ECG Challenge Response ECG Response: December 2, 2014 A 65-year-old man with a history of obesity and severe chronic obstructive pulmonary disease presents to the emergency room with increasing shortness of breath and a productive cough. A chest x-ray shows changes of chronic obstructive pulmonary disease but no acute pathology. It is felt that he has a chronic obstructive pulmonary disease exacerbation and is begun on antibiotics, steroids, and albuterol inhalers. Several minutes after presenting, his heart rate is noted to increase and become irregular. An ECG is obtained.
The rhythm is irregular as there are several long RR intervals, all of which are the same. Therefore, the rhythm is regularly irregular with group beating and an average rate of 120 bpm. The QRS complexes are narrow (0.08 sec) and have a normal morphology. The axis is about 0° (positive QRS complex in lead I and biphasic in lead aVF). There is downsloping ST segment depression and T wave abnormalities seen in leads I, II, III, aVR (the ST elevation in this lead is actually ST depression), and leads V3 through V6 (^). The J point and downsloping ST changes are consistent with subendocardial ischemia. The QT/QTc intervals are normal (320/450 ms). During each long RR interval there is a P wave seen before the QRS complex (+). The P wave is negative Correspondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Parkway, West Roxbury, MA 02132. E-mail [email protected] (Circulation. 2014;130:2067-2068.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.114.013885
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2068 Circulation December 2, 2014 in leads II, III, aVF, and V4 through V6. Hence this is not a sinus P wave. There are P waves seen before the subsequent QRS complexes, most obvious in lead V1 (v) and also V2 where they are notching the T waves (↓). All of the P waves have the same morphology and they have a constant PP interval at a rate of 150 bpm. Therefore, the underlying rhythm is atrial tachycardia. However, the PR intervals are not constant and can be seen to progressively prolong (└┘) from 0.16 sec (the first PR interval after the pause) to 0.30 sec just before the pause. It can be seen that the pause or long RR interval is the result of a P wave that is not followed by a QRS complex (*; ie, it is nonconducted). Therefore this is a second degree AV block (defined as a regular rhythm with an occasional nonconducted P wave) and there is progressive PR interval lengthening with one nonconducted P wave after which the PR interval shortens to its baseline value (ie, 0.16 sec). This defines Mobitz type I or Wenckebach. Please go to the journal’s Facebook page for more ECG Challenges: http://goo.gl/cm4K7. Challenges are posted on Tuesdays and Responses on Wednesdays.
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ECG Response: December 2, 2014 Circulation. 2014;130:2067-2068 doi: 10.1161/CIRCULATIONAHA.114.013885 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/130/23/2067
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
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The rhythm is irregular as there are several long RR intervals, all of which are the same. Therefore, the rhythm is regularly irregular with group beating and an average rate of 120 bpm. The QRS complexes are narrow (0.08 sec) and have a normal morphology. The axis is about 0° (positive QRS complex in lead I and biphasic in lead aVF). There is downsloping ST segment depression and T wave abnormalities seen in leads I, II, III, aVR (the ST elevation in this lead is actually ST depression), and leads V3 through V6 (^). The J point and downsloping ST changes are consistent with subendocardial ischemia. The QT/QTc intervals are normal (320/450 ms). During each long RR interval there is a P wave seen before the QRS complex (+). The P wave is negative Correspondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Parkway, West Roxbury, MA 02132. E-mail [email protected] (Circulation. 2014;130:2067-2068.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.114.013885
Downloaded from http://circ.ahajournals.org/ 2067 at UNIV OF SOUTH DAKOTA on April 11, 2015
2068 Circulation December 2, 2014 in leads II, III, aVF, and V4 through V6. Hence this is not a sinus P wave. There are P waves seen before the subsequent QRS complexes, most obvious in lead V1 (v) and also V2 where they are notching the T waves (↓). All of the P waves have the same morphology and they have a constant PP interval at a rate of 150 bpm. Therefore, the underlying rhythm is atrial tachycardia. However, the PR intervals are not constant and can be seen to progressively prolong (└┘) from 0.16 sec (the first PR interval after the pause) to 0.30 sec just before the pause. It can be seen that the pause or long RR interval is the result of a P wave that is not followed by a QRS complex (*; ie, it is nonconducted). Therefore this is a second degree AV block (defined as a regular rhythm with an occasional nonconducted P wave) and there is progressive PR interval lengthening with one nonconducted P wave after which the PR interval shortens to its baseline value (ie, 0.16 sec). This defines Mobitz type I or Wenckebach. Please go to the journal’s Facebook page for more ECG Challenges: http://goo.gl/cm4K7. Challenges are posted on Tuesdays and Responses on Wednesdays.
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ECG Response: December 2, 2014 Circulation. 2014;130:2067-2068 doi: 10.1161/CIRCULATIONAHA.114.013885 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/130/23/2067
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
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