Saturday, January 30, 2021

ECG Blog #189 (ECG MP-6) — Is this Some Type of Wenckebach? (SVT - PACs - Flutter - ATach - Laddergram)

I thought today’s case would be an excellent follow-up to my last post, which was ECG Blog #188 — in which I reviewed a step-by-step approach for drawing laddergrams, with links to more than 20 clinical examples of detailed laddergram analysis.


BForewarned! — Laddergram analysis of the arrhythmia that appears in Figure-1 is complex. I fully acknowledge that it took me considerable time to figure out the mechanism of this arrhythmia. That said:

  • As interesting as the laddergram of the ECG mechanism is — the laddergram is not the “Take-Home” Point in today's case. So, while true that only more advanced interpreters may figure out the complete answer to this case — what is much MORE important, is the problem-solving approach to this arrhythmia.
  • Regardless of your ECG experience level — I cover many PEARLS in arrhythmia interpretation in this post that are relevant to any clinician charged with interpreting ECG rhythms.
  • I walk you through a step-by-step approach to how I derived my laddergram for this tracing in the 2-part ECG Video that is found just below Figure-1 (ECG Media Pearl #6). Please spend a few minutes to WATCH this ECG Media PEARL before you check out my detailed laddergram in Figure-2 at the bottom of this post.
  • Your COMMENTS on this case are WELCOME!


Today's CASE: Interpret the ECG shown below in Figure-1:

  • Does this rhythm represent some form of Wenckebach?

Figure-1: How would YOU interpret this 2-lead rhythm strip? Are you up for the challenge of drawing a laddergram? NOTE: No history is available on the patient — but the history is really not essential for assessing this arrhythmia (See text).

Detailed review of my approach to this arrhythmia is covered in the 2-part video of my ECG Media PEARL #6: 

NOTE: Because of video size limitations — I’ve had to break this video into 2 parts:

  • Part 1 (5:30 minutes) — Initial approach to the rhythm.
  • Part 2 (4:00 minutes) — Deriving the laddergram.
  •   — NOTE: I've reproduced the final laddergram in today's case in Figure-2, which is shown below the videos.

Part 1 Video (5:30 minutes) — Initial approach to the rhythm.

Part 2 Video (4:00 minutes) — Deriving the laddergram.

Review of the Final Laddergram:

The final laddergram in today's case that was derived in Part-2 of the Video is shown below in Figure-2:

Figure-2: Review of the final laddergram.

Laddergram Review: The underlying rhythm in Figure-2 is ATach (Atrial Tachycardia), as shown by the RED arrows that represent regular-occurring P waves.

  • The first finding to note is group beating — in that a repetitive pattern of alternating long-short intervals is seen. That this is not due to chance should be obvious from the fact that shorter R-R intervals are all almost the same duration — and — longer R-R intervals are also almost all of the same duration.
  • Many P waves are not conducted. The marked difference in duration between longer and shorter R-R intervals is what suggested to me that there might be dual-level block within the AV Nodal Tier. (Part-2 of the video showed why the more common single level block was unlikely in today's case.)
  • Many P waves in Figure-2 are conducted! We know this to be true — because there are 2 sets of PR intervals that continually repeat. That is — the relatively long PR interval that is seen before beat #1 is the same as the PR interval before beats #3, 5, 7 and 9.
  • And, the same very short PR interval that we see before beat #2 — is seen to repeat before beats #4, 6 and 8. However, this PR interval looks too short to conduct. 
  • KEY Point for Constructing Laddergrams: Much of the time with faster atrial rhythms — the P waves that conduct to the ventricles are not those P waves that are closest to the next QRS complex. This is a result of "concealed" conduction that delays forward conduction of selected atrial impulses.
  • As a result of the above observations — I contemplated a number of different possibilities for the mechanism of conduction within the 2 levels of the AV Nodal Tier. The one that "fits" best is shown in Figure-2 — in which I postulate 4:3 AV Wenckebach conduction within the upper AV Nodal Tier — and — 3:2 AV Wenckebach conduction within the lower AV Nodal Tier.

 The important point to recognize, is that the combination of group beating — dropped beats but regular-occurring P waves — and — the identical PR interval preceding the QRS complex that ends each of the pauses in this tracing — overwhelmingly suggest that some type of Wenckebach conduction is present.
  • The rhythm is not 3rd-degree (complete) AV Block — because identical PR intervals prior to multiple QRS complexes (ie, prior to beats #1, 3, 5, 7 and 9) in this regular pattern prove that there is conduction of at least some beats.
  • The rhythm is not Mobitz II 2nd-degree AV Block — because the PR interval never stays the same for consecutively conducted beats.
  • This patient may not necessarily need a pacemaker — because the mechanism of the conduction defect is AV Wenckebach (albeit at 2 levels within the AV Node) — and the overall ventricular response is not excessively slow.
  • Additional clinical details would be needed to better appreciate the overall longterm outcome.

  • P.S. — I intentionally did not comment regarding QRS duration on this tracing because I thought it impossible to tell from the 2 leads given (especially in view of the suboptimal resolution) — if the QRS was wide or narrow. The terminal S wave in left-sided lead V6 suggests that there may be some right-sided delay — but whether this reflects incomplete vs complete RBBB is impossible to tell without better resolution and a 12-lead tracing. That said — regardless of QRS width, my interpretation of the rhythm would be the same.


Acknowledgment: My appreciation to Abo Ali Mohamed (from Libya) for the case and this tracing.



Saturday, January 23, 2021

ECG Blog #188 - How to Read/Draw Laddergrams

Learning to draw Laddergrams is challenging. I fully acknowledge that it took me significant time until I felt comfortable with this skill. That said — learning to read laddergrams is EASY — and important for enhancing your understanding of more complex arrhythmias.
  • I cover the basics of what a laddergram is in the 5-minute ECG Video below. With this as introduction — you should be able to understand the mechanism portrayed in most laddergrams you will see.
  • For those who are interested in drawing laddergrams — I walk you through a step-by-step approach in my ECG Blog #69 (followed by links at the BOTTOM of this page to more than 109 clinical examples of laddergrams that I've drawn to illustrate cases).
  • NOTE: You do not need to know how to draw laddergrams in order to attain excellence in arrhythmia interpretation — BUT — Becoming comfortable in reading laddergrams will be invaluable for taking you to your next level!

  • User-Friendly LINK  = — takes you to this ECG Blog #188.

ECG Media Pearl #5: This video (5:00 minutes — revised 11/10/2021) reviews the basics of what a Laddergram is. The laddergram that I briefly illustrate (beginning at ~4 minutes in the video) is excerpted from my ECG Blog #187 (which provides additional detail on this case — including in the Addendum to Blog #187, several other possibilities for the mechanism of the arrhythmia).

How to Draw a Laddergram (Step-by-Step Demonstration) 
  • See ECG Blog #69 For a verbal Step-by-Step on drawing a Laddergram
  • For additional practice, see any of the many LINKS below at the bottom of today's blog post!
  • CLICK HERE — To DOWNLOAD my FREE PowerPoint Laddergram STENCIL (Here is the user-friendly LINK to my FREE PowerPoint Laddergram Stencil — ).


As a Summary of essential laddergram elements — I've added the following 2 figures (taken from my ACLS-2013-ePub book). Legends explaining the basic laddergram elements in Panel A and Panel B appear below each Figure.


For Practice in Reading Laddergrams Please CHECK OUT the following ECG Blogs I've written in which I've added laddergram illustrations:
  • ECG Blog #189 (with an illustrative ECG video that traces construction of the laddergram in this challenging case)and — My ECG Blog #187 (which illustrates how sometimes more than a single laddergram explanation is possible)
  • A case with Group Beating (Step-by-Step demonstration) — See ECG Blog #164 —
  • A patient with syncope and hypotension (Step-by-Step demonstration) — See ECG Blog #168 —
  • Inferior STEMI + AV Wenckebach — See ECG Blog #154 —
  • Mobitz I + Acute MI — See ECG Blog #55 —
  • Mobitz I + Junctional Escapes — See ECG Blog #63 —
  • Group Beating + PACs — See ECG Blog #147 —
  • Escape-Capture — See ECG Blog #163 —
  • Fusion Beats — See ECG Blog #129 —
  • Interpolated PVCs — See ECG Blog #68 —
  • AIVR with Retrograde Conduction — See ECG Blog #107 —

  • Lots of AV Dissociation (not 3rd-Degree) — ECG Blog #202
  • Is AV Block complete? — See ECG Blog #191 (and Blog #405)
  • AV Dissociation by "Default" — See ECG Blog #192
  • AV Dissociation by "Usurpation" — See ECG Blog #247
  • AIVR with Junctional Escape & Fusion Beats — See ECG Blog #194
  • Isorhythmic AV Dissociation — See ECG Blog #195
  • Mobitz I + Alternating Hemiblock — See ECG Blog #206
  • Challenging AV Block case ... — See ECG Blog #216
  • ATach with Wenckebach — See ECG Blog #223
  • Inferior MI with Mobitz I — See ECG Blog #224

  • Dual Level Wenckebach — See ECG Blog #226

  • Recent Inferior MI with Mobitz I — See ECG Blog #232
  • High-Grade (not Complete) AV Block — ECG Blog #235
  • 3:1 AV Block, probably Mobitz II — See ECG Blog 237
  • Echo Beats + subtle Mobitz I — See ECG Blog #239
  • Laddergram of "Fast-Slow" AVNRT — See ECG Blog #240
  • Laddergram of Fascicular Bigeminy — See ECG Blog #241

  • AFlutter with Dual-Level Wenckebach (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #243

  • AV Dissociation by "Usurpation" — See ECG Blog #247
  • Mobitz I ended by Echo Beat — See ECG Blog #251 (with Step-by-Step Laddergram demonstration).
  • Escape-Capture Bigeminy (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #256
  • ATach with probable Complete AV Block — See ECG Blog #257
  • Bigeminy with Dual-Level Wenckebach (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #259
  • ATach with Wenckebach (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #261
  • An unusual case of AV Wenckebach (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #267
  • What is "Supernormal" Conduction?  — See ECG Blog #268 —

  • Why 3-QRS Shapes? — Trigeminy, Ashman aberrancy (Step-by-Step laddergrams of HOW to draw this!)See ECG Blog #279

  • Bigeminy/Random P Waves? (Step-by-Step VIDEO explanation of how I derived my laddergram for this complex rhythm) — See ECG Blog #280

  • "Fast-Slow" AVNRT with Electrical Alternans and variable retrograde conduction — See ECG Blog #281 — 
  • An irregular AIVR with recent MI — See ECG Blog #285

  • A complex Mobitz I that "does not obey the rules" (Step-by-Step laddergrams of HOW to draw this!)See ECG Blog #286

  • Another case of Mobitz I with Bradycardia-dependent (Phase 4) Wenckebach — See ECG Blog #295
  • A complex Mobitz I with Inferior OMI (I am not certain of the arrhythmia mechanism — See ECG Blog #304
  • No Symptoms but a Slow Rate (Mobitz I) — See ECG Blog #307
  • Recent Inf.-Post MI with complex Mobitz I — See ECG Blog #311
  • SA Block — See ECG Blog #312
  • Escape-Capture BigeminySee ECG Blog #315
  • Fascicuar Escape with retrograde conduction — See ECG Blog 327
  • Isorhythmic AV DissociationSee ECG Blog #328
  • Atypical Mobitz I (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #331  —
  • High-Grade AV Block (complex) — See ECG Blog #332
  • 2nd Degree but Impossible to Classify = Complex (Step-by-Step laddergrams)See ECG Blog #336
  • AV Dissociation by "Usurpation" (Step-by-Step laddergrams) — See ECG Blog #338
  • Mobitz I vs Mobitz II (2:1)See ECG Blog #344 (and Blog #404)
  • Dual-Level AV Block, Mobitz I See ECG Blog #347
  • Isorhythmic AV Dissociation in 20yo — See ECG Blog #357
  • Congenital AV Block in 20yo (2:1, Mobitz I?)See ECG Blog #358
  • PVCs Interpolated PVCsConcealed ConductionSee ECG Blog #359
  • AV Dissociation by "usurpation" in a 14yo — See ECG Blog #362
  • ATach with 3:2 Wenckebach conductionSee ECG Blog #370
  • Ventricular Salvos (concealed conduction) — Laddergram shows the mechanism (and proves this is not aberrancy) — See ECG Blog #372
  • AIVR (Laddergram proves AV Dissociation)See ECG Blog #373
  • Myocarditis + complex Wenckebach (Step-by-Step laddergrams)See ECG Blog #376
  • Interpolated PVCsSee ECG Blog #378
  • Reentry SVT from a PVCSee ECG Blog #379
  • Atypical AV Wenckebach (with NO pause! )See ECG Blog #389
  • Complete AV BlockSee ECG Blog #390
  • Fascicular VT with multiple Fusion BeatsSee ECG Blog #393
  • Complex sinus rhythm with frequent PVCs with concealed conduction (Step-by-Step laddergrams)See ECG Blog #395
  • Sinus rhythm with a long AV Wenckebach cycleSee ECG Blog #397
  • Hyperthyroid with a very irregular ATach plus unusual Wenckebach conduction — See ECG Blog #398
  • Which Laddergram is correct? High-grade AV Block — See ECG Blog #399
  • What kind of Block? Mobitz I and Alternating BBB — See ECG Blog #401 —
  • Is it Wenckebach? A challenge with AV Dissociation (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #411
  • Complete AV BlockSee ECG Blog #413
  • AV Dissociation by Default with marked Sinus Arrhythmia — See ECG Blog #414
  • Acute Inf-Post OMI with Dual-Level WenckebachSee ECG Blog #416
  • Very Irregular VT (with Fusion beats — and retrograde conduction)See ECG Blog #417 — 
  • ATach with Wenckebach conduction (Step-by-Step laddergrams of HOW to draw this!) — See ECG Blog #420
  • Subtle Mobitz I (with junctional escape beats) in a patient with posterior OMI — See ECG Blog #421
  • Asymptomatic 92yo with fascicular NSVT and "MAT spectrum" — See ECG Blog #428
( 82 laddergram cases up to #430 )

For Additional Practice in Reading Laddergrams Please CHECK OUT the following posts in Dr. Smith's ECG Blog (Please scroll down to the BOTTOM of the page for My Comment with laddergram illustration. Many of these will show step-by-step how I construct the laddergram).
  • Acute Inferior MI — from January 19, 2020 post.
  • Interpolated PVCs — from April 9, 2020 post.
  • AV Wenckebach (very long PR) — Sinus Arrhythmia — Use of Atropine (with Step-by-Step illustration for drawing this laddergram) — from May 16, 2020 post.
  • No Clinical Information — from May 28, 2019 post.
  • Drug Overdose and a Fascinating Arrhythmia — from June 13, 2020 post.
  • Palpitations and a Complicated Rhythm (Phase 4 = Bradycardia-induced Aberrancy — Step-by-Step Laddergrams) — from August 17, 2020 post.
  • Is there Wenckebach? (Dual AV Nodal Pathways with Mobitz I — jump in PR interval!) — from September 9, 2020 post.
  • High-grade AV Block with bundle branch escape — from September 24, 2020 post.
  • Group Beating that is not Wenckebach — from September 26, 2020 post.
  • Drawing Junctional Escape — from October 9, 2020 post.

  • A Fall and a Rhythm to Recognize (Digoxin) — from November 24, 2020 post.

  • AV Dissociation by "Default" — from February 9, 2021 post.
  • Isorhythmic AV Dissociation ("default" ) — from February 17, 2021 post.
  • A complex tracing with probable Mobitz I + an accelerated fascicular rhythm + variable degrees of fusion with the underlying rhythm — from June 17, 2021 post.
  • Dual-Level Wenckebach following Cardiac Arrest — from October 25, 2021 post.
  • Mobitz I with long PR (Vent. Standstill) — from March 14, 2022 post.
  • Acute Inf. MI with SA Block — from May 25, 2022 post.
  • A Pacer tracing with blocked beats — from August 3, 2022 post.
  • Assessing a long Wenckebach cycle (MY Post! ) — from January 26, 2023 post (also covers clinical significance of a very long 1st-degree ≥0.30 second).
  • Is this Rhythm Puzzling to You? (MY Post! — on AV Wenckebach with a very long PR interval) — from March 30, 2023 post.
  • AV Wenckebach misdiagnosed as AFib (not "Trifascicular" Block! ) — from April 6, 2023 post.
  • Dual-Level AV Wenckebach — from May 26, 2023 post.
  • Isorhythmic AV Dissociation (My CASE— from June 26, 2023 post.
  • Junctional Escape + AV Wenckebach — from July 30, 2023 post.
  • SA Block vs blocked PACs (Group Beating! ) — from August 30, 2023 post.
  • AIVR usurps Mobitz I — from October 3, 2023 post.
  • Mobitz I vs Mobitz II — from January 23, 2024 post.

  • Precordial Swirl with Ladder of intermittent Fascicular Escape! — from the March 22, 2024 post by W.Frick.
(27 laddergram cases up to May 10, 2024)


NOTE (5/16/2024): I'll continue to add links to this page of additional laddergrams I use to illustrate cases.
  • SEND ME cases of your interesting arrhythmias that you'd like to see published on my ECG Blog. I'm always happy to acknowledge your contribution on the blog post! THANKS for your interest!

ADDENDUM (11/16/2021):
Yalena Bradford raised my attention to an interesting arrhythmia case. While fully acknowledging that I am unable to come up with a "definitive answer" laddergram — I thought the process that I worked through in this 7-minute Video may nevertheless prove insightful. COMMENTS are Welcome on this case! — :) Ken Grauer, MD

ECG Blog #187 (Ischemia - MI - Complete AV Block - Wenckebach - Mobitz II - AV Dissociation)

The patient whose ECG is shown in Figure-1 is a man in his 50s who presented to the ED with new-onset chest pain.

  • Unfortunately — there is no long lead rhythm strip ... There is also slight distortion of the complexes in this tracing due to some angulation when a photo of this ECG was made. That said — tracing quality is sufficient for accurate interpretation.


QUESTIONS Regarding ECG #1:

  • HOW would you interpret the ECG in Figure-1?
  • Is there a probable “culprit” artery?
  • Is there AV Block? IF so — Is this complete AV Block?


Figure-1: ECG obtained from a man in his 50s with new chest pain (See text).


This wasn’t my patient. I thought it might be helpful to describe the sequence of my thought process for assessing this case based on the information I was given.


As always — I like to begin by first interpreting the cardiac rhythm. Only after I take an initial look at the rhythm — do I look at the rest of the 12-lead. The problem with this initial look at the rhythm in this case — is that there is no long lead rhythm strip. This limits us to looking at the 12 leads that are shown, with no single lead showing more than 6 or 7 consecutive beats.

  • MY Approach: Since we lack a long lead rhythm strip — I look for a lead in which P waves are evident. Ideally, this would be lead II — since the presence of upright P waves with similar P wave morphology in lead II would define the underlying rhythm as sinus. On occasion, when P waves are not well seen in lead II — I’ll select another lead in which they are.
  • For ECG #1 — P waves are well seen (and upright) in lead II. These P waves look to be fairly regular — and this suggests that the mechanism of the underlying rhythm is most likely to be sinus. The atrial rate is increased at ~130/minute.
  • PEARL #1: This is a challenging arrhythmia! KEY to determining what the etiology of this arrhythmia is — is determining whether or not the atrial (P wave) rhythm is or is not regular (or at least almost regular). Using CALIPERS allows you do to this in less than 5 seconds. The reality is — that IF you do not regularly use calipers for rhythm interpretation — then you will never get good at interpreting complex arrhythmias. And, IF you do not yet use calipers — I guarantee that your skill in rhythm interpretation will instantly improve the moment you start to do so.

PEARL #2: The immediate question I had regarding the rhythm in this tracing — was whether some form of AV Block was present? This is why determining whether the atrial rhythm is regular is important — because AV Block is unlikely if P waves are not regular (or at least almost regular).

  • NOTE: It is common with 2nd- and 3rd-degree AV Block for there to be slight irregularity in the P-P interval due to the presence of ventriculophasic sinus arrhythmia. This slight irregularity is felt to result from variable coronary perfusion due to the AV Block itself (ie, P waves that closely follow QRS complexes tend to occur a bit sooner than P waves that do not "sandwich" a QRS complex — because of better SA node perfusion). But the amount of P-P interval variation tends to be small, and significantly less than is seen with PACs or sinus pauses in a patient with sick sinus syndrome.


Continuing My Initial Assessment of the Rhythm:

  • By the Ps, Qs & 3R Approach (See Audio Pearl #3) — The QRS complex is narrow everywhere in ECG #1 — so the mechanism of this rhythm is supraventricular. 
  • P waves are upright and fairly regular in lead II. 
  • The R-R interval is clearly not regular — but I did get the impression that there appeared to be a “regular irregularity” (ie, some form of group beating) in this tracing. 
  • Looking in those leads for which I was clearly able to identify P waves in (ie, lead II; lead V6, among others) — it seemed as if at least some of the PR intervals repeated! This repetition of some of the PR intervals is unlikely to be due to chance — and suggests there is conduction of at least some of the P waves!
  • It also appears that at least some of the regularly-occurring P waves are not conducted (because they are not followed soon after by any QRS complex).
  • NOTE: Because I used calipers and because I followed a systematic approach (ie, looking for Ps, Qs & the 3Rs) — I was able to make the above observations within seconds!

PEARL #3: Suggestion of group beating and a fairly regular atrial rhythm and — the fact that at least some of the regularly-occurring P waves are not conducting — tells us that some form of AV Block is likely

  • That said, we can already rule out 3rd-degree (ie, complete) AV Block — because the ventricular rhythm is clearly not regular and — repetition of several of the PR intervals tells us that some of the P waves are being conducted! (No P waves at all would be conducted if the rhythm was 3rd-degree AV block).

PEARL #4: By the “KISS” Method (ie, Keep ISimple” Stupid) that I use for assessing the AV Blocks ... — IF an AV Block is present — and if we know the rhythm is not simple 1st-degree AV Block (because PR intervals in ECG #1 vary) — and IF we have ruled out 3rd-degree AV Block (as per Pearl #3) — then the type of AV Block must be a form of 2nd-degree AV Block.

PEARL #5: As discussed in Audio Pearl #4 (See ECG Blog #186) — There are 3 basic Types of 2nd-degree ABlock: i) Mobitz I ( = AV Wenckebach) 2nd-degree AV Block (in which there is gradual increase in the PR interval until a beat is dropped)ii) Mobitz II 2nd-degree AV Block (in which the PR interval remains constant until one or more P waves in a row are not conducted)andiii) 2nd-degree AV Block with 2:1 AV Conduction (in which you can not tell IF the PR interval would increase if given a chance to — since you never see more than a single conducted P wave in a row because of the 2:1 block).

  • The rhythm in ECG #1 is clearly not simple 2:1 AV Block (since the ventricular rhythm is irregular — and therefore doesn’t show strict 2:1 AV conduction).
  • Mobitz II is rare! In my experience — over 95% of all 2nd-degree AV Blocks that I have seen in over 40 years of looking for AV blocks, turn out to be Mobitz I. The importance of recognizing those rare cases of Mobitz II that do occur — is that a pacemaker will usually be needed. This is because of the disturbing tendency of Mobitz II to suddenly develop a very high-grade form of AV block (ie, nonconduction of multiple P waves in a row). The QRS complex will almost always be wide with Mobitz II (because this more severe form of AV block usually arises from lower down in the conduction system) — and Mobitz II is usually associated with acute anterior MI (from acute LAD occlusion).
  • In contrast, with Mobitz I — the QRS complex is usually narrow (unless there already was underlying bundle branch block) — the PR interval of the 1st conducted beat in any cycle will often manifest 1st-degree AV block — and, the site of acute MI will usually be inferior (because this generally less severe form of AV block tends to arise at the level of the AV node — which is regularly supplied by either the RCA or left circumflex coronary artery).


BOTTOM LINE Regarding My Thoughts thus Far: I’ll emphasize that I was not at all certain about the rhythm in ECG #1 at this point in time. That said — I definitely did suspect some form of Mobitz I 2nd-degree AV Block because:

  • There was an underlying regular sinus rhythm.
  • The QRS complex was narrow.
  • There seemed to be group beating — with conduction of several beats (best seen in lead V6) that manifest a constant (and slightly prolonged) PR interval.


At this point in the process, even though I had not yet made a definitive diagnosis of the rhythm — I turned toward assessment of the rest of the 12-Lead ECG in Figure-1. Practically speaking — further clarification of the rhythm diagnosis at this point would not have altered initial management, and this patient did present with new-onset chest pain that needed to be assessed! Continuing on with assessment of the rest of the 12-lead ECG:

  • The QTc interval in ECG #1 looks borderline.
  • The frontal plane axis looks normal (about +20 degrees).
  • There is no chamber enlargement.


Regarding Q-R-S-T Changes in ECG #1:

  • Regarding Q waves — Considering the small size of the QRS complex in the inferior leads, a large (and wide) Q wave is present in lead III, and a smaller Q wave is seen in lead aVF.
  • R wave progression is appropriate — with transition (where height of the R wave becomes greater than depth of the S wave) occurring normally between leads V3-to-V4.


The most remarkable findings in ECG #1 relate to ST-T Wave Changes:

  • All 3 inferior leads show significant ST elevation (especially given the small size of the QRS complex in leads III and aVF). At the end of these elevated ST segments appears a small amplitude upright (ie, hyperacute) T wave.
  • There is reciprocal ST depression in both of the high lateral leads (ie, in leads I and aVL).

PEARL #6: Did YOU appreciate that “magic” = mirror-image opposite picture for the SHAPE of the ST-T wave in leads III and aVL that I previously emphasized in ECG Audio Pearl #2?

  • The fact that the shape of the ST elevation in lead III of ECG #1 is a “mirror reflection” of the shape of the reciprocal ST-T wave depression in lead aVL (within the small GREEN rectangle in Figure-2) — essentially confirms recent or acute inferior STEMI.
  • Note that the same “magic” relationship exists for the shape of the ST depression in lead aVL — which is a “mirror reflection” of the shape of the ST elevation in lead III (within the small BLUE rectangle in Figure-2).


Figure-2: To facilitate visualization of the mirror-image opposite view in selected leads — I have flipped vertically (to create a mirror-image reflection) one QRST complex in leads IIIaVLV2 and V3 — and I show these mirror-image reflections within the colored rectangles (See text).

In the Chest Leads:

  • The ST segment in lead V1 of ECG #1 is flat (neither elevated nor depressed).
  • There is J-point ST depression in each of the 5 remaining chest leads. The fact that the amount of this ST depression is maximal in lead V2 (in association with recent or acute inferior MI) is diagnostic of acute posterior involvement.

PEARL #7: Use of the Mirror Test facilitates visualizing the ECG signs of acute posterior MI. 

  • Flipping a few anterior leads upside-down provides an ECG picture of what is occurring in the “mirror-image” posterior wall — which now manifests deep Q waves, ST elevation and deep T wave inversion suggestive of acute posterior MI (within the RED rectangles in Figure-2).

PEARL #8: Normally with acute posterior MI — each of the anterior leads (ie, leads V1, V2, V3 and often V4) will show at least some ST depression. The fact that the ST segment in lead V1 is flat (instead of depressed) suggests that in addition to acute infero-postero MI — there is probably also acute RV involvement (ie, acute Right Ventricular MI often produces ST elevation in right-sided lead V1 — which may be attenuated or cancelled out by simultaneous ST depression from ongoing posterior MI)

  • Right-sided chest leads would be needed to prove there is acute RV involvement in ECG #1 — but IF acute RV MI is present, this would confirm the RCA (Right Coronary Artery) as the “culprit” artery — because the LCx (Left Circumflex) coronary artery does not perfuse the right ventricle.
  • NOTE: For more on the ECG diagnosis of acute RV MIPlease see ECG Blog #190.

PEARL #9: Acute coronary occlusion typically manifests with ST elevation over the affected lead areas — and reciprocal ST depression in opposite lead areas. Reperfusion of the acutely occluded artery (either following thrombolytic therapy or angioplasty — or occurring spontaneously) — is usually heralded by T wave inversion in leads that initially showed ST elevation. 

  • The mirror-image of T wave inversion in posterior leads (within the RED rectangles in Figure-2) — is development of T wave peaking. The fact that T waves appear peaked and more-upright-than-expected at the end of the marked ST depression seen in leads V2 and V3 (as well as in other chest leads) — suggests that there may already have been some spontaneous reperfusion in ECG #1.


Final THOUGHTS on the Rhythm: Now that we’ve assessed the rest of 12-lead ECG (and now that we've diagnosed acute ongoing infero-postero MI with probable RV involvement) — we can return for a more detailed look at the rhythm. This is best done by means of a Laddergram:

  • I’ve already highlighted features of the rhythm in ECG #1 that strongly suggest the Mobitz I ( = AV Wenckebach) form of 2nd-degree AV Block. These included — i) regular atrial rhythm; ii) group beating; iii) narrow QRS complex — and, iv) evidence of some conduction, in the form of similar PR intervals in front of several QRS complexes. The fact that we have now also have v) acute inferior STEMI (from acute RCA occlusion) — makes it all but certain that some form of AV Wenckebach is operative for the rhythm seen in ECG #1.
  • The various possible forms of Mobitz I can be complex — and may involve multi-level AV block — AV nodal escape beats — and/or “concealed” conduction (that may alter the inherent escape pacemaker rate). Clearly, the brevity of the rhythm strip available in ECG #1 (which is further altered by slight angulation of the paper, therefore slight distortion of this tracing) makes definitive rhythm diagnosis impossible from assessment of this tracing alone. That said — I propose the mechanism that I've drawn in the laddergram shown below in Figure-3. Explanation of this laddergram appears in the legend to this Figure.

BOTTOM LINE Regarding Today’s Case: It's important to appreciate that precise determination of the rhythm in Figure-3 is not essential for initial clinical decision-making — as it will not alter initial management. Practically speaking — the following description of findings on ECG #1 should more than suffice for initial appropriate decision-making:

  • There is sinus rhythm with 2nd-degree AV Block of the Mobitz I type, with intermittent AV dissociation and occasional junctional escape beats.
  • Acute or at least recent infero-postero OMI (Occlusion-based MI) — with probable acute RV involvement (Posterior chest leads would be needed to confirm this).
  • Some evolutionary changes — with development of inferior Q waves (in leads that still manifest ST elevation and, suggestion of at least partial coronary reperfusion, given taller-than-expected T wave peaking in anterior chest leads.
  • Given the clinical presentation (ie, a man in his 50s with new-onset chest pain) — prompt cardiac catheterization is clearly indicated to better define the anatomy and current state of “culprit” artery opening (ie, it is likely that acute reperfusion could benefit this patient!).

Figure-3: Laddergram for the 6 beats we see in lead II of ECG #1. Colored arrows show regularity of the underlying sinus rhythm. The QRS complex is narrow and similar in morphology for all 6 beats. 

  • The PR interval preceding beat #3 is clearly too short to conduct. This tells us that beat #3 must be an AV nodal escape beat. 
  • The PR interval preceding beats #2 and 6 is the same — which suggests that both of these beats are conducted by the RED P waves that precede them.
  • The PR interval preceding beats #1 and 5 is also the same, albeit slightly longer than the PR interval preceding beats #2 and 6. This suggests that beats #1 and 5 are also both conducted by the RED P waves that precede them (albeit with a slightly longer PR interval than for beats #2 and 6).
  • The P waves highlighted by BLUE arrows are clearly not conducted. They all either occur during the refractory period — or, are isolated to a point in the middle of an R-R interval, and distant from any neighboring QRS complex.
  • I was uncertain about the etiology of beat #4 (red Question Mark). Although theoretically possible for the PINK P wave preceding it to conduct — I suspected beat #4 was an AV nodal escape beat, because its PR interval is so much shorter than the PR interval for other beats on this tracing that we know are conducted.
  • I selected PINK for those P waves in Figure-3 that I suspect would have conducted if not for “concealed” conduction from the 2 AV nodal escape beats.
  • Alternatively — It could be that instead of a 2nd AV nodal escape beat, the BLUE P wave in the middle of the R-R interval of beats #3-to-4 might be conducting with a very long PR interval (which would still prevent conduction of the next sinus P wave by retrograde concealed conduction). Another (even less likely) theory — might be alternate conduction in dual AV nodal pathways that manifest different degrees of AV block.
  • In Conclusion: While impossible to be certain of the precise mechanism for the rhythm in Figure-3 from this very short rhythm strip — it is virtually certain that some form of AV Wenckebach is present — since we see conducting P waves with dropped beats (in BLUE) — and, suggestion in at least the lower level of the AV node that PR intervals increase, punctuated by dropped beats.




  • My appreciation to Antranik Ohanian (from Lebanon) for the case and this tracing.




  • For more on the Basics of AV Block — See my ECG Blog #186
  • See ECG Blog #188 for review on HOW to Read (and/or Draw) a Laddergram.
  • For more on use of the Mirror Test to facilitate recognizing acute Posterior MI — See my ECG Blog #56 — and — My Comments at the bottom of the September 21, 2020 post and the February 16, 2019 post in Dr. Smith’s ECG Blog.


ADDENDUM (1/24/2021):
As is often the case with complex arrhythmias — there is more than a single possible explanation ... The challenge with today's tracing — is that we only have 6 beats, and this patient "did not read the textbook" during the time this rhythm strip was recorded (ie, the usual "rules" for Wenckebach blocks are not strictly followed ...).
  • David Richley offered the following alternative explanation to the laddergram I proposed above (Figure-4):

Figure-4: Laddergram proposed by David Richley. Dave offers the following explanation: "This is not CHB – it is Wenckebach AV block. However, I disagree with Ken's Figure-3 laddergram regarding a couple of the details:
  • A long rhythm strip would have been useful — but even without one, I think we can be confident that both beat #3 and beat #4 are NOT escape beats. For one thing, they are both preceded by very different RR intervals, and escape intervals should be constant. 
  • Secondly, if beat #3 were an escape beat —  its preceding RR interval of 0.7 sec would be equivalent to an ‘escape’ rate of 86 bpm, in which case we would expect to see a prolonged accelerated junctional rhythm, perhaps interrupted by occasional capture beats. 
  • Instead, I think that beat #3 is a conducted sinus beat — but that the P wave that connects to it is the one on the T wave of beat #2. 
  • So — Is beat #4 the sole escape beat? I think it could be, but I suspect that it is another conducted beat, but with a shorter PR interval than the other conducted beats because of the relatively long preceding pause. This would be an example of RP/PR reciprocity — the longer the RP interval, the shorter the following PR interval. 
  • Figure-4 is the laddergram that I’ve drawn a to illustrate what I think is going on. The theory I have just outlined requires that there be 2 successive blocked P waves — which is certainly unusual in Wenckebach AV block, but I think I have seen it before. Of course, there may be better alternative explanations.

David Richley always stimulates discussion on complex arrhythmias, often in ways that make me "go back to the drawing board". Marriott has shown cases of Wenckebach in which successive P waves are non-conducted in Wenckebach blocks — so this is (as Dave postulates) indeed possible! That said — I still think it less likely for even a relatively longer pause as is seen between beats #3-4 to result in enough improved conduction to allow beat #4 to conduct with a PR interval as short as 0.13 second, as Dave's laddergram suggests ( = my opinion).

I therefore propose yet one final laddergram in Figure-5 — although I fully acknowledge that it too has weaknesses in the mechanism proposed.

Figure-5: Final laddergram I propose as a potential mechanism for today's case ...

BOTTOM LINE: It's worthwhile to appreciate that complex arrhythmias do not always lend themselves to a single simple solution — especially when the period of ECG monitoring is extremely limited (as it is in today's case). That said — what we do know — is that this patient had an acute infero-postero OMI with some form of 2nd-degree AV block in which a Wenckebach mechanism is operative. 

ADDENDUM #2 (1/27/2021):
I have just received the following message from Jerry Jones, MD, FACEP, FAAEM regarding this interesting tracing. Like David Richley — Jerry is another trusted colleague of mine with international expertise and a love for complex arrhythmias. Jerry supports the 2nd laddergram that I proposed (which appears in Figure-5) — and he labeled the 10 P waves for clarity (Figure-6). I am adding his comments in the form of this 2nd Addendum:

Figure-6: Dr. Jerry Jones favors the laddergram from Figure-5. He labeled the 10 P waves for clarity (See explanation by Dr. Jones below).

Dr. Jerry Jones said the following (Figure-6):

  • P wave “a” conducted with a prolonged PR interval.
  • P wave “b” did not conduct due to refractoriness because its RP interval was too short.
  • P wave “c” conducted with a prolonged PR interval.
  • P wave “d” conducted with a prolonged PR interval because its RP interval was sufficiently long to allow concudtion and there is no other way to explain the presence of R wave #3. A premature junctional beat would be essentially a deus ex machina.
  • P wave “e” did not conduct because PR interval is too short.
  • P wave “ ” may or may not have conducted with a prolonged PR interval.
  • P wave “g” did not conduct due to concealed conduction by the previous P wave and the likelihood of a significant 1 st degree AV block.
  • P wave “h” conducted with a prolonged PR interval.
  • P wave “ ” did not conduct due to refractoriness because its RP interval was too short.
  • P wave “ ” conducted with a prolonged PR interval.

Dr. Jones added the following:

  • Wenckebach conduction can be present without resulting in a dropped beat. I wouldn’t be influenced by the “normal” PR interval preceding R wave #4.
  • We must assume that P wave “ f ” conducted because we HAD to assume that P wave “d” with a shorter RP interval conducted. I am not in favor of invoking sudden ectopic junctional beats to explain my way out of a difficult dysrhythmia. 
  • I don’t think P wave “g” could have conducted because: 1) I think there is a baseline significant 1 st degree AV block present; and, 2) since we must assume that P wave “f” conducted, it would have blocked P wave “g” due to concealed conduction. That does NOT rule out the possibility that P waves “f” and “g” both failed to conduct, resulting in a junctional escape beat (ie, beat #4). The PR interval involving P wave “f” may have simply taken too long and was usurped by a junctional escape focus.
  • No P wave with an RP interval shorter than the RP of P wave “d” conducted. Certainly — a true rhythm strip could have clarified things immensely.
  • The presence of a prolonged PR interval complicates the matter a bit. Some of the most challenging dysrhythmias I’ve ever encountered turned out to have nothing more than a 1st degree AV block as the basis.
  • I teach my classes that you can recognize a 3rd degree AV block because there is no interruption of the escape rhythm and it is a very regular rhythm (unless interrupted by a PVC). Actually, that is not entirely true — the escape focus can develop a Mobitz I or II exit block, and result in an irregular rhythm, or allorhythm. That is very rare (unless you are an electrophysiologist). That said — I tried deciphering this as an accelerated junctional rhythm with an exit block, but I couldn’t get it to result in anything believable.
  • I don’t think a multilevel AV block is applicable here because we are in sinus rhythm with a rate that looks like the low to mid 80’s. The P-P intervals shorten a bit at the end while the R-R intervals increase slightly.
  • If any beat were an escape beat, it would have to be beat #4, because it ends the longest R-R interval.

My BOTTOM LINE in this fascinating Case Remains the Same:  It's worthwhile to appreciate that complex arrhythmias do not always lend themselves to a single simple solution — especially when the period of ECG monitoring is extremely limited (as it is in today's case). That said — what we do know — is that this patient had an acute infero-postero OMI with some form of 2nd-degree AV block in which a Wenckebach mechanism is operative.