This is an original illustration by Dawn Altman. You may use it free of charge to enhance your presentations or student handouts. Click on image, or right click and SAVE image. For permission and charges for use in publications or for marketing uses, please contact the artist at [email protected]
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 taken from an elderly woman who complains of feeling weak and tired. We have no other clinical information, unfortunately.
There is an obvious bradycardia, with more P waves than QRS complexes. Here is what we see:
* Atrial rate is around 115/min. and P waves are regular and all alike.
* Ventricular rate is around 35/min. and QRS complexes are regular and all alike.
* PR intervals, when they occur, are all the same at 162 ms.
* QRS duration is wide at 122 ms.
* QTc interval is prolonged at 549 ms.
What does this mean? There is sinus tachycardia with second-degree AV block because the atrial rate is over 100/min, but not all P waves are conducted. The AV block looks like a Type II (Mobitz II) block because the PR intervals are all the same. This is a reliable indicator of conduction. (Not third-degree AVB). The wide QRS complexes are due to right bundle branch block. The ECG signs of RBBB are: 1) wide QRS; 2) supraventricular rhythm; and 3) rSR’ pattern in V1 and Rs, with a wide little s wave, in Leads I and V6.
This rhythm strip shows third-degree AV block, also called complete heart block or complete AV block. The P waves are from the sinus node, and are regular at a rate of about 120/min. (Sinus tachycardia). This is a good strip for showing your students how to "march out" the P waves to find the ones that are hidden behind QRS complexes or T waves. Knowing that the P waves are regular, it is easy to find the hidden ones.
The QRS complexes are wide at 0.14 seconds, and regular, with a rate of about 28/min. On first glance, it APPEARS that there are PR intervals. That is, it appears that some of the P waves are conducting. If you measure the PR intervals carefully, you will note that they are NOT equal. There is no connection between the P waves and the QRS complexes - this strip has just caught them near each other. If we ran the strip longer, we would see the PR intervals "come apart", proving they are not real. The QRS complexes are coming from an IDIOVENTRICULAR ESCAPE RHYTHM. They are regular, wide, have no P waves associated with them, and the rate is below 40 bpm.
Patients with CHB that results in a very slow heart rate sometimes need emergency treatment aimed at increasing the rate. When the escape rhythm is idioventricular, it is assumed that the AV block is located below the AV node, and emergency temporary pacing is often the method of choice. In fact, a permanent implanted pacemaker is almost always needed. When the AV block is located in the AV node, the escape rhythm will be junctional (narrow QRS complexes, rate about 40-60 bpm).
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.
All our content is FREE & COPYRIGHT FREE for non-commercial use
Please be courteous and leave any watermark or author attribution on content you reproduce.