This rhythm strip is recorded in two simultaneous leads, which is always preferable to one single lead. It is a good example of atrial fibrillation with a rapid ventricular response. Atrial fib that has not been treated will usually have a rapid ventricular rate. This reflects the ability of the AV node to conduct a tachycardia, within limits. The natural slow conduction of the AV node allows it to act as a "filter", preventing the huge numbers of impulses generated by the atrial fibrillation from reaching the ventricles. In this case, about 140 beats per minute are able to make it through the AV node into the ventricles. In some patients, preexisting cardiac conditions such as valve insufficiency or CHF may make this rate dangerous for the patient. The rate may lower cardiac output in some people, and this must be considered in light of the fact that the loss of P waves in atrial fib also lowers cardiac output significantly.
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This is a very interesting ECG taken from an acute M.I. patient. Your basic level students will be able to appreciate the ST elevation in V1 through V3. Although the elevations are not very high, there are plenty of other abnormalities that point to acute STEMI: the ST segments are flat and there are marked ischemic T waves in the lateral leads: V4 through V6 and I and aVL. The patient was suffering an acute episode of chest pain.
It is also noticeable that R wave progression in the precordial leads (V1 through V6) is not optimal, as there is still a significant S wave in V6. We do not know if this is an electrode placement issue or not. The QT interval is just at the high limit of normal.
For your more advanced students, aVR has ST elevation. It is not reciprocal of an ST depression in Lead II. Research has shown that ST elevation in aVR and V1, especially when the ST elevation is greater in aVR, is a strong indication of proximal LCA or a Left Main occlusion. Unfortunately, we do not have cath results for this patient. In acute M.I. patients, higher mortality rate has been associated ST elevation in aVR.
For more information about ST elevation in aVR, click here: https://login.medscape.com/login/sso/getlogin?urlCache=aHR0cDovL3d3dy5tZWRzY2FwZS5jb20vdmlld2FydGljbGUvNTg5Nzgx&ac=401
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Those of you who have followed the ECG Guru for a while are very familiar with the work of Dr. Ken Grauer, M.D. He is a generous contributer to the ECG Guru website, and functions as our official Consulting Expert. He has published many books and e-publications which are (in our opinion) some of the BEST ECG references available, and he has worked hard to keep them low priced to make them available to all of us. He also offers seemingly endless ECG knowledge and insights for FREE, via this website, his own website, and social media.
Dr. Ken Grauer has recently been producing ECG instructional videos. The latest is a three-part series (Videos 10, 11, and 12), which tackle the topic of the BASICS OF ECG RHYTHM INTERPRETATION. These videos cover the basics for those who are just beginning their ECG training, as well as for those who want a refresher. More advanced concepts are included along the way to keep the interest of those who are already experienced. There are also excellent examples of how to teach the basics for those of you who are instructors. It is presumed that the viewer of the videos has a beginning background in health care sciences, and in anatomy and physiology. To facilitate navigating through this 3-part (2 hour) video series, Dr. Grauer has made a LINKED CONTENTS that takes you to the precise place in the video for each given content area. There you will also find links to Dr. Grauer's other publications and free resources.
A laddergram is a diagram of conduction through the heart, presented in a minimum of three tiers, one for the atria, one for the AV junction, and one for the ventricles. Laddergrams are very useful for presenting and testing your theory of a dysrhythmia. Instructors often use them to illustrate complex dysrhythmia mechanisms.
If you don't yet have experience in using laddergrams, go to this LINK to find a short PowerPoint presentation that will give you the basics to get started. Be careful - it can be a bit addicting to construct laddergrams, like working a puzzle. If you want to use laddergrams to teach your students, this PowerPoint presentation can help you introduce them to the concept.
Our thanks to Jason Roediger, ECG Guru and dysrhythmia expert, for the laddergram depicted here, and the many LADDERGRAMS featured in his blog posts on this site to see the discussion accompanying this ECG, go to this LINK (Warning: this is an ECG Challenge, which is advanced material)
“For another step-by-step review from Dr. Ken Grauer on How to Draw a Laddergram - Please check out Dr. Ken Grauer’s ECG Blog #69 - GO TO - http://tinyurl.com/KG-Blog-69
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