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 116 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 = https://tinyurl.com/KG-Laddergrams — 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).
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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 — tinyurl.com/KG-Laddergram-Stencil ).
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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.
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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 Bigeminy — See ECG Blog #315 —
- Fascicuar Escape with retrograde conduction — See ECG Blog 327 —
- Isorhythmic AV Dissociation — See 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 PVCs — Concealed Conduction — See ECG Blog #359 —
- AV Dissociation by "usurpation" in a 14yo — See ECG Blog #362 —
- ATach with 3:2 Wenckebach conduction — See 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 PVCs — See ECG Blog #378 —
- Reentry SVT from a PVC — See ECG Blog #379 —
- Atypical AV Wenckebach (with NO pause! ) — See ECG Blog #389 —
- Complete AV Block — See ECG Blog #390 —
- Fascicular VT with multiple Fusion Beats — See 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 cycle — See 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 Block — See ECG Blog #413 —
- AV Dissociation by Default with marked Sinus Arrhythmia — See ECG Blog #414 —
- Acute Inf-Post OMI with Dual-Level Wenckebach — See 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 —
- A long Wenckebach Mobitz I Cycle — See ECG Blog #437 —
- Dual-Level Wenckebach — See ECG Blog #439 (Step-by-Step laddergrams of HOW to draw this!) —
- A challenging Wenckebach — See ECG Blog #449 (Step-by-Step laddergrams of HOW to draw this! ) —
- Vagal Hypertonia — See ECG Blog #450 —
( 86 laddergram cases up to #453 )
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.
- AFlutter with dual-level Wenckebach conduction — from the June 3, 2024 post
- AIVR (with "takeover" of AIVR from sinus rhythm) — from the August 9, 2024 post by Dr. Frick.
- SA Block (Where did the P waves go? — complex laddergram) — from the August 14, 2024 post by Dr. Frick.
(30 laddergram cases up to October 24, 2024)
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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
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