Ken Grauer, MD

FEBRUARY 18, 2023

These findings suggest that instead of VT — the rhythm in Figure-1 is AFib with a fairly rapid ventricular response. Since the rhythm is supraventricular (ie, AFib ) — we can accurately assess QRS morphology. Given a lack of prior history — I don’t know if the AFib on ECG #1 is ( or is not ) a new finding.

Blog 78

Blog AFIB Chest Pain STEMI 78

Ken Grauer, MD

MARCH 12, 2023

What is unusual about this arrhythmia? NOTE: The ECG in Figure-1 has been recorded at the usual 25mm/second speed — but with the Cabrera format ( Please see my Editorial Note near the top of the page in ECG Blog #365 for review of the basics of this recording system ). ECG Blog #287 — More on AFlutter.

Blog 78

Blog Atrial Flutter Arrhythmia AFIB 78

Ken Grauer, MD

JULY 9, 2023

By the P s , Q s , 3 R Approach ( See ECG Blog #185 ): The rhythm in Figure-1 is clearly not R egular. PEARL #2: As cited in ECG Blog #252 — my favorite truism in arrhythmia interpretation is, "The commonest cause of a pause is a blocked PAC". ECG Blog #199 and ECG Blog #366 — for Review of M AT.

Blog 78

Blog Cardiac Arrest Pulmonary AFIB 78

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

See our other blog posts of hypothermia and Osborn waves -- Massive Osborn Waves of Severe Hypothermia (23.6 Sci 5[4] 268-270, 2015 ) both highlight a likely association between acute development of ischemic J waves — and high risk of developing malignant ventricular arrhythmias ( My Comment in the September 23, 2020 post ).

Blog 139

Blog Cardiac Arrest Atrial Fibrillation Bradycardia 139

Dr. Smith's ECG Blog

DECEMBER 13, 2024

NOTE: The ECGs in today's case are recorded in the Cabrera Format ( See Dr. Grauer Comment in the October 26, 2020 post of Dr. Smith's ECG Blog for review on the Cabrera Format ). Since the patient was stable and tolerating the arrhythmia it was decided to treat with IV Amiodarone for medical conversion. Smith : What do you think?

AFIB 104

AFIB Atrial Fibrillation Tachycardia Blog 104

MIBHS

JANUARY 31, 2025

This blog explores the ways wearable technology can help track heart health, the advantages it offers, and how it contributes to better outcomes for those requiring surgical intervention. These early warnings are critical, as AFib increases the risk of stroke and other heart-related complications.

Heart Rhythm 52

Heart Rhythm Technology AFIB Exercise 52

Dr. Smith's ECG Blog

MARCH 15, 2023

. = My Comment by K EN G RAUER, MD ( 3/15 /2023 ): = I found today’s case highly instructive in highlighting a number of important aspects regarding the presentation and initial treatment of a patient who presents to the ED with new AFib. I focus my comment on a few additional aspects regarding new AFib.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Arrhythmia Exercise 52

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? The answer to this question is fascinating — albeit extending beyond the scope of this ECG Blog. Smith immediately say the rhythm was AFlutter with 1:1 AV conduction? Does Exercise Induce Non-Sinus Tachyarrhythmias?

Atrial Flutter 65

Atrial Flutter Exercise AFIB Tachycardia 65

Dr. Smith's ECG Blog

JULY 5, 2018

My Comment , by K EN G RAUER, MD ( 7/5/2018 ): This blog post provides an excellent example of how a patient with SSS ( = S ick S inus S yndrome ) may present. during which sinus bradycardia and arrhythmia are seen but not to a degree that produces symptoms. New slow AFib reflects a combination of these rhythm problems.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Bradycardia Pacemaker 52

Dr. Smith's ECG Blog

FEBRUARY 18, 2024

This could be easily overlooked since there is complete heart block, but recognizing the atrial arrhythmia may mean prescribing anticoagulation to prevent stroke. As I discussed in detail in My Comment at the bottom of the page in the January 13, 2024 post in Dr. Smith's ECG Blog — pacemaker spikes tend to be a high frequency signal.

Pacemaker 110

Pacemaker Blog Atrial Fibrillation Electrophysiology 110

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 ). WPW Cardiac arrhythmias ( including AFib ). Depth of the inverted T waves in leads V4 and V5 in Figure-1 attains this range. ( PEARL #1: Truly “giant” T waves are not overly common.

Chest Pain 95

Chest Pain Cardiomyopathy Blog AFIB 95

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished. Learning Points: Acute arrhythmias such as SVT, rapid AF, and atrial flutter may coexist and/or be caused by ischemia, or vice versa.

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52

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 ). The "usual rules" of cardiac arrhythmias are simply not always followed in critically ill patients.

Cardiogenic Shock 128

Cardiogenic Shock Cardiac Arrest Hospital Ischemia 128

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

I've copied KEY points from My Comment in the August 6, 2022 post in Dr. Smith's ECG Blog — regarding the answer to this question. Other Arrhythmias ( PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib ). Figure-1: The initial ECG in today's case. QTc prolongation.

Tachycardia 116

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 116

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 114

Atrial Flutter Tachycardia Atrial Fibrillation AFIB 114

Dr. Smith's ECG Blog

MAY 26, 2023

This was a very complex case and the details are too much for an ECG Blog, but suffice it to say that, s hortly thereafter, the patient had an asystolic arrest and was resuscitated. It will not always be possible to be 100% certain about the etiology of an arrhythmia from the single "snapshot" we get from a 10-second rhythm strip.

Cardiogenic Shock 98

Cardiogenic Shock Arrhythmia Blog Education 98

Dr. Smith's ECG Blog

MARCH 11, 2020

Therefore — the rhythm in ECG #1 is almost certain to be AFib ( A trial F ibrillation ) , seen here with a “rapid” ventricular response. Under normal conditions with AFib — the refractory period of the AV node does not allow more than 150-to-200 impulses/minute to be conducted to the ventricles.

AFIB 52

AFIB Tachycardia Atrial Fibrillation Arrhythmia 52

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 ). I have emphasized on many occasions in Dr. Smith's ECG Blog how AFlutter is by far (!) This patient presented to the ED “after a couple of days of chest discomfort”. Why was it Wrong to Think the Rhythm was AFlutter?

Tachycardia 121

Tachycardia Electrophysiology Atrial Flutter Ischemia 121

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

JANUARY 15, 2024

ECG 2 Especially in the context of the first ECG, readers of this blog will readily appreciate the ST elevations and hyperacute T waves in II, III, aVF, V6, and to a lesser extent V5. As discussed on this blog many times before, proportionality is key to the diagnosis of OMI by ECG. [link] I also texted the ECG to Dr. Smith.

Chest Pain 65

Chest Pain Blog Arrhythmia Critical Care 65

Dr. Smith's ECG Blog

SEPTEMBER 12, 2023

Figure-2: A rapid method for estimating the QTc ( Figure from My Comment in the March 19, 2019 post in Dr. Smith's ECG Blog ). == Clinical Implications of a Short QTc: The differential diagnosis for today's tracing, with its short QTc ~360 msec. ) — but as can be seen, my estimate of ~360 msec. mg/dL — vs normal values = 4.4-5.2

Cardiac Arrest 70

Cardiac Arrest Blog Atrial Fibrillation AFIB 70

Dr. Smith's ECG Blog

JANUARY 22, 2020

C linical P oints R egarding E CG # 1 : We are told that the patient is a middle-aged woman and that she previously had been in AFib with LBBB. While I agree that AFib + complete AV block is the most likely rhythm diagnosis I'd like to see additional monitoring strips to be sure. Clinically What has happened in the interim?

Pulmonary 52

Pulmonary AFIB Atrial Fibrillation Pacemaker 52

EMS 12-Lead

APRIL 28, 2022

The QRS is wide in B — but the rhythm is irregularly irregular with no sinus P waves — so this most probably represents rapid AFib with an atypical RBBB/LPHB morphology. We now see that QRS morphology in lead II during sinus rhythm is similar to the QRS morphology in lead II during rapid AFib (beats #1-5 in lead II in A).

Tachycardia 52

Tachycardia AFIB Arrhythmia Coronary Artery Bypass Graft 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

Learning points : Takotsubo can lead to cardiac arrest from ventricular arrhythmia. 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 ).

Cardiac Arrest 69

Cardiac Arrest Cardiomyopathy Arrhythmia Atrial Fibrillation 69

Dr. Smith's ECG Blog

JUNE 1, 2020

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 ). The reason I initially thought the underlying rhythm was AFib — is that no atrial activity is seen in any lead and the rhythm “looks” irregular. See text ).

Tachycardia 52

Tachycardia AFIB Blog Heart Disease 52

Dr. Smith's ECG Blog

NOVEMBER 25, 2022

He has a family history concerning for arrhythmia. Given the circumstances of his car crash, we presume it was due to an underlying arrhythmia. He has a family history concerning for arrhythmia with his father requiring some sort of device (PPM, ICD, unclear) at a young age.

Arrhythmia 52

Arrhythmia Blog Chest Pain Cardiac Arrest 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

M Y A NSWER: The issue of whether C omputerized E CG I nterpretations are “at fault” for an inaccurate ECG diagnosis has been addressed numerous times on this blog. How can you avoid overlooking this arrhythmia? The reasons for overlooking this arrhythmia are simple: True MAT is not a common rhythm. GET a 12-lead!

Atrial Fibrillation 52

Atrial Fibrillation Tachycardia Arrhythmia Pulmonary 52

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.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 16, 2018

During hospital admission she had a variety of atrial arrhythmias, which eventually resolved, likely due to her decreasing flecainide level. For example: Statistical likelihood that the regular WCT in ECG #1 might be AFlutter ( instead of VT ) is greatly increased in a patient with AFib who is taking Flecainide.

Tachycardia 52

Tachycardia Atrial Flutter AFIB Atrial Fibrillation 52

Dr. Smith's ECG Blog

APRIL 6, 2023

Taking a Closer LOOK : There is a fairly marked sinus arrhythmia ( RED arrows in Figure-2 ). PEARL # 1: It is common with 2nd- and 3rd-degree AV block to see a "ventriculophasic" sinus arrhythmia. I've also carefully measured all P-P intervals in milliseconds — to illustrate the surprisingly marked sinus arrhythmia.

Arrhythmia 52

Arrhythmia Atrial Fibrillation AFIB Outpatient 52

Dr. Smith's ECG Blog

JULY 5, 2023

Instead — my thoughts were as follows: The rhythm is sinus , with marked bradycardia and a component of sinus arrhythmia. WPW Cardiac arrhythmias ( especially AFib ). Smith's — in that despite the alarming ST-T wave changes, I did not think ECG #1 was the result of an acute event. Abnormal ST-T wave abnormalities.

Chest Pain 52

Chest Pain STEMI Congenital Heart Disease Heart Disease 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2020

The chart revealed that the arrhythmia was not new. Extending beyond the scope of this emergency medicine ECG Blog — is that clinical and ECG manifestations of the various subtypes of cardiac amyloidosis may vary depending on the specific type of this deposited protein. Atrial arrhythmias ( especially AFib or AFlutter ).

Atrial Flutter 52

Atrial Flutter Cardiomyopathy Chest Pain Arrhythmia 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

With the history of Afib, CTA abdomen was ordered to r/o mesenteric ischemia vs ischemic colitis vs small bowel obstruction. We’ve presented many variations on this theme on Dr. Smith’s Blog — with today’s case being distinguished by its discovery on abdominal exam ! The patient had mild but diffuse abdominal tenderness.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

DECEMBER 23, 2019

Adenosine is safe in VT and may be useful in making the diagnosis. == MY Comment by K EN G RAUER, MD ( 12/23/2019 ): == It is ALWAYS great to welcome the contributions to Dr. Smith’s ECG Blog from Dr. Brooks Walsh — a highly skilled clinician + good friend and colleague who always stimulates conversation on important emergency medicine topics.

Tachycardia 52

Tachycardia Atrial Flutter Cardiomyopathy Atrial Fibrillation 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 ? ). to diagnose almost any arrhythmia. What is the R ate? looking both at the atrial and ventricular rates IF these are different ). Is the rhythm R egular? (

Pacemaker 52

Pacemaker Chest Pain AFIB Blog 52

Dr. Smith's ECG Blog

OCTOBER 28, 2023

WPW Cardiac arrhythmias ( especially AFib ). 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 ). The Problem: None of the above ECG findings are specific for HCM.

Preserved Ejection Fraction 58

Preserved Ejection Fraction Sudden Cardiac Death Heart Failure Chest Pain 58

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