Ken Grauer, MD

MARCH 29, 2023

M y I MPRESSION : The rhythm in Figure -1 is almost certain to be very rapid AFib in a patient with WPW. NOTE #2: Surprisingly, it is not uncommon for patients in AFib with WPW to be hemodynamically stable — despite having exceedingly rapid ventricular rates. ECG Blog #284 — Reviews a case similar to today's Very Fast AFib.

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Blog AFIB Arrhythmia Download 78

Dr. Smith's ECG Blog

MAY 3, 2024

Despite the irregularity of QRS complexes — this rhythm is not AFib — because at least some definite P waves are present ( RED arrows that I added at the bottom of ECG #1 ). Smith has noted — recognition of Shark Fin morphology told us that the seemingly wide and irregular rhythm in Figure-1 was almost certain to be supraventricular!

Cardiogenic Shock 126

Cardiogenic Shock Cardiac Arrest Hospital Ischemia 126

Ken Grauer, MD

SEPTEMBER 13, 2024

I was sent the ECG shown in Figure-1 — being told only that providers on the case suspected AFib ( A trial Fib rillation ) with RBBB ( R ight B undle B ranch B lock ) aberrancy. Working through a case of a regular WCT Rhythm in this 80-something woman — See My Comment in the May 5, 2020 post on Dr. Smith’s ECG Blog.

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Blog Tachycardia Arrhythmia AFIB 98

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Is longterm endurance-training a risk factor for AFib and AFlutter? == Why is Today's Initial Rhythm AFlutter? Moderate" exercise seems to have a protective effect with reduced risk of AFib — whereas "excessive" exercise has been shown to significantly increase the risk of developing AFib, especially as adults age.

Atrial Flutter 64

Atrial Flutter Exercise AFIB Tachycardia 64

Dr. Smith's ECG Blog

JULY 5, 2024

As we often emphasize ( See My Comment in the May 5, 2020 post of Dr. Smith's ECG Blog ) — Statistically (ie, even before we look at the ECG itself ) — at least 80% of all regular WCT rhythms without clear sign of P waves will turn out to be VT ( V entricular T achycardia ). I'd add the following thoughts to Dr. Smith's discussion.

Atrial Flutter 112

Atrial Flutter Tachycardia Atrial Fibrillation AFIB 112

Dr. Smith's ECG Blog

MARCH 11, 2020

== MY Comment by K EN G RAUER, MD ( 3/12/2020 ): == A young adult presented to the ED with the “heart awareness” and the ECG shown in Figure-1 — but with no more than slight shortness of breath. Therefore — the rhythm in ECG #1 is almost certain to be AFib ( A trial F ibrillation ) , seen here with a “rapid” ventricular response.

AFIB 52

AFIB Tachycardia Atrial Fibrillation Arrhythmia 52

DAIC

APRIL 9, 2024

AFib Facts and Impacts Atrial fibrillation is the most common cardiac arrhythmia, affecting 2% of individuals worldwide. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). doi:10.1093/europace/euae043. Eur Heart J.

Atrial Fibrillation 105

Atrial Fibrillation Ablation Heart Rhythm Blood Clot 105

Ken Grauer, MD

APRIL 26, 2024

This defines the rhythm as AFib ( A trial F ibrillation ) , here with a controlled ventricular response ( ie, overall heart rate between ~70-to-100/minute ). Recognizing hyperacute T waves — patterns of leads — an OMI ( though not a STEMI ) — See My Comment at the bottom of the page in the November 8, 2020 post on Dr. Smith's ECG Blog.

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Blog STEMI Aneurysm AFIB 156

Ken Grauer, MD

JANUARY 13, 2024

HCM is an "umbrella term" applied to the presence of LVH in the absence of "abnormal cardiac loading conditions" ( Hughes et al — JAHA 9:e015294, 2020 ). WPW Cardiac arrhythmias ( including AFib ). Tall R wave in lead V1 and/or early transition in the chest leads ( reflecting increased "septal" forces ).

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Blog Ischemia AFIB Hypertension 159

Ken Grauer, MD

FEBRUARY 28, 2023

As a result, in order to differentiate MAT from the much more commonly encountered irregularly irregular rhythm ( which is AFib ) — we need to be certain we are seeing multiple different P wave morphologies that are constantly changing. Clinically , the importance of recognizing MAT — is that treatment is different than the treatment of AFib.

Blog 78

Blog COVID-19 AFIB Pulmonary 78

Dr. Smith's ECG Blog

JUNE 14, 2024

The April 6, 2023 post — excessive baseline artifact misdiagnosed as AFib ( instead of sinus rhythm with AV Wenckebach — as in Figure-4 in this post ). The November 10, 2020 post — for PTA. The October 17, 2020 post — for a 70-year old woman with " Artifactual VT ". The March 17, 2023 post — for PTA.

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Atrial Fibrillation Tachycardia Blog Chest Pain 81

Dr. Smith's ECG Blog

DECEMBER 26, 2023

For more on Giant T waves — See My Comment at the bottom of the page in the June 22, 2020 and September 19, 2022 posts in Dr. Smith's ECG Blog ). Types of HCM: As per Hughes et al ( JAHA 9:e015294, 2020 ) — HCM is an "umbrella term" applied to the presence of LVH in the absence of "abnormal cardiac loading conditions".

Chest Pain 93

Chest Pain Cardiomyopathy Blog AFIB 93

Dr. Smith's ECG Blog

AUGUST 17, 2022

The rhythm is rapid AFib. These are the "Take-Home" Lessons from today's tracing: As per Dr. Smith — Rapid AFib may sometimes simulate acute posterior OMI. This anterior ST depression often resolves ( or at least greatly decreases ) when AFib is controlled and the heart rate slows. The February 11, 2020 post ( LA-RA reversal ).

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Atrial Fibrillation Ischemia AFIB Tachycardia 52

Dr. Smith's ECG Blog

JANUARY 22, 2020

See this terrible case: Computer often fails to diagnose atrial fibrillation in ventricular paced rhythm, and that can be catastrophic == MY Comment , by K EN G RAUER, MD ( 1/22/2020 ): == Our THANKS to Dr. Smith for presenting this extremely interesting case. Clinically What has happened in the interim?

Pulmonary 52

Pulmonary AFIB Atrial Fibrillation Pacemaker 52

Dr. Smith's ECG Blog

FEBRUARY 18, 2024

The April 6, 2023 post — excessive baseline artifact misdiagnosed as AFib ( instead of sinus rhythm with AV Wenckebach — as in Figure-4 in this post ). The November 10, 2020 post — for PTA. The October 17, 2020 post — for a 70-year old woman with " Artifactual VT ". The March 17, 2023 post — for PTA.

Pacemaker 109

Pacemaker Blog Atrial Fibrillation Electrophysiology 109

Dr. Smith's ECG Blog

APRIL 24, 2022

Patient was referred to electrophysiologic testing due to suspicion of afib and WPW. During electrophysiologic testing AVRT was induced, which degenerated to afib with ortho and antidromic conduction. Despite the near regularity in places — the reasons I immediately thought of WPW with very rapid AFib were i ) As per per Drs.

AFIB 52

AFIB Tachycardia Atrial Fibrillation Blog 52

Dr. Smith's ECG Blog

OCTOBER 28, 2023

WPW Cardiac arrhythmias ( especially AFib ). 23/WCC — 2/21/2020 ). 23/WCC — 2/21/2020 ). 23/WCC — 2/21/2020 ). 23/WCC — 2/21/2020 ). Tall R wave in lead V1 and/or early transition in the chest leads ( reflecting increased "septal" forces ). Abnormal ST-T wave abnormalities. Conduction defects (ie, LBBB, IVCD ).

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Preserved Ejection Fraction Sudden Cardiac Death Chest Pain Heart Failure 57

Dr. Smith's ECG Blog

AUGUST 13, 2020

Time Window for Reperfusion; Acuteness on the ECG) == MY Comment by K EN G RAUER, MD ( 8/13/2020 ): == This is a challenging case — which is made all the more difficult by suboptimal quality of the initial 12-lead ECG — and lack of additional simultaneously-recorded leads for the arrhythmia tracings. Would you give Thrombolytics?

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Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

JUNE 1, 2020

== MY Comment by K EN G RAUER, MD ( 6/1 /2020 ): == YOU are asked to interpret the ECG shown in Figure-1. MY THOUGHTS on ECG #1: My initial impression on looking at the ECG in Figure-1 — was that the rhythm was either rapid AFib in a patient with WPW — or — PMVT ( P oly M orphic VT ). Unfortunately, no history is available to assist.

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Tachycardia AFIB Blog Heart Disease 52

Dr. Smith's ECG Blog

SEPTEMBER 12, 2023

For more on my systematic approach — Check out My Comment in the May 3, 2020 post ). Assuming the patient did not have hypercalcemia and there was no history of cardiac arrest, unexplained syncope or AFib at an early age — cardiac risk from a “short” QTc is clearly less than for patients with frank SQTC.

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Cardiac Arrest Blog Atrial Fibrillation AFIB 68

Dr. Smith's ECG Blog

JULY 7, 2023

MY Thoughts on Today's ECG: As per Dr. Smith — the rhythm in ECG #1 appears to be AFib with a controlled ventricular response ( ie, irregularly irregular without clear sign of P waves ). Figure-1: The initial ECG in today's case. ( To improve visualization — I've digitized the original ECG using PMcardio ). What else?

Chest Pain 52

Chest Pain AFIB Blog Atrial Fibrillation 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

I have periodically called attention to examples of the Ashman phenomenon as they occur in Dr. Smith's ECG Blog ( See My Comments in the January 5, 2020 post — the June 17, 2020 post — and the March 30, 2023 post , among others ).

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Cardiac Arrest Cardiomyopathy Arrhythmia Atrial Fibrillation 67

Ken Grauer, MD

JULY 22, 2023

I see the following: Although there is no long lead rhythm strip — we can see that the rhythm is AFib with a controlled ventricular response ( ie, irregularly irregular rhythm without P waves — and with a heart rate between ~70-110/minute ). Regarding Intervals: There is no PR interval ( since the rhythm is AFib ).

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Blog Chest Pain STEMI AFIB 78

Ken Grauer, MD

JULY 9, 2023

ECG Blog #71 — Regarding the Ashman Phenomenon with AFib. These cases provide insight to assessment for MAT: The January 5, 2020 post in Dr. Smith’s ECG Blog — for an example of MAT. ECG Blog #70 — Reviews the A shman P henomenon ( re aberrant conduction ). I link to 2 additional illustrative Cases taken from Dr. Smith’s ECG Blog.

Blog 78

Blog Cardiac Arrest Pulmonary AFIB 78

Ken Grauer, MD

MARCH 12, 2023

Among the fast Supraventricular Rhythms: This is not AFib — because the rhythm is regular. P utting I t A ll T ogether : — The Rhythm in Figure-1 What we have just described is the following: A regular WCT ( = W ide- C omplex T achycardia ) at a rate very close to 300/minute — without clear sign of atrial activity.

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Blog Atrial Flutter Arrhythmia AFIB 78

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient also has a history of AFib and HFmrEF ( = H eart F ailure with M inimally- R educed E jection F raction ). The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). This patient presented to the ED “after a couple of days of chest discomfort”.

Tachycardia 119

Tachycardia Electrophysiology Atrial Flutter Ischemia 119

Ken Grauer, MD

MAY 26, 2023

The importance of the new OMI ( vs the old STEMI ) Paradigm — See My Comment in the July 31, 2020 post in Dr. Smith's ECG Blog. What is certain — is the continued marked ST depression in the mid-chest leads, consistent with an ongoing, extensive infarction in this patient with severe symptoms and hypotension. =

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Blog Ischemia STEMI Cardiac Arrest 78

Dr. Smith's ECG Blog

JANUARY 5, 2020

of all cases, and 62% of Veritas® misdiagnoses). == MY Comment , by K EN G RAUER, MD ( 1/5/2020 ): == This case illustrates a number of important teaching points. AFib is the irregularly irregular rhythm that is most commonly confused with MAT — and , AFib is much, much, much more common than true MAT. GET a 12-lead!

Atrial Fibrillation 52

Atrial Fibrillation Tachycardia Arrhythmia Pulmonary 52

Dr. Smith's ECG Blog

JANUARY 15, 2024

The April 6, 2023 post — excessive baseline artifact misdiagnosed as AFib ( instead of sinus rhythm with AV Wenckebach — as in Figure-4 in this post ). The November 10, 2020 post — for PTA. The October 17, 2020 post — for a 70-year old woman with " Artifactual VT ". The March 17, 2023 post — for PTA.

Chest Pain 64

Chest Pain Blog Arrhythmia Critical Care 64

Dr. Smith's ECG Blog

JANUARY 19, 2020

Resuscitation was initiated and this ECG was obtained: Likely AFib (irregularly irregular) with bradycardia. Consider thrombolytics for OMI when PCI is not an option. == MY Comment by K EN G RAUER, MD ( 1/19/2020 ): == There is a LOT to talk about regarding the series of tracings in this unfortunate case.

Bradycardia 52

Bradycardia STEMI AFIB Pacemaker 52

Dr. Smith's ECG Blog

JANUARY 26, 2023

and if not — Is the rhythm “irregularly irregular”, as in AFib — or is there a pattern of “regular" irregularity in the form of group beating ? ). What is the R ate? looking both at the atrial and ventricular rates IF these are different ). Is the rhythm R egular? ( If P waves are present — Are P waves R elated to neighboring QRS complexes?

Pacemaker 52

Pacemaker Chest Pain AFIB Blog 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2020

Diagnosis : Extremely slow Atrial flutter == MY Comment , by K EN G RAUER, MD ( 11/15/2020 ): == Some of the most interesting ECG cases I have seen have been picked up “reading through a stack of ECGs” — in the same manner that Dr. Smith picked up today’s case. Atrial arrhythmias ( especially AFib or AFlutter ). Prolonged QTc interval.

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Atrial Flutter Cardiomyopathy Chest Pain Arrhythmia 52

Dr. Smith's ECG Blog

JANUARY 26, 2020

Is This a Simple Right Bundle Branch Block? == MY Comment , by K EN G RAUER, MD ( 1/26/2020 ): == Dr. Smiths ECG Blog has presented too-numerous-to-count cases of hyperkalemia ( See My Comment in the 12/11/2018 post there are many others! ). Is this just right bundle branch block?

Bradycardia 52

Bradycardia Ischemia Cardiac Arrest AFIB 52

Dr. Smith's ECG Blog

FEBRUARY 17, 2023

Assuming there was no history of cardiac arrest, unexplained syncope or AFib at an early age — cardiac risk from a “short” QTc is clearly less than for patients with frank SQTC.

Chest Pain 52

Chest Pain Cardiac Arrest STEMI Arrhythmia 52

Dr. Smith's ECG Blog

MARCH 6, 2020

Figure-4: I’ve postulated a laddergram for ECG #3 in Today’s Case ( For more on the use of laddergrams — See My Comment in the February 20, 2020 post ). That said — ATach can not be ruled out until EP study is done. Our THANKS to Dr. Smith for presenting this case!

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Heart Failure Tachycardia Atrial Flutter Cardiomyopathy 52

Dr. Smith's ECG Blog

JANUARY 26, 2025

Note: The ECG in Figure-1 was initially recorded using the Cabrera Format ( See Comment by Dr. Grauer at the bottom of the page in the October 26, 2020 post for review of the Cabrera Format ). The AFib had been well controlled on Flecainide for many years. Facilitating conversion of AFib to AFlutter as another proarrhythmic effect.

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Atrial Flutter Tachycardia AFIB Hospital 66

Dr. Smith's ECG Blog

NOVEMBER 23, 2024

The April 6, 2023 post — excessive baseline artifact misdiagnosed as AFib ( instead of sinus rhythm with AV Wenckebach — as in Figure-4 in this post ). The November 10, 2020 post — for PTA. The October 17, 2020 post — for a 70-year old woman with " Artifactual VT ". The March 17, 2023 post — for PTA.

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Blog Chest Pain Myocardial Infarction Critical Care 63