13 seconds.

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