Nil significant medical history or medications. He complained of light-headiness at the time of clinical review. BP, Sats, RR, temp and BSL were all within normal limits.
Check out the comments on our original post here.
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- Ventricular rate 42 bpm
- Atrial rate 84 bpm
- Irregular atrial activity
- Short P-P (Green) followed by long P-P (Red) - see image below
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- The shorter P-P interval occurs when a ventricular (QRS) complex occurs between the P waves whilst the longer P-P interval occurs when there is no ventricular (QRS) complex between the P waves
- This phenomenon is known as Ventriculophasic Arrhythmia
- 2:1 AV Block with ventricular (QRS) complexes only occurring after every second P wave
- QRS - Prolonged (160ms)
- Subtle ST elevation leads II, III, aVL
- RBBB Morphology
- 2:1 2nd Degree AV Block
- Bifascicular block
- RBBB + LAFB
- Ventriculophasic Sinus Arrhythmia
- Symptomatic Patient with syncope
What happened ?
The patient was referred to the cardiology team and had an uneventful PPM insertion.
Ventriculophasic Sinus Arrhythmia
This ECG is a nice example of ventriculophasic arrhythmia, this phenomenon can be seen in up 40% of case of complete AV block and, as in this case, can be seen with 2nd degree AV block also.
You get a shorter P-P interval when there is an associate QRS complex with a longer P-P when there is no QRS between the P waves. Several mechanisms have been proposed including alterations in sinus node perfusion related to ventricular contraction and the mechanical effects of atrial stretch.
To make things more confusing there is a much rarer paradoxical phenomenon when the P-P is longer when a QRS is contained between them.
It is important to recognized as the P-P variability may be mistaken for other ECG features such as U waves for example.
You can read more about ventriculophasic sinus arrhythmia in this nice case report of the paradoxical version here:
- Liu T, Shehata M, Wang X. Paradoxical ventriculophasic sinus arrhythmia during 2:1 atrioventricular block. Journal of Cardiology Cases , Volume 3 , Issue 1 , e37 - e39
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.