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ECG Basics: Sinus Rhythm With Ventricular Bigeminy

Submitted by Dawn on Tue, 07/07/2015 - 15:03

This rhythm strip offers two leads taken at the same time, Lead II and Lead V1.  The Lead II strip may not look "typical" to a beginning student, because the sinus beats are very small and biphasic.  This is due to an axis shift, which cannot be evaluated without more leads.

One of the best teaching opportunities in this strip is the concept of "underlying rhythm" with ectopy.  The underlying rhythm here is sinus.  But there are sinus P waves which are hidden, making the sinus rate twice what it appears to be.  The P waves are invisible in the Lead II strip, with baseline artifact making them even harder to see.  But in V1, we are able to find them at the end of the PVCs' T waves.  The sinus rhythm is a bit irregular toward the end of the strip.  There are probably many things a more advanced practitioner could say about this strip, but it usually requires more than one or two leads to do a complete evaluation.  For your basic student, it is a good example of sinus rhythm with ventricular bigeminy.

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ECG Basics: Normal Sinus Rhythm With Premature Ventricular Contractions

Submitted by Dawn on Sat, 02/21/2015 - 17:22

This ECG shows an underlying rhythm of normal sinus rhythm at a rate of 80 / min.  There are two premature ventricular contractions (PVCs).  The sinus rhythm actually continues uninterrupted, causing a “compensatory pause”.  If you march out the P waves, you may even see hints of the hidden P waves in the ST segments of the PVCs.  The P waves that occur in the ST segments of the PVCs land in the refractory period of the ventricles, and so are unable to continue into the ventricles and cause a QRS. 

 

It is also permissible to call these beats “ventricular premature beats (VPBs)” or “ventricular premature complexes (VPCs)”.  

Dawn's picture

Left Bundle Branch Block With Left Atrial Enlargement

Submitted by Dawn on Sun, 06/08/2014 - 22:29

This ECG, kindly donated by Dr. Ahmed from India, is from a 70-year-old man shows a sinus rhythm at 80 bpm with left bundle branch block (LBBB), left atrial enlargement (LAE), and a premature ventricular contraction (PVC). The ECG criteria for LBBB is:  1) Wide QRS  - greater than or equal to .12 seconds;  2) Supraventricular rhythm;  3) QRS that is negative in V1 and positive in Leads I and V6. In leads with a positive QRS, we will see some ST depression, and in leads with a negative QRS, some ST elevation.  This is "normal" for the wide QRS rhythm, and does not indicate injury or ischemia, although it does not rule it out, either.  LBBB is an indicator of cardiac disease, but not specific to one etiology.

There is a PVC seen as the 8th beat from the left, and it gives you a chance to show your students a wide-complex beat that is NOT associated with a P wave and is premature, compared to the wide-complex SINUS beats with LBBB.  The PVC, being wide-complex, also has similar ST changes:  the ST segments and T waves are DISCORDANT with the QRS complexes.

The P waves show some signs of enlargement of the left atrium.  The P waves in Lead II are tall and pointed, and the P waves in V1 are biphasic.  Left atrial enlargement in a patient with LBBB would not be surprising, as both are associated with left ventricular dysfunction.  Patients with these ECG patterns should be thoroughly evaluated for congestive heart failure.  Patients with LBBB, low ejection fractions, and heart failure are treated with cardiac resynchronization therapy, using a pacemaker that paces the atria and each ventricle, synchronizing both the A-V coupling interval and the depolarization of the ventricles for optimum cardiac output.

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ECG BASICS: Sinus Rhythm With Ventricular Bigeminy

Submitted by Dawn on Thu, 05/09/2013 - 13:20

Nice, clear example of ventricular bigeminy with an underlying sinus rhythm.  We do not know from this strip if the sinus rhythm is a bradycardia at a rate of about 42 per minute, or if the underlying sinus rhythm is actually at a rate of 85 per minute, with every other sinus beat inhibited by the occurance of a PVC.  In the first possibility, the ventricular beats would be considered "escape" beats, positively contributing to the patient's heart rate.  In the second instance, the rather late-occurring PVCs would cause the heart to be refractory, preventing the sinus P wave from conducting it's impulse to the ventricles.   Sometimes, we can see signs of the sinus P wave "hiding" in the PVC, but in this case, if P waves exist, they fall almost exactly in the middle of the ventricular beats' QRS complex, making them invisible.  A good strategy would be to watch the strip continuously for some time, hoping to catch the conduction of two sinus beats in a row, solving the dilemma.

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