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This strip was obtained from a woman who presented to her doctor’s office with hypertension. While there is some artifact in the baseline, it is possible to determine the presence of P waves, thanks in part to having two leads to assess. We have provided an unmarked version of the strip for you to use, and also a marked version for the sake of this discussion.
The underlying rhythm is sinus bradycardia, at about 60 bpm, but with some slight variation in the P to P intervals (about 920 ms to 1040 ms). Because of the artifact, it is difficult to determine the exact P to P intervals, and the exact morphology of the P waves. So, we can’t say for sure that the P waves are all alike.
The AV block occurs at a 3:1 ratio. That is, for every three P waves, one is conducted and produces a QRS complex. When the P waves are not conducted, an escape rhythm occurs.
The escape rhythm occurs at an escape interval of about 1720 ms. In other words, when a QRS does not occur by that time, the escape beat is produced. It appears to be from the AV junction, in spite of the slow rate, because the escape QRSs look like the sinus conducted QRSs. Both sinus and junctional rhythms are conducted along the bundle branches and produce the same QRS morphology. The QRS complexes are approximately .08-.10 seconds wide. Note that QRS complexes numbered 3, 5, and 7 have a P wave fused to the beginning of the QRS, making the QRS look wide when it is not. A junctional escape rhythm results from AV block in the AV node, as the junction is the first available pacemaker below the AVN.
This patient was scheduled for a treadmill stress test in her doctor’s office, which was cancelled. She had no cardiac symptoms at the time of the ECG, except the above-noted hypertension. Unexplained bradycardia, especially when accompanied by AV node blocks, should trigger an assessment for inferior wall M.I., since the inferior wall of the LV shares a blood supply with the SA and AV nodes in the majority of people.
This ECG was recorded from a 75-year-old man with substernal chest pain and diaphoresis. It shows a pretty classic picture of acute inferior wall M.I. The second ECG is a repeat tracing with the V4 wire moved to the V4 Right position, and it is positive for right ventricular M.I. The patient was found to have a 100% occlusion of the right coronary artery, which was opened and stented in the cath lab.
There are several other examples of IWMI with RVMI in our archives, so we will confine this commentary to the ECG signs that make these tracings so typical of right coronary artery occlusion. Once you are familiar with the typical pattern of IWMI / RVMI, it is easy to see, even when the ST elevation is subtle (as this one certainly is NOT).
Signs of IWMI in these ECGs are:
· ST elevation in inferior leads II, III and aVF.
· Reciprocal ST depression in leads I and aVL.
Signs of RVMI in these ECGs are:
· ST elevation in V4 right.
· ST elevation in V1 without ST elevation in V2.
This ECG is from an 80-year-old woman who had an acute inferior wall M.I. with a second-degree AV block.
Some people incorrectly call ALL second-degree AV blocks that are conducting 2:1 "Type II". This is incorrect, as Mobitz Type I can also conduct with a 2:1 ratio. The progressive prolongation of the PR interval will not be seen with a 2:1 conduction ratio, because there are not two PR intervals in a row.
This is a good example of a Type I, or Wenckebach, block which is initially conducting 2:1. At the end of the ECG, two consecutive p waves conduct, showing the "progressively-prolonging PR interval" hallmark of a Type I block. Type I blocks are supraHisian - at the level of the AV node - and generally not life-threatening. Blocks that are conducting 2:1 present a danger, however, in the effect they have on the rate. Whatever the underlying rhythm is, the 2:1 block will cut the rate in half! This patient has an underlying sinus tachycardia at 106, so her block has caused a rate of 53. In light of her acute M.I., that rate is probably preferable to the sinus tach. This patient’s BP remained stable, and she did not require pacing.
The ST signs of acute M.I. are rather subtle here. Note the "coving upward" shape in Lead III, and the reciprocal depressions in I, aVL, V1, and V2. Type I blocks are common in inferior wall M.I., since the AV node and the inferior wall often share a blood supply - the right coronary artery.
While the print quality of this ECG is not the best, it is a great teaching ECG because it starts out with 2:1 conduction, then at the end of the strip, proves itself to be a Wenckebach block.
This ECG shows a second-degree AV block, Mobitz Type II. It is also called “high grade AV block” because there is a 3:1 ratio of P waves to QRS complexes and a resulting slow rate.
Right bundle branch block and left anterior fascicular block are also present, as is common with Type II blocks. The underlying rhythm is sinus. Second-degree AVB, Type II, usually represents an intermittent tri-fascicular block: often right bundle branch block and left anterior fascicular block (hemiblock) are present, and the left posterior fascicle develops an intermittent block. During times of tri-fascicular block, the P waves are not conducted. When the posterior fascicle is conducting, a QRS occurs.
A differential diagnosis for this ECG is complete heart block with ventricular escape rhythm. A longer strip would be needed to see the P waves eventually dissociate from the QRSs, if they are going to do so. Clinically, there is really little difference in the treatment of a high-grade "second degree" block and a "third degree" block. Both are treated with emergency support of the slow rate, as needed, and then a permanent implanted pacemaker.
It is notable that, in this case, the interpretation given by the machine is completely incorrect, even including the intervals. This is not common, but does occur. The machine's interpretation should be considered, but not followed blindly.
This patient has an underlying atrial fibrillation with complete heart block and an idioventricular escape rhythm. She was treated successfully with a permanent implanted pacemaker.
To continue on a topic started by Jason Roediger in his February ECG Challenge -
This series of two ECGs was taken from a 71-year-old man who complained of dizziness and near-syncope the day before these ECGs were done. He was seen in an Emergency Dept., and advised to follow up with a neurologist. On the day of these ECGs, still feeling dizzy and like he would pass out, he called EMS again. He denied chest pain. We do not know his past medical history. The first ECG was taken at 10:22 am. His BP was 177/76 and SpO2 99%. It shows a regular sinus rhythm (p waves marked by small asterisks) at a rate of about 75 / min. There is a high-grade AV block, meaning that some P waves are conducted (beats 2, 4, 7), but most are not. In addition, he has an escape rhythm, probably ventricular, at a rate of just over 40 / min. The overall effect of the escape rhythm is to keep the heart rate above 40 beats per minute.
Fifteen minutes later, at 10:37 am, another ECG is taken. The patient's BP is 154/86. This ECG shows the high-grade AV block quite well, but this time, most of the QRS complexes on the strip are conducted from P waves. It is difficult to see all the P waves in every lead, but if you remember that all three channels are run simultaneously, you will find evidence of the P waves in at least one of the three leads represented at any given time. (Example: V1, V2, and V3 - V3 shows the P waves well). The next-to-last QRS on the page is interesting, as it has a different PRI than the normally conducting beats. Is this a fusion beat or an aberrantly-conducted one? It probably does not matter to the outcome of the patient.
The slowing of the rate in the second strip gives us a clue as to why the patient felt dizzy, but the blood pressures recorded did not catch hypotension. Possibly if the patient had been standing instead of lying on a stretcher, we would have seen more hemodynamic changes.
Unfortunately, we do not know the outcome of this patient, but it seems he is a candidate for an implanted pacemaker.
Today's basic rhythm strip illustrates second-degree AV block, Type II. Even though there is fine baseline artifact present, it is easy to measure the P-to-P interval, and your students will be able to see that every third P wave falls in the T wave. The PR intervals are constant and the atrial rate is about 110/min. The ventricular rate results from a 3:1 conduction ratio, and is less than 30/min. For your students who have learned about bundle branch block, this strip shows a right bundle branch block, which is very common in second-degree Type II blocks, as they usually represent "intermittent tri-fascicular block" - that is, two of the three fascicles in the bundle branches are blocked, and one is intermittently blocked. Other combinations of complete block and intermittent block are possible, resulting in intermittent failure of conduction. This strip can start a lively classroom discussion about treatment of bradycardias. See comments below for discussion of terminology, second-degree AVB and high-grade AVB. This strip can be used as a good example of high-grade AVB.
This 67 year old man is noted to have a slightly irregular pulse. At the beginning of this ECG, he appears to be in NSR with a first-degree AV block. Twice, P waves are non-conducted. Careful measurement of the P to P interval shows that it is regular, there are no PACs noted. The PR interval changes very subtly by lengthening just before the non-conducted P waves. A hint when non-conducted P waves are noted, first check for non-conducted PACs. If the sinus rhythm is regular, check the PR interval before the non-conducted beat, and the PR interval immediately after the non-conducted beat. You will see the PRI preceding the non-conducted P is longer than the PRI after the NCP.
Wenckebach conduction is caused by RP/PR reciprocity. In other words, the shorter the RP interval, the longer the PR interval. So, as the PRI lengthens, the QRS "moves" to the right, eventually causing the next regular sinus P wave to fall into the refractory period and fail to conduct. This results in a pause, or a long RP interval, which shortens the next PRI.
If you or your students would like to review AV Blocks, go to this LINK for Dr. Grauer's excellent, FREE, self-directed tutorial.
For a slightly more advanced discussion of RP/PR reciprocity, see Jason's Blog.
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