7 Responses

  1. Abhi

    Atrial flutter wit high degree AV block (5:1 conduction)
    – Heart rate in 60’s and regular
    – complete RBBB
    – T wave inversions in v1 which goes with RBBB
    – st segment in v2 is not very clear. Usually it should be depressed or iso electric in Rbbb. Not sure whether it is elevated or not.
    – there are no reciprocal st changes in the other leads.

  2. Nagarjuna R Gujjula

    I agree with Abhi, he caught most of the stuff I see, here are few things I have observed.

    1.Rhythm is regular in A Flutter with high degree block with 5:1 conduction
    2.Rate is about 60 bpm
    3.QRS duration > 100 and rsR pattern consistent with RBBB, further wide and slurring S wave in lateral leads I, aVL, V5 and V6 supports RBBB
    4. ST segment is usually depressed and T waves are inverted in the precordial leads in the RBBB, but here in V1 and V2 there is a possibility of R wave which is obscured by ST segment elevation which is concordant with QRS complex, this type of pattern can be associated with Anterior wall MI.

    This 55 yo Male patient presenting with chest pain and RBBB in the EKG with mentioned ST changes in the anterior leads, I will be worried about Anterior wall MI. I will get Troponin level and repeat serial EKG’s to note further evolutionary changes

    I will get Cardiology consultation and Bed side Echo to see if He have Anterior wall motion abnormalities which can support our possible diagnosis.


  3. Mohammed Saleh

    It is an interesting EKG, it’s a rhythm riddle.
    Atrial flutter with high grade block with an underlying RBBB is an important differential.
    However, a more deep look will make the diagnosis of atrial flutter questionable. The baseline is really bizarre for an atrial flutter, specially evident in the precordial leads. The atrial rate (if we considered atrial flutter) is way above 300 bpm (as evident in lead III) which is more like atrial fibrillation rate rather than flutter. Also by more meticulous inspection I can appreciate P waves in some leads (lead II and V5) which would fit with sinus P waves. All of this put together makes me think that the baseline is showing artifacts rather than true flutter waves.
    What I would do is to ask for repeating this EKG ensuring that the patient is very still during the recording to abolish muscle artifacts. This would unmask either sinus rhythm or a true flutter wave.
    Also this might reveal a repolarization change secondary to possible ischemia which is really hard to appreciate with this baseline.
    A last differential for this EKG is atrial fibrillation with complete heart block since the QRS is rather regular. But I think this differential is unlikely.

  4. Dr. Smer

    Good input everyone…!

    Let me first say that I cannot imagine Dr. Abu Hazeem take your call off just for diagnosis of atrial flutter (AFL). Having said that you need to be very suspicious about this EKG, I admit it is tricky and tough one

    Mohammed Saleh this was astute observation. At first glance, this EKG looks like AFL with high degree AV block (5:1 AV block). But you need to ask yourself why a 55-year-old male has high degree AV block! He either has significant underlying conduction disease or developed AFL then was started on large dose AV nodal blocking agent (BB, CCB, amio or Digoxin) versus the simpler option, could this be an artifact ? because his heart rate is regular and within normal. At this point, it would be a good idea to look at the leads that you can best see P wave, leads II and V5. In this particular EKG strip, if you look at the beginning of the rhythm strips (lead II & V5) at the bottom of this EKG, you can appreciate clear P waves.

    Another important point that Mohammed Saleh pointed out is that atrial rate in AFL is approximately 280-300 bmp (one large box), in this example, if we assume that the artifact waves were flutter waves, the rate close to 600 bmp (half large box), which is against diagnosis of AFL, yet typical for (atrial fibrillation) AF. As you know, AF is always irregular, unless patient in complete AV block. In these situations, the heart rate is bradycardic, because the regular rhythm is coming from escape junction rhythm.

    I think you all got the RBBB correct. keep in mind, RBBB does not mask ST segment changes, you should be able to call STEMI in RBBB, it is the LBBB that masks the ST segment changes.

    If you are curious why this young patient has artifact on his EKG, he had pneumonia and was having rigors/tremors while obtaining the EKG.

    Thank you


  5. Amy Arouni, MD

    I am so very proud of the residents who took a stab at this ekg! It was a tricky one and it is really great to see the effort you put into this. Keep up the good work.


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