Second and third beats are second degree type 1, then accelerated junctional rhythm with RBBB.
– Progressive prolongation of PR followed by dropped beat (Wenckebach phenomenon) suggestive of 2nd degree heart block, mobitz type 1.
– Rate of 60-70 ppm
– LAD + Prominent R in V1 suggestive of Bifascicular Block (RBBB + LAFB)
– No evident ST segment deviation, the T wave looks somewhat biphasic (not sure). QT doesn’t look prolonged.
I will admit the patient in a tele bed for monitoring for any pauses or progression to higher grade of block, hold his BB and trend Troponins to exclude any potential ischemia.
– LAD leads I,II
– Non specific T wave inversion
– Possible LVH by aVL modified cornell criteria.
– V1 long strip:
started with wide QRS complex then 2 sinus beats conducted with 2nd degree Mobitz 1 wenckebach AV block (sinoatrial rate 75/min) then 5 beats of wide QRS complexes at a rate of 75/min (isorhythmic or slightly exceeding the sinus) with gradual onset and offset giving the characteristic appearance of AIVR although DDx would include:
– AJR with RBBB.
– Slow VT.
– rate dependent RBBB
Sinus rhythm with RBBB/ LAD (bifasicular block) and Second degree AV block mobtiz type 1
– Junctional rhythm and captured sinus beats with p waves (2nd and 3rd beat)
– I think the 2nd sinus p wave is not conducted as the PR interval is very long. There is complete Av dissociation, followed by junctional rhythm.
– I see some p waves merged with t waves in lead II and v1.
-Wide QRS in v1 is related to junctional + RBBB.
It looks like AIVR because of BBB.
I see what you say Abhi when I look to V1 long strip, you are right, it’s tricky!!!
– Rhythm: mainly junctional escape rhythm. Sinus in 2nd, 3rd and last beats.
– Rate: 70 for ventricular escape beats. 75 for sinus beats (p waves embedded in T waves)
– Axis: left
– PR: progressively prolonging in sinus beats
QRS: wide with rsr pattern in V1,2,3 >> RBBB
2nd degree AV block type 1 with accelerated junctional escape rhythm, most likely 2ry to BB and amiodarone.
– RBBB ( RSR pattern)
– Poor R wave progression.
( may suggest anterior MI )
– second degree AV block mobitz type 1
– Incomplete trifasicular block ( bifasicular block+ 2nd degree AV block )
– pt need to be admitted to tele, work up to rule out ACS, stop BB
I have to admit, this was tough ECG..! but I think you all did very good job interpreting it.
This is sinus rhythm with second degree AV block, Mobitz I (Wenckebach). Best seen on V1 strip rhythm with 8 to 7 AV conduction, start counting from the second beat on the strip rhythm.
An interesting finding noted in V1, when rhythm start with complete RBBB in the 1st beat, then the next P wave did not conduct to the ventricle, which gives time for the conduction system and the right bundle to recover and the complete RBBB disappear in the 2nd and 3rd beats. However, because this 85 year old gentleman probably has significant underling conduction disease, the next beats shows complete RBBB, until the P wave again fail to conduct to the ventricle and right bundle recover and RBBB disappear in the last beat in the strip rhythm.
Good job everyone
16 Apr 2017
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