ECG Blog #253 (67) — PVCs or Aberrant Conduction?

The 2 tracings that are shown in Figure-1 and Figure-2 were obtained during and shortly after a screening ETT ( = Exercise Treadmill Test).

 

QUESTIONS:

• Are the earlier-than-expected wide beats in both tracings PVCs (Premature Ventricular Contractions) or PACs (Premature Atrial Contractions) with aberrant conduction?
• What are the clinical implications of these early wide beats?

 

Figure-1: 12-lead ECG and dual-lead rhythm strip obtained from an ETT during exercise (See text).

 

Figure-2: 12-lead ECG and dual-lead rhythm strip obtained from an ETT after exercise (See text).

 

  — The Case Continues BELOW today's Audio Pearl ... —

 

 

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NOTE: Some readers may prefer at this point to listen to the 11:15-minute ECG Audio PEARL before reading My Thoughts regarding the ECGs in Figure-1 and Figure-2. Feel free at any time to refer to My Thoughts on these tracings (that appear below ECG MP-67).

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Today's ECG Media PEARL #67 (9:10 minutes Audio) — Applies the wisdom from 2 of my favorite sayings to the "art" of ECG interpretation. These 2 sayings are = "Birds of a Feather" and "Forest from Trees".

 

 

 

Some Brief Concepts on ETT Basics:

Performing and interpreting ETTs is a skill that extends beyond the scope and purpose of my ECG Blog. That said — review of the 2 tracings in Figure-1 and Figure-2 illustrates some important concepts very relevant to distinction between PVCs vs aberrantly conducted PACs.

• The principle of Exercise Treadmill Testing (ETT) is simple: The patient performs a progressively increasing degree of exercise on a moving treadmill while the clinician monitors a series of parameters, including hemodynamic factors (ie, heart rate, blood pressure) — ST-T wave response to exercise — the cardiac rhythm — and the patient's tolerance for increasingly demanding exercise (ie, Assessing the patient for development of chest pain, shortness of breath, dizziness, fatigue, etc.).
• Much more than just the ST segment response to exercise is monitored. It is true that the ECG finding of flat or downsloping ST depression in a patient who develops chest pain with no more than low-level exercise during the ETT is a clear indication for prompt cardiac catheterization. But so much more can be learned! For example, the patient who denies all symptoms during the ETT — but who looks to be obviously fatigued at low-level exercise with development of associated arrhythmias and hypotension is at even higher risk of an acute cardiac event — because that patient lacks a "warning system" (ie, It is likely that such a patient will develop and deny fatigue with associated hypotension and arrhythmias during low-level activities of daily living — which poses a real risk of cardiovascular collapse if activity is continued).
• The treadmill always wins. By progressively increasing the speed and degree of incline of the treadmill — even the most athletically fit individual will eventually fatigue. And THAT is one of the goals of performing an ETT (or "Stress" Test) — namely, that you want to see the ECG response to exercise when your patient is subjected to a level of activity at least comparable (if not exceeding) what that person does every day in an unmonitored situation at home.
• The final point I'll make relates to the purpose of the ETT in today's case — which was as a screening test to assess this asymptomatic patient for exercise capacity and exercise prescription. How intense of an exercise effort will be appropriate for this patient? Insight into an individual's suitability for a given degree of unsupervised exercise can be gained from their performance on the ETT.
•  
• NOTE: For those interested — In 1998, I wrote a user-friendly manual regarding the basics of performing and interpreting ETTs in the office (which I did and taught for years). Realizing that this manual is now 20+ years old ... the basic principles are still valid. CLICK HERE for FREE download of my ETT Pocket Brain PDF (Linked Contents in the PDF Bookmarks facilitate a quick overview of the subject).

 

 

My Sequential THOUGHTS on Today's Case:

Realizing that we lack historical details about the patient in today's case — as well as not knowing for how long he/she exercised on the treadmill, nor their physiologic response — we still can interpret these 2 tracings with regard to the etiology of the early ectopic beats:

 

ECG #1 — Obtained during Exercise:

• The underlying rhythm appears to be sinus tachycardia at a rate close to ~150/minute. Although we do not know the age of the patient, nor the stage of exercise during the ETT that Figure-1 was obtained — the chances are good that at the least — a reasonable degree of exercise has been achieved by the test (ie, probably at least 85% of maximal predicted heart rate for age).
• A number of wider beats are seen in Figure-1. The 2 most obvious wide beats are seen in simultaneously-obtained leads V1, V2 and V3 (ie, beats #15 and 19).
• Looking at the long lead rhythm strips (of lead II and lead V5) — at least a few other wider (different-looking) beats are seen (ie, beats #7, 11, 23). 
• Each of the different-looking beats occur a little bit early! That said — I could not tell from Figure-1 if these wider (different-looking) beats were PVCs or PACs with aberrant conduction.
• Clinically — it would not matter if these slightly early, different-looking beats were PVCs or aberrantly conducted PACs because: i) The ST segment response in Figure-1 shows no more than a minimal amount of rapid-upsloping ST depression, which is a normal (non-ischemic) response to exercise; and, ii) If the patient was appropriately tolerating the amount of exercise — PVCs at the frequency seen here, that do not occur in runs are not necessarily an indication to stop the test.
• ETT NOTE: Fusion beats are common during exercise testing. This is because as heart rate increases — the R-R interval correspondingly decreases, which means there is a much greater chance for the occurrence of any PVCs that are seen to coincide with sinus-conducted beats. This explains why beats such as #7, 11 and 23 that do not look extremely wide may nevertheless represent PVCs (ie, if these beats are fusion beats).
• ETT NOTE: In general, the amount of artifact increases at increasing degrees of exercise — because the patient is having to walk up an ever increasing incline at faster and faster speeds. As a result — rhythm interpretation and assessment of the ST segment response to exercise may be challenging. This is why the most helpful tracing for assessing ST-T wave changes during ETT is usually the immediate post-Exercise tracing — because the heart rate will still be fast, with great reduction in the amount of artifact compared to tracings obtained during exercise.

 

ECG #2 — Obtained after Exercise:

• ETT NOTE: ECG monitoring is usually continued for between 6-10 minutes after the completion of maximal exercise (unless the patient is still having symptoms or arrhythmias after this period of time). ST segment depression that only occurs at peak exercise, and is not accompanied by chest pain — and, which promptly resolves in recovery (ie, within 2-4 minutes after stopping the test) is less likely to indicate significant underlying coronary disease.
• Although we are not told when during the post-exercise period ECG #2 was obtained — the fact that the sinus rate is barely over 100/minute in ECG #2 (compared to ~150/minute in ECG #1) suggests that at least several minutes have already passed in the recovery period after stopping the test. That said — there are still frequent wider (different-looking) beats, as is best seen in the long lead II and V5 rhythm strips in Figure-3.
• Sinus P waves are highlighted by RED arrows in Figure-3. Note that different-looking QRS complexes occur every 4th beat (ie, Beats #2, 6, 10 and 14 in Figure-3 are each wider and very different-looking compared to the other sinus-conducted beats in this tracing).
• Note that there are 2 different QRS morphologies for the wider beats in Figure-3, that I have labeled X1 and X2. The KEY for determining the etiology of these wider beats is highlighted by the YELLOW arrows in the long lead II rhythm strip. There is an unmistakeable notch under each of these YELLOW arrows that is not present either in or just after the T wave in the other sinus-conducted beats (ie, No notch is seen over the vertical BLUE lines in the long lead II rhythm strip). This proves that these YELLOW arrows each highlight a premature P wave (PAC), that precedes each of the wider beats in the long lead II rhythm strip in Figure-3.
• PEARL #1: The best clue that a wider, different-looking early beat is an aberrantly conducted PAC — is when this beat is preceded by a PAC (which it is in Figure-3, as proved by the notch under each of the YELLOW arrows).
• PEARL #2: The next best clue in favor of aberrant conduction is the finding of a QRS morphology for the wider, different-looking beats that resembles some form of known conduction defect. Note that QRS morphology for each of the wider beats labeled X1 in Figure-3 is consistent with LBBB conduction (ie, upright [albeit notched] QRS in lateral leads I, V5 and V6 — and predominantly negative QRS with extremely steep S wave downslope for beat #10 in lead V1).
• Bottom Line: The underlying rhythm in Figure-3 is sinus with atrial quadrigeminy — in which every 4th P wave is a PAC (YELLOW arrows) that conducts with LBBB aberration (X1 beats).

 

 

Figure-3: I have labeled ECG #2 to highlight key features of the different-looking beats (See text).

 

 

Taking Another Look at ECG #1 — Obtained during Exercise:

• In Figure-4 — I have labeled the slightly early, different-looking beats from Figure-1 with either an X1 or X2 notation — corresponding to the 2 different QRS morphologies that we identified in Figure-3.
• As previously stated — the rapid rate and amount of artifact induced by exercise made it extremely difficult to confidently identify premature atrial activity in ECG #1. That said — we still can assess QRS morphology for the 2 clearly widened beats in simultaneously-obtained leads V1, V2, V3 of Figure-4.
• The beat in lead V1 that is labeled X1 (in Figure-4) manifests a predominantly negative QRS with very steep S wave downslope that looks identical to QRS morphology of beat #10 in lead V1 in Figure-3. 
• QRS morphology in the long lead V5 rhythm strip for the 3 complexes labeled X1 in Figure-3 manifests a notched-R morphology. This is similar to the notched-R morphology in the long lead V5 rhythm strip for beat #15 in Figure-4. So, even though we are not able to identify a premature P wave before beat #15 in the long lead V5 of Figure-4 (because of all the artifact produced during exercise) — it is likely that the etiology of this X1 beat in Figure-4 is the same as the etiology that we proved for the 3 X1 complexes in Figure-3 ( = aberrantly conducted PACs).
• Taking another look at beat #19 in Figure-4 (that we have labeled with an X-2 notation) — there is an rsR' morphology for this beat #19 in lead V1, in which the S wave descends below the baseline — and the R' is slender and manifests a taller right "rabbit ear". This QRS morphology for beat #19 in lead V1 is extremely typical for RBBB aberration — which is supported by the finding of a wide terminal S wave for this same beat #19 in the long lead V5 rhythm strip.
• PEARL #3: By the "Birds of a Feather" concept (See the above Audio Pearl #67) — Since the "theme" of the slightly early, different-looking beats in these 2 tracings is that these are aberrantly conducted PACs (as proven by the YELLOW arrows that highlight premature P waves!) — the chances are that other slightly early, different-looking beats are also aberrantly conducted supraventricular impulses (and not PVCs). 

 

CONCLUSION: These 2 tracings, taken from a screening ETT — provide an insightful example of how careful observation allows identification of subtle-but-evident premature P waves (PACs) that confirm a supraventricular etiology for the sighty early, different-looking beats. 

• PACs are conducted with varying degrees of RBBB and LBBB aberration. 
• The modest amount of rapid-upsloping ST depression during exercise, that resolves in recovery suggests a negative screening test for ischemia (although clearly, additional details about the patient and specifics on exercise parameters during each stage of the test would be needed for full analysis).

 

Figure-4: I have labeled ECG #2 to highlight key features of the different-looking beats (See text).

 

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Acknowledgment: My appreciation to Massimo Bolognesi (from Cesena, Italy) for the case and this tracing.

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Related ECG Blog Posts to Today’s Case: 

• ECG Blog #128 — Reviews the concept of Fusion Beats.
• 
  
• ECG Blog #211 — Reviews why some beats (and rhythms) are conducted with aberration (and why the most common form of aberrant conduction manifests RBBB morphology). 
• ECG Blog #33 — Reviews a case showing blocked and aberrantly-conducted PACs. 
• ECG Blog #66 — Reviews a case showing blocked and aberrantly-conducted PACs. 
• ECG Blog #140 — Reviews a case showing PACs with varying aberrant morphology.

ECG Blog #252 — Mobitz I? Mobitz II? or Not?

The ECG in Figure-1 was obtained from a middle-aged patient who was thought to have advanced AV block.

 

QUESTION:

• Is the rhythm Mobitz I? — Mobitz II? — or not?

Figure-1: 12-lead ECG and long lead II rhythm strip from a patient thought to be in AV block (See text).

 

  — The Case Continues BELOW today's Audio Pearl ... —

 

 

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NOTE: Some readers may prefer at this point to listen to the 11:15-minute ECG Audio PEARL before reading My Thoughts regarding the ECG in Figure-1. Feel free at any time to refer to My Thoughts on this tracing (that appear below ECG MP-66).

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Today's ECG Media PEARL #66 (11:15 minutes Audio) — Delves into the theme that "Common Things are Common". This recording is full of PEARLS for expediting recognition of blocked PACs — Atrial Flutter — AFib — VT — Mobitz I vs Mobitz II 2nd-degree AV block — Left Anterior vs Posterior Hemiblock — and SSS (Sick Sinus Syndrome).

 

 

 

My Sequential Approach to Today's Case:

There is a temptation to look at the rhythm in Figure-1 — and immediately suspect some form of 2nd-degree AV block. I'll suggest a different approach!

• My 1st impression on seeing the long lead II rhythm strip in today's tracing was that there is group beating in a supraventricular (ie, narrow QRS) bigeminal pattern!

 

PEARL #1: As discussed in ECG Blog #232 — recognition of a bigeminal supraventricular pattern when the 1st beat in each pairing is conducted, should suggest the following differential diagnosis:

• Sinus rhythm with atrial or junctional bigeminy (ie, every-other-beat is a PAC or a PJC).
• Sinus rhythm with atrial trigeminy — in which every-third P wave is a PAC that is "blocked" (non-conducted).
• Some form of SA ( = Sino-Atrial) Block.
• Mobitz I, 2nd-Degree AV Block ( = AV Wenckebach) with 3:2 AV conduction.
• Mobitz II, 2nd-Degree AV Block.

 

PEARL #2: Another way to look at the bigeminal pattern of group beating that we see in Figure-1 — is that each group of 2 beats is separated by a short pause.

• As emphasized above in today's Audio Pearl — by far, the commonest cause of a pause is a blocked PAC. In clinical practice — the finding of blocked PACs is far more common than any form of AV block.
• Therefore — within seconds of seeing today's tracing — my thoughts were that statistically, the most likely cause of the pauses seen in Figure-1 is blocked PACs. As a result — I knew that my assessment would need to focus on confirming or excluding this possibility. 

 

 

At this point, I took a closer look at the rhythm — applying the systematic Ps, Qs and 3Rs approach (as discussed in detail in ECG Blog #185):

• P waves — are present (RED arrows in Figure-2 highlight upright sinus P waves in lead II).
• The QRS is narrow — which confirms that the rhythm is supraventricular.
• The rhythm in Figure-2 is not "Regular" — so the Rate varies. That said — there is group beating, with a repetitive pattern of alternating short-long intervals. P waves are Related to neighboring QRS complexes — in that each QRS complex in this tracing is preceded by a sinus P wave with a fixed PR interval.

Figure-2: I've labeled sinus P waves from Figure-1 with RED arrows. I've also measured the R-R interval for the shorter and longer R-R intervals ( = 720 and 1560 msec., respectively).

 

PEARL #3: Now that we have systematically assessed the 5 parameters in the Ps, Qs & 3R approach — it's time to consider the entities in the differential diagnosis that we suggested earlier in Pearl #1.

• The rhythm in Figure-2 is neither Mobitz I nor Mobitz II 2nd-degree AV block. The reason we can easily rule out 2nd-degree AV block — is that the atrial rhythm is not regular! (RED arrows in Figure-2). With rare exceptions, for there to be AV block — the P-P interval should be at least fairly regular, and this is definitely not the case in this tracing. That is — no P wave is seen near the mid-point of each pause, as would be expected if some form of 2nd-degree AV block was present.
• Additional reasons why the most common form of 2nd-degree AV block ( = Mobitz I) is not present in Figure-2 are that: i) The PR interval is not increasing: — and, ii) Wenckebach periodicity is not seen (ie, the pause [1560 msec.] is not less than twice the shortest R-R interval [720 msec.] — as discussed in ECG Blog #164).
• The rhythm in Figure-2 is neither atrial nor junctional bigeminy — because similar-looking sinus P waves with a constant PR interval precede each QRS complex on the tracing. Morphology for the P waves preceding beats #2, 4, 6 and 8 should look different if atrial or junctional bigeminy was present.
• SA block is unlikely because: i) In my experience — this conduction disturbance is extremely rare in clinical practice; — and, ii) Wenckebach periodicity should be present IF there was Type I SA block — and — the longer R-R intervals in Figure-2 should be almost exactly twice the duration of shorter R-R intervals if there was Type II SA block (and 1560 msec. is clearly more than 2 X 720 msec.).
• By the process of elimination — we can now focus on determining IF the cause of the group beating in Figure-2 is indeed the result of blocked PACs.

 

HOW to Assess for the Possibility of Blocked PACs:

As emphasized above in today's Audio Pearl — the commonest cause of a pause is a blocked PAC. Sometimes the blocked PAC(s) will be obvious — and, sometimes not. That said — I guarantee that once you begin to regularly look for blocked PACs, you will begin to find them with surprising frequency!

• The KEY to identifying a specific ECG finding — is to know when to look for it. The secret is to look for blocked PACs whenever you encounter any unexpected pause in the rhythm.
• HOW to Look: Carefully examine the ST segment and T wave at the onset of the pause. Compare this ST segment and T wave at the onset of the pause — with the ST-T wave of all normally conducted sinus beats on the tracing. Is there any difference?
• NOTE: Detecting blocked PACs can be challenging! One has to distinguish between minor variations that naturally occur from beat-to-beat in the ST-T wave — from notches or deflections that are the result of a premature P wave buried within (and therefore deforming) the ST-T wave.
• IF in doubt — Look at simultaneously-recorded leads! 12 leads are better than one! Sometimes "tell-tale" signs of a hidden non-conducted PAC may only be evident in some (but not all) of the leads on a 12-lead tracing.
• For practice — examples of blocked PACs can be found in ECG Blog #33 — Blog #57 —  Blog #66 — and Blog #147, among others.

 

CONCLUSION to Today's Case:

The rhythm in today's case is exceedingly subtle — because the blocked PACs are extremely well hidden. The "normal" ST-T wave appears after the 1st beat in each pair (ie, the ST-T waves for beats #1, 3, 5 and 7 in Figure-3).

• I've labeled with YELLOW arrows those leads in today's tracing in which the T wave appears to be noticeably more peaked than the normal T wave that precedes it. Perhaps the easiest lead for noticing this difference is for beats #5 and 6 in lead V1 — in which the YELLOW arrow clearly highlights deepening of the inverted T wave caused by the blocked PAC, that is not present for the T wave of beat #5.
• Ideally, we would have additional monitoring on this patient to confirm the appearance of the "normal" ST-T wave in each of the 12 leads. That said, despite near identical appearance of all QRS complexes on this tracing — the 2nd T wave in each group is consistently a little bit different in appearance than the 1st T wave in multiple leads. This strongly supports my impression that the rhythm is Atrial Trigeminy, in which every-third-beat is a blocked PAC. 
• Interpretation of the remainder of this 12-lead ECG is unremarkable. There are no acute changes.
• 
  
• BOTTOM LINE: The patient does not have any form of AV block. Instead, the rhythm is sinus — with atrial trigeminy, in which each PAC is "blocked" (because it occurs very early in the absolute refractory period). Clinically — attention should focus on potential causes of PACs (ie, caffeine, alcohol, dehydration, anxiety — or other underlying medical issues) — but overall, the rhythm diagnosis is much less worrisome than would be the case if there was AV block.

Figure-3: I've labeled with YELLOW arrows those leads in today's tracing that suggest where blocked PACs may be hiding (and subtly deforming the peak of the T wave).

 

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Acknowledgment: My appreciation to Praneet Manekar (from Amritsar, India) for the case and this tracing.

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Related ECG Blog Posts to Today’s Case: 

• ECG Blog #185 — Reviews the Ps, Qs and 3R Approach to Systematic Rhythm Interpretation.
• ECG Blog #232 — Reviews the concept of a Bigeminal Rhythm (which may be due to Atrial or Ventricular Bigeminy, Wenckebach conduction — or other causes — Listen to Audio Pearl #47).
•  
• ECG Blog #164 — Reviews a case of Mobitz I 2nd-Degree AV Block, with detailed discussion of the "Footprints" of Wenckebach.
•  
• ECG Blog #33 — Reviews a case showing blocked and aberrantly-conducted PACs. 
• ECG Blog #66 — Reviews a case showing blocked and aberrantly-conducted PACs. 
• ECG Blog #147 — Reviews a case showing blocked PACs. 
• ECG Blog #57 — Reviews a case showing atrial bigeminy with blocked PACs.

 

 

Related ECG Blog Posts to Today’s AUDIO Pearl: 

• The July 5, 2018 post in Dr. Smith's ECG Blog — (Please see My Comment at the bottom of the page for Review on the ECG diagnosis of Sick Sinus Syndrome). 
• 
  
• ECG Blog #196 — Reviews "My Take" on assessing the Regular WCT (Wide-Complex Tachycardia) — with tips for distinguishing between VT vs SVT with either preexisting BBB or aberrant conduction. 
• ECG Blog #220 — Reviews the differential diagnosis for List #1: Causes of a Regular WCT Rhythm without clear sign of atrial activity (Media Pearl #37 in this blog post is an Audio that reviews assessment to determine IF the patient is Hemodynamically Stable).
• 
  
• ECG Blog #164 — Reviews a case of Mobitz I 2nd-Degree AV Block, with detailed discussion of the "Footprints" of Wenckebach.
• ECG Blog #236 — Reviews in our 15-minute Video Pearl #52 how to recognize the 2nd-Degree AV Blocks (including "high-grade" AV block). 
• ECG Blog #186 — Reviews when to suspect 2nd-Degree, Mobitz Type I.
• 
  
• ECG Blog #229 — Reviews distinction between AFlutter vs ATach (and WHY AFlutter is so commonly overlooked — Listen to Audio Pearl #45). 
• The November 12, 2019 post in Dr. Smith's ECG Blog — Reviews another case of a Regular SVT rhythm.
• The October 16, 2019 post in Dr. Smith's ECG Blog — My Comment (at the bottom of the page) reviews my approach to another case of a Regular SVT rhythm.
• ECG Blog #199 — Reviews the ECG diagnosis of MAT (Watch Video Pearl #16).
•   
• ECG Blog #203 — Reviews a "user-friendly" approach to the Hemiblocks (LAHB/LPHB) and Bifascicular Blocks — Watch Video Pearl #21).