You can check out the comments on our original post here.
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- Atrial rate ~205 bpm
- Ventricular rate ~66 bpm
- Regular atrial activity
- Irregular ventricular conduction
- Normal (75 deg)
- QRS - Normal (100ms)
- QT - 320-340ms
- ST Depression leads II, III, aVF, V4-6
- Atrial activity
- Positive P wave leads II, III, aVF, and V1
- Inverted P wave leads I & aVL
- Morphology - small, low voltage waves
- R-R Intervals vary without pattern
- Atrial flutter with variable conduction
- Atypical micro-rentry left atrial focus
- DDx includes atrial tachycardia with variable conduction
- Distinct between flutter and atrial tachycardia principally of interest only if ablation and EP mapping required
One of our blog team electrophysiologist has looked at the ECG and made the following points.
- A two level block is a reasonable explanation but this ECG is a little atypical for that.
- 2:1 Blocks usually occur below the AV node rather than above
- Wenckeback conduction if present usually occurs at or above the AV node
- This facilitates conduction patterns such as 5:2 or 7:3
- Variable block is probably due to significant vagal changes on the AV node
- AV Node conduction is independent of atrial or ventricular activity and will vary conduction based on autonomics which vary beat to beat
The patient was admitted under the cardiology team. She underwent successful DC cardioversion after electrolyte replacement. Myocardial perfusion study revealed no reversible ischaemia or evidence of prior ischaemia. Recent echo revealed severe left atrial enlargement, mild right atrial enlargement, and stable appearance of the mitral valve replacement. She was discharge with ongoing cardiology follow-up.
References / Further Reading
Life in the Fast Lane
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.