tag:blogger.com,1999:blog-3364570834099131201.comments2024-03-18T02:26:22.794-04:00ECG InterpretationECG Interpretationhttp://www.blogger.com/profile/02309020028961384995noreply@blogger.comBlogger1105125tag:blogger.com,1999:blog-3364570834099131201.post-65445130615613139222024-03-06T16:42:42.043-05:002024-03-06T16:42:42.043-05:00To H.S.Cho — Just wanted you to know that your com...To H.S.Cho — Just wanted you to know that your comment motivated my further research of the concept you raised ( = PD-PAVB) — and as a result, I have acknowledged you in the ADDENDUM that I just wrote to this ECG Blog #419. THANKS again for your comment! — :) KenECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-6325569384408554322024-03-06T09:31:11.161-05:002024-03-06T09:31:11.161-05:00Thank you for your comment Marko! As I mention abo...Thank you for your comment Marko! As I mention above in my discussion — lead V4 in does look abnormal. That said, the KEY point is that it is lead V3 that we KNOW is abnormal in a patient with new CP — and whereas by itself lead V4 might not catch attention — in the context of KNOWING that V3 is abnormal, we can better appreciate that the much more subtle findings in lead V4 are most probably part of the same process!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-70924323907834426602024-03-06T09:25:46.321-05:002024-03-06T09:25:46.321-05:00Excellent thought! Nice write-up of PD-PAVB ( = Ph...Excellent thought! Nice write-up of PD-PAVB ( = Phase 4 or Pause-Dependent Paroxysmal AtrioVentricular Block) by Bosah et al may be found here — https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9391957/ — As per discussion by Bosah et al — sudden block of repetitive atrial impulses may be seen in patients with severe underlying Purkinje system disease if an "appropriately-timed" PAC or PVC occurs. The condition may similarly remit if another "appropriately-timed" PAC or PVC occurs — but longterm, pacing definitely needed! THANKS again for your comment! ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-43083826478364722412024-03-02T05:34:37.757-05:002024-03-02T05:34:37.757-05:00Thank you for your response Thank you for your response The DUFFhttps://www.blogger.com/profile/04875919599089674980noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-26981685282037820912024-03-02T02:27:41.246-05:002024-03-02T02:27:41.246-05:00This patient may have been suffering from paroxysm...This patient may have been suffering from paroxysmal AV block(such as phase 4 AV block) that also requiring permanent pacemaker implantation..H.S.Chonoreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-12558435928948451472024-02-24T04:06:27.520-05:002024-02-24T04:06:27.520-05:00Thank you for your wonderfull blog. I have one que...Thank you for your wonderfull blog. I have one question. Is it a T wave in v4 a little bit broad than normal.Thanks for your answer. I wish all the best. Markohttps://www.blogger.com/profile/07067318617871055984noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-14567641810637050152024-02-12T00:21:14.230-05:002024-02-12T00:21:14.230-05:00THANK YOU for the kind words! So glad my material ...THANK YOU for the kind words! So glad my material is helpful! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-21893035699736761822024-01-03T21:46:58.038-05:002024-01-03T21:46:58.038-05:00You are one best the teacher I have heard so far. ...You are one best the teacher I have heard so far. I am blown away with your teaching style. It is simple and uncomplicated. Thank you.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-44971546730965317592024-01-01T15:02:59.958-05:002024-01-01T15:02:59.958-05:00THANKS so much for the kind words Marko! As always...THANKS so much for the kind words Marko! As always — seeing a specific ECG would facilitate answering your question! But as a "general answer" — it depends on whether the sudden QRS widening is preceded by P waves — or no P waves (as in a patient with Atrial Fibrillation — as per ECG Blog #32 = https://tinyurl.com/KG-Blog-32). <br /><br />If we are dealing with an episode of AFib that speeds up and then conducts with BBB ( = rate-related aberration) — then the underlying rhythm will remain irregular during this run of wider beats!<br /><br />VT will not be preceded by atrial activity. In contrast — a patient with sinus rhythm in which the rate of this sinus rhythm speeds up will continue to be preceded by P waves.<br /><br />And then there are all the OTHER factors (of QRS morphology; frontal plane axis, etc.) — that go into deciding if a rhythm is SVT with rate-related aberration vs VT.<br /><br />Again — IF you have a specific rhythm you are concerned about — You'll see the icon in the RIGHT column above "To Send an E-Mail" — Thanks again for your interest! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-15460297184315641412024-01-01T14:56:29.850-05:002024-01-01T14:56:29.850-05:00THANKS so much for your continued support! — :)THANKS so much for your continued support! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-19136327131663486342023-12-30T05:19:35.689-05:002023-12-30T05:19:35.689-05:00Another GREAT post, Thanks. We enjoyed that.Another GREAT post, Thanks. We enjoyed that.Plus Ultrahttps://www.blogger.com/profile/01735827112800682222noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-63481025237534239922023-12-26T02:22:03.309-05:002023-12-26T02:22:03.309-05:00Hello dr. Grauer. Thank you for this wonderfull bl...Hello dr. Grauer. Thank you for this wonderfull blog. I have one question here. How can i distinguish between rate related bbb and VT. Thank you for your answer. I wish you happy New year and all the best in your private and business life.Markohttps://www.blogger.com/profile/07067318617871055984noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-78452177403784628942023-12-24T20:40:51.661-05:002023-12-24T20:40:51.661-05:00THANK YOU for your comment! As you highlight — sub...THANK YOU for your comment! As you highlight — suboptimal quality of this tracing makes it difficult to draw conclusions. That said — I ALWAYS look for AFlutter (as I cannot tell you HOW MANY times I have seen this rhythm overlooked, even by cardiologists). I also always have my calipers nearby (to take out when/if the patient is stable). The ventricular rate is clearly faster than the usual 140-160/min range that is most commonly seen with untreated AFlutter — and although I looked in ALL 12 leads — I could not get 2:1 atrial activity to "march out" in any lead. You can see irregularly irregular AFlutter — but in my opinion, I did not see flutter activity.<br /><br />That said — You are completely correct that AFlutter and AFib may evolve into the other, sometimes back-and-forth over a period of time. But I didn't think there was AFlutter in this tracing. THANKS again for your comment! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-8332856817678812432023-12-24T20:31:45.539-05:002023-12-24T20:31:45.539-05:00THANK YOU for your EXCELLENT comment! As I often e...THANK YOU for your EXCELLENT comment! As I often emphasize — complex arrhythmias (such as this tracing) may often have more than a single plausible explanation. So I cannot say 100% that I am correct. I did consider MULTIPLE possibilities — and as I explain in step-to-step detail in Figures-5,6,7 — I concluded that k was conducting retrograde as the most plausible way I could explain events. But I fully admit that I cannot "prove" this is the mechanism. And, as you see in the Addendum (in Figure-8) — H.S. Cho postulated another mechanism that might be the correct one.<br /><br />All of this said — I would emphasize the "BOTTOM LINE" that I write in my Addendum — namely, that the "theme" of today's rhythm remains that in this patient with uncontrolled hyperthyroidism — there is a markedly irregular ATach with periods of Wenckekbach conduction out of the AV Node. THANKS again for your comment! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-5076684851206553312023-12-24T20:25:56.341-05:002023-12-24T20:25:56.341-05:00My pleasure! — :)My pleasure! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-43978312009018804112023-12-24T20:24:58.401-05:002023-12-24T20:24:58.401-05:00Hi. First — I will say that there may often be mor...Hi. First — I will say that there may often be more than a single laddergram explanation for complex arrhythmias such as this one. So I cannot say 100% that I am right and you are wrong. That said — I did consider Mobitz I — but as I explain in Figure-9 — I thought it more logical that beats #2,4,6,8 were junctional escape beats.<br /><br />As per the legend for Figure-9 — I believe beats #2,4,6 and 8 represent junctional escape beats — because: i) These beats occur at the end of longer R-R intervals which are of similar duration; ii) The PR intervals preceding these beats are extremely long; iii) As per Figure-4 — the PR intervals preceding these beats are not constant; and, iv) While all QRS complexes in today’s tracing are narrow — QRS morphology of these even-numbered beats is slightly different (ie, less negative) compared to the QRS morphology of odd-numbered beats. As noted above in PEARL #1 — this difference in QRS morphology is often an important clue suggesting a different site of origin. THANKS again for your excellent comment!<br /><br />P.S. It is Mobitz I that shows progressive PR interval lengthening before dropping a beat — whereas the PR interval remains constant with Mobitz II.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-63247128541797468782023-12-24T20:14:43.164-05:002023-12-24T20:14:43.164-05:00VERY true — the more ECGs you see — the better you...VERY true — the more ECGs you see — the better you become at recognizing what they show! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-66873153479138744772023-12-24T20:12:31.936-05:002023-12-24T20:12:31.936-05:00My pleasure! Thank you for your interest! — :) My pleasure! Thank you for your interest! — :) ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-56953619182468533402023-12-24T20:11:40.625-05:002023-12-24T20:11:40.625-05:00And YOUR comment "made my day". So glad ...And YOUR comment "made my day". So glad this post was helpful to you! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-83262356903109265562023-12-24T20:10:28.828-05:002023-12-24T20:10:28.828-05:00Thank you! — :) Thank you! — :) ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-32859682942379145412023-12-17T21:52:41.403-05:002023-12-17T21:52:41.403-05:00Is it a Mobitz II 2nd-degree AV block (with 3:2 co...Is it a Mobitz II 2nd-degree AV block (with 3:2 conduction)? I think that P waves # b, e, h, k are conducted with beats #2, 4, 6, 8 (PRs interval is the same and longer than PRs of beats #1, 3, 5, 7). Thank you! Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-84066637020089884092023-12-11T08:37:08.431-05:002023-12-11T08:37:08.431-05:00what about T wave changes in III and aVF?what about T wave changes in III and aVF?Janus de Geushttps://www.blogger.com/profile/03530201161567815397noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-34690078940974780542023-12-07T14:07:36.626-05:002023-12-07T14:07:36.626-05:00Big thanks and appreciation from Iraq Big thanks and appreciation from Iraq Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-7758561689732819352023-11-05T16:34:38.239-05:002023-11-05T16:34:38.239-05:00V2 and V3 in the initial ECG appear to have possib...V2 and V3 in the initial ECG appear to have possible flutter waves (or deflections where a wave might be) before and after the T wave. Perhaps it is Atrial Flutter with a 2:1 block? I feel like A Flutter and A Fib are sometimes on a continuum where a patient might slip in and out of one to the other and back where organized, regular flutter waves become irregular fibrillation waves. Could the irregularity be from ectopic beats or the equivalent of ‘sinus’ arrhythmia? The quality of the tracing makes it hard to tell. <br /><br />Regardless, adenosine would not have converted that, either. And the repeat ECG is clearly A Fib Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-9607586677598999922023-10-19T18:45:14.520-04:002023-10-19T18:45:14.520-04:00I have just spotted a interpolated PVCs and I se...I have just spotted a interpolated PVCs and I searched your blog for information and I found this to be a treasure! Excellent explanation! My case is interesting and it is a little different from yours. You made my day!!!!Anonymousnoreply@blogger.com