What Is the Rhythm?

from Medscape Cardiology

Posted 12/08/2004

Kyuhyun Wang, MD

1. This tracing shows regular wide-QRS tachycardia at a rate of 135/min. What is the rhythm? Choose 1 from the list below.
A) Sinus tachycardia with right bundle branch block (RBBB)

B) Ectopic atrial tachycardia with RBBB

C) Atrial flutter with 2:1 atrioventricular (AV) conduction and RBBB

D) Ventricular tachycardia with 1:1 retrograde V-A conduction

• C) Atrial flutter with 2:1 atrioventricular (AV)
conduction and RBBB is correct.
This tracing illustrates regular wide-QRS
tachycardia at 134/min. Typical RBBB is present
(broad S waves in leads I, aVL, and V6).
• In V1, there seems to be only one P wave in
front of each QRS, suggesting sinus
tachycardia. But in lead II, there are typical
"domes" of atrial flutter, as drawn.
The Cause of Bradycardia

From Medscape Cardiology

Kyuhyun Wang, MD

1. Which of the following is the cause of the bradycardia shown on this tracing? Choose 1 from the list below.
A) Sinus bradycardia

B) Nonconducted atrial bigeminy

C) 2:1 AV block
• B) Nonconducted atrial bigeminy is correct.
• Discussion
•
• Every other P wave (↓) occurs prematurely that
fails to conduct to the ventricles because it
occurs during the refractory period of the
conduction system. It is not 2:1 AV block
because the P waves do not occur regularly. It is
not sinus bradycardia because there is an extra
P wave between the QRSs.
Which Electrolyte Problem?

From Medscape Cardiology

Kyuhyun Wang, MD

1. Which electrolyte problem is this tracing suggestive of?

• Answer: Hyperkalemia
• Discussion
• As the tracing shows, this patient has a regular rhythm at a rate of
101/min. The QRSs are very wide; wider than those seen with
ordinary bundle branch block. T-waves are tall in V1-3. These
findings are all characteristic of hyperkalemia. The serum potassium
level was 7.2 mEq/L. The rhythm may be sinus with the P-waves
hidden in the ST segment or sino-ventricular rhythm if P-waves are
truly not present. Atrial muscle is more sensitive to hyperkalemia
than the specialized conduction system is. At certain levels of
hyperkalemia, the atrial muscle becomes inexcitable ("paralyzed")
while the special internodal conduction system is still excitable.
Then, the sinus impulses will conduct to the ventricles through the
conduction system without the atria being depolarized – thus
referred to as sino-ventricular rhythm.
What Do These Group Beatings Suggest?

from Medscape Cardiology

Posted 01/18/2005

Kyuhyun Wang, MD

1. Which of the following does this tracing show? Choose 1 from the list below.
A) Nonconducted atrial quadrigeminy

B) 4:3 AV Wenckebach phenomenon

C) Sinus node dysfunction

D) Sinus arrhythmia
 B) 4:3 AV Wenckebach phenomenon is correct.

The P-waves (highlighted by the arrows in Figure 2) occur regularly. Every 4th P-wave is
blocked indicating second degree AV block. The lengthening of the PR interval indicates
Wenckebach phenomenon (type I second degree AV block). Thus, when QRSs occur in
groups, Wenckebach phenomenon should be considered.
Nonconducted atrial quadrigeminy is incorrect because the blocked P-wave does not occur
prematurely; sinus node dysfunction is incorrect because the P-wave is present during the
"pause"; and sinus arrhythmia is incorrect because, as mentioned above, the P-waves
occur regularly.
Which Part of the Ventricle Is Infarcted?

from Medscape Cardiology

Posted 01/11/2005

Kyuhyun Wang, MD

1. This patient has a myocardial infarction. Which part of the left ventricle is involved? Choose 1 from the list below.
A) High lateral wall (leads I and aVL)

B) Inferior wall (leads II, III, and aVF)

• A) High lateral wall (leads I and aVL) is correct.
Discussion
• This tracing is from a patient who has high lateral wall
infarction due to an occlusion of the diagonal branch
manifested by ST elevation in leads I and aVL. The ST
depression noted in the inferior leads is an obligatory,
reciprocal response of the ST elevation in aVL, and there
is nothing wrong with the inferior wall.
• How do we know which are the primary and which are
the secondary changes? Go with the ST elevation, and
you will be right most of the time.
•
Arrhythmias of Wolff-Parkinson-White Syndrome (IV)

from Medscape Cardiology

Posted 10/26/2004

Kyuhyun Wang, MD

1. What does this tracing show? Choose 1 from the list below.
A) Pre-excitation of alternate beats

B) Electrical alternans

C) Ventricular bigeminy
• A) Pre-excitation of alternate beats is correct.
Discussion
• Every other QRS looks different, raising a possibility of
electrical alternans or ventricular bigeminy.
• This tracing is from a patient with WPW syndrome. At
this time, only every other beat is pre-excited (note the
short PR interval and delta wave of every other beat that
is pre-excited). WPW syndrome can manifest
intermittently, ie, several beats at a time, several hours
at a time, or only every other beat, as in this case. In
electrical alternans, the QRS width remains the same,
while in this tracing, every other beat is wider with a delta
wave (pre-excited). Also, the typical delta waves rule out
ventricular bigeminy.
 Arrhythmias of Wolff-Parkinson-White Syndrome (III)

from Medscape Cardiology

Posted 10/19/2004

Kyuhyun Wang, MD

1. This tracing is from a patient with Wolff-Parkinson-White (WPW) syndrome. The accessory pathway is involved in this rhythm. What is the
rhythm? Choose 1 from the list below:
A) Atrial fibrillation with conduction to the ventricle through the accessory pathway

B) Polymorphic ventricular tachycardia

• A) Atrial fibrillation with conduction to the ventricle through the
accessory pathway is correct.
This tracing depicts irregularly irregular rhythm at a rate close to
300/min. This patient with WPW syndrome develops atrial fibrillation
and the atrial impulses are conducted to the ventricle through the
accessory pathway. This accessory pathway has a much shorter
refractory period than the AV node and is capable of transmitting
atrial impulses at a faster rate than the AV node, resulting in the
tracing presented here. The ventricular rate is too fast, and this is a
life-threatening arrhythmia.
• One should not hesitate to deliver a shock to the precardium to
convert the atrial fibrillation to sinus rhythm. If the patient is alert and
stable, ibutilide or procainamide can be tried intravenously, which
can either slow down the ventricular rate or, better yet, convert the
atrial fibrillation. Digitalis given intravenously, verapamil, and
adenosine are contraindicated because they can facilitate the
conduction through the accessory pathway even further, or can
reduce the blood pressure even further.
Arrhythmias of Wolff-Parkinson-White Syndrome (II)

from Medscape Cardiology

Posted 10/12/2004

Kyuhyun Wang, MD

1. This tracing is from a patient with Wolff-Parkinson-White (WPW) syndrome. The accessory pathway is involved in this rhythm. What is
the rhythm? Choose 1 from the list below.
A) Orthodromic AV re-entrant tachycardia

B) Antidromic AV re-entrant tachycardia

• B) Antidromic AV re-entrant tachycardia is correct.
Discussion
• This tracing depicts regular tachycardia at a rate of
180/min. This is a form of AV re-entrant tachycardia. The
QRSs are wide, indicating that the ventricle is activated
through the accessory pathway and the retrograde
conduction back to the atria is through the AV node, called
antidromic AV re-entrant tachycardia. This type comprises
5% of cases of AV re-entrant tachycardia. As in
orthodromic AV re-entrant tachycardia, the AV node is
involved in the re-entry circuit and AV blocking maneuver
or drugs have a chance of converting this rhythm. If one
has to use a drug, adenosine is the drug of choice, since it
acts so quickly.
Arrhythmias of Wolff-Parkinson-White Syndrome (I)

from Medscape Cardiology

Posted 09/23/2004

Kyuhyun Wang, MD

1. This tracing is from a patient with Wolff-Parkinson-White (WPW) syndrome. The accessory pathway is involved in this rhythm. What
is the rhythm? Choose 1 from the list below.
A) Orthodromic A-V re-entrant tachycardia

B) Antidromic A-V re-entrant tachycardia

• A) Orthodromic A-V re-entrant tachycardia is correct.
Discussion
• This tracing depicts regular tachycardia at a rate of 180/min. No
P waves are seen. The QRSs are narrow, indicating that the
anterograde conduction is through the AV node and the
retrograde conduction through the accessory pathway, also
called orthodromic AV re-entrant tachycardia. Ninety-five
percent of AV re-entrant tachycardia is this type and 5% is
antidromic (anterograde conduction via accessory pathway and
retrograde conduction to atrium via AV node). AV blocking
maneuvers or drugs have a chance of terminating this rhythm.
If one has to use a drug, adenosine is the drug of choice, since
it acts very quickly.
What Is the Reason for the Tall R Waves in Lead V1?

from Medscape Cardiology

Posted 09/09/2004

Kyuhyun Wang, MD

1. What is the reason for the tall R waves in lead V1? Choose the correct answer from the list below:
A) Posterior infarct

B) Right ventricular hypertrophy

C) Wolff-Parkinson-White syndrome

D) Reversed V1-V3 leads

• D) Reversed V1-V3 leads is correct.
Discussion
• Among the precordial leads, the lead with the most
diphasic P wave (initially positive, then negative) is V1. In
this tracing, the P wave in V3 is most diphasic and leads
V1 and V3 are reversed, which is the most common form
of reversed leads. Right ventricular hypertrophy should
be accompanied by right axis deviation and deep S
waves in V6, which is not the case here. Wolff-
Parkinson-White syndrome should show short PR
interval and delta waves in some or all leads, which are
not seen here. In an old posterior infarction, the R waves
remain taller in V2 and V3, which does not happen here.
Anteroseptal Infarct, RBBB, and Posterior Fascicular Block?

from Medscape Cardiology

Posted 08/05/2004

Kyuhyun Wang, MD

1. What does this tracing show? Select the correct answer from the choices listed below.
A) Anteroseptal infarct (ASMI), right bundle branch block (RBBB), and posterior fascicular block

B) ASMI and posterior fascicular block, but not RBBB

C) ASMI and RBBB, but not posterior fascicular block

D) RBBB and posterior fascicular block, but not ASMI

• A) Anteroseptal infarct (ASMI), right bundle branch
block (RBBB), and posterior fascicular block is
correct.
Discussion
• Q waves in V1-4 are diagnostic of anteroseptal infarct.
Q-wave infarction affects only the initial portion of the
QRS complex, not the latter portion. Therefore, of the
rsR' pattern of right bundle branch block (RBBB) in V1,
the R wave is replaced by a Q wave while the R' wave
remains. That is what is seen in V1-3 in this tracing. In
RBBB, right axis deviation (RAD) in which the R wave
duration in lead I is less than 40 msec before it becomes
an S wave (I would describe it as "too much, too early
RAD") is highly suggestive of left posterior fascicular
block, which is what this tracing shows.
Which Electrolyte Problem (II)?

from Medscape Cardiology

Posted 07/13/2004

Kyuhyun Wang, MD

1. Which electrolyte problem is this tracing suggestive of?

• Hypokalemia is correct.
• Discussion
• In leads V1-3, the T waves are shallowly
inverted and are followed by a prominent
U wave. These findings are highly
suggestive of hypokalemia. The serum
potassium was 2.2 mEq/L at the time.
Name the Electrolyte Problems

from Medscape Cardiology

Posted 07/01/2004

Kyuhyun Wang, MD

1. Name 2 electrolyte problems present in this tracing.

• Hypocalcemia and hyperkalemia is correct.
• Discussion
• The QT interval is long. When the long QT
interval is due to a long ST segment with a
delayed onset of the T wave, it is specific for
hypocalcemia. Besides, the T waves are tall,
narrow, and pointed and are highly suggestive of
hyperkalemia. This combination of electrolyte
problems is common in patients with chronic
renal failure, which this patient has. The serum
potassium level was 8.2 mEq/L and calcium 5.4
mg/dL at the time.
What Is the Rhythm?

from Medscape Cardiology

Posted 05/27/2004

Kyuhyun Wang, MD

1. What is the rhythm? Choose the correct answer from the list below.
A) Atrial fibrillation

B) Multifocal atrial tachycardia (MAT)

• B) Multifocal atrial tachycardia (MAT) is correct.
Discussion
• Narrow QRS, irregularly irregular rhythm at a mean
rate of 160/min is present. One P wave is present in
front of each QRS (see leads II, III, aVL, and V1-6).
The P-P intervals keep changing and the P-wave
morphology keeps changing. These findings are
characteristic of MAT.
Inferior and Anteroseptal Myocardial Infarction?

from Medscape Cardiology

Posted 05/20/2004

Kyuhyun Wang, MD

1. This tracing shows acute inferior infarct. The ST-segment is elevated in lead V1 as well. What is the reason? Choose the correct answer from the list below.
A) Concomitant anteroseptal infarct

B) Right ventricular (RV) infarct

• B) Right ventricular (RV) infarct is correct.
Discussion
• Acute inferior infarct is evident, and the ST elevation in V1
indicates RV infarct. Simultaneous involvement of both the
right coronary artery (RCA) and left anterior descending
artery (LAD) is very, very rare. Besides, if LAD is also
involved, resulting in anteroseptal infarction, the ST
elevation should be seen in V2 and V3 as well. RV
infarction occurs only if the proximal RCA is occluded. That
is the case here, judging from the fact that the ST segment
is reciprocally depressed in lead I as well as in aVL. If this
inferior infarct were due to circumflex artery occlusion, the
ST segment would be depressed only in aVL, not in lead I.
Mobitz Type I or II 2° AV Block?

from Medscape Cardiology

Posted 05/12/2004

Kyuhyun Wang, MD

1. What does this tracing show? Choose the correct answer from the list below.
A) Type II, then type I, then back to type II 2° AV block

B) Type I 2° AV block all along

C) Type II 2° AV block all along

• B) Type I 2° AV block all along is correct.
Discussion
• 2:1 AV block is present initially, then, in the middle of the
tracing, 3:2 AV Wenckebach phenomenon, then back to 2:1
AV block. Here, 2:1 conduction ratio can be considered as
the shortest Wenckebach cycle, ie, the conduction ratio of
5:4 becomes 4:3, then 3:2, and finally 2:1. Thus, during 2:1
AV block, if a typical Wenckebach phenomenon is
manifested somewhere in the tracing, it is type I all along. If
Wenckebach phenomenon is not seen during 2:1 AV block,
pay attention to the QRS width and the PR interval of
conducted beats; if the QRS is narrow and the PR interval is
long, the block is most likely within the AV node. Otherwise,
the block is below the His bundle. This distinction is
important because the block within the AV node is mostly
due to reversible conditions and relatively benign, whereas
the block below the His bundle is not due to reversible
conditions and is more troublesome, often requiring a
pacemaker.
Infarction?

from Medscape Cardiology

Posted 05/05/2004

J. Willis Hurst, MD, MACP

1. Choose the correct interpretation from the list below.

A) Subendocardial infarction

B) Pericarditis

C) Brugada waves

D) Extensive anterior-septal infarction

• D) Extensive anterior-septal infarction is correct.
The large mean S-T segment vector is directed
anteriorly and represents extensive epicardial injury.
Large Q waves are seen in V1 – V4. This signifies the
presence of a large extensive anterior-septal myocardial
infarction.
• Discussion
• The patient was a 73-year-old woman with symptoms of
myocardial infarction. One can predict from the direction
of the S-T segment that the obstructed artery would have
been in the left anterior descending coronary artery or,
less likely, in the left main coronary artery. Coronary
arteriogram revealed 90% obstruction of the proximal left
anterior descending coronary artery and 30% to 40%
narrowing of the mid portion of the right coronary artery.
Myocardial Infarction?

from Medscape Cardiology

Posted 04/28/2004

Kyuhyun Wang, MD

1. What do the Q waves in leads II, III, aVF, and V5-6 reflect? Choose the correct answer from the list below.
A) Infero-lateral infarct

B) Normal septal Q waves

• B) Normal septal Q waves is correct.
Discussion
• These Q waves are not wide enough (> 1 small box width)
and, therefore, are not pathologic. The earliest part of the
ventricle that undergoes depolarization is the ventricular
septum. The vector of this depolarization is pointed to the
patient's right and a little superiorly, resulting in Q waves in
inferior and lateral precordial leads -- normal septal Q waves.
For them to be abnormal, or pathologic, they have to be wider
than 1 small box width (40 msec). However, normal septal Q
waves do not exist in V2, and any Q wave is abnormal in this
lead.
A 48-Year-Old Female

from Medscape Cardiology

Posted 03/17/2004

J. Willis Hurst, MD

1. The electrocardiogram featured above was recorded on a 48-year-old female. Select the correct interpretation from the list below.
A) Anteroseptal myocardial infarction

B) Right ventricular hypertrophy

C) Generalized pericarditis

D) Brugada abnormalities
• A) Anteroseptal myocardial infarction is correct.
The initial QRS force (Q wave vector) is directed to the
right and very posteriorly away from the anteroseptal
portion of the left ventricle. The mean S-T vector is
directed anteriorly toward an area of anteroseptal
epicardial injury. The mean T vector is directed slightly to
the right and slightly anterior, indicating lateral ischemia.
There is a left atrial abnormality.
• Discussion
• This tracing was recorded from a 48-year-old female with
a characteristic story of chest pain due to myocardial
infarction.
Acute Infarction?

from Medscape Cardiology

Posted 03/10/2004

Kyuhyun Wang, MD

The findings in V2-3 suggest acute anteroseptal infarction. However, this tracing was taken recently from a patient who had an acute anteroseptal infarction
6 months earlier and has not had any additional cardiac events since. The ECG findings remain unchanged since the infarction.

1. What cardiac diagnosis do the ECG findings suggest?

• Ventricular aneurysm is correct!
• Discussion
• Persistent ST elevation after an infarction,
especially when it is combined with
terminal T wave inversion as in this case,
is a very good ECG feature of a ventricular
aneurysm, which this patient has.
Infero-posterior Infarction?

from Medscape Cardiology

Posted 03/03/2004

Kyuhyun Wang, MD

1. What does this tracing show? (Choose 1 from the list below.)
A) Wolff-Parkinson-White (WPW) syndrome

B) Infero-posterior infarct

C) Right ventricular hypertrophy

• A) Wolff-Parkinson-White (WPW)
syndrome is correct.
Discussion
• Findings in leads II, III, and aVF suggest old
inferior infarction. However, the negative
initial deflection of the QRS is actually a
negative delta wave. Short PR interval and
delta waves are evident in leads I and aVL.