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 #185 — Review of the P s, Q s, 3 R Approach for systematic rhythm interpretation.

Blog 78

Blog Cardiac Arrest Pulmonary AFIB 78

Ken Grauer, MD

MAY 26, 2023

ECG Blog #185 — Review of the P s, Q s, 3 R Approach for systematic rhythm interpretation. ECG Blog #271 — Reviews the concept of diffuse Subendocardial Ischemia. ECG Blog #316 — The patient died. ECG Blog #184 — That magical inverse relationship between leads III and aVL. ECG Blog #183 — deWinter-like T waves.

Blog 78

Blog Ischemia STEMI Cardiac Arrest 78

Ken Grauer, MD

FEBRUARY 15, 2024

Given the irregular irregularity of beats #4-through 17 — Is this a run of AFib ( A trial Fib rillation ) with aberrant conduction? This raises the question if beats #4-thru-17 might represent a run of AFib with aberrant conduction? For more on fusion beats — See ECG Blog #128 and Blog #129 ). See ECG Blog #133 ).

Blog 131

Blog AFIB Arrhythmia Circulation 131

ECG Cases

OCTOBER 17, 2023

In this ECG Cases blog Dr. Jesse McLaren guides us through 10 cases, driving home the points that sepsis is a common cause of rapid Afib and diffuse ST depression with reciprocal ST elevation in aVR, myo/pericarditis is a diagnosis of exclusion, endocarditis or lyme carditis can cause AV block, PE can cause low grade fever and ECG signs of acute RV (..)

Pericarditis 90

Pericarditis AFIB Blog Atrial Fibrillation 90

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 The rhythm is irregularly irregular, and appears to be AFib with a fairly slow ventricular response ( overall rate <70/minute ) — although marked baseline artifact renders the search for atrial activity futile.

Cardiac Arrest 132

Cardiac Arrest Blog Atrial Fibrillation AFIB 132

Ken Grauer, MD

JANUARY 13, 2024

For more regarding ECG criteria for LVH — See the ADDENDUM below and/or ECG Blog #73 and ECG Blog #245. A bout H CM ( Different Forms of this Entity ): I've excerpted what appears below from My Comment in the December 26, 2023 post in Dr. Smith's ECG Blog. WPW Cardiac arrhythmias ( including AFib ).

Blog 148

Blog Ischemia AFIB Hypertension 148

Dr. Smith's ECG Blog

MARCH 7, 2024

This does NOT seem irregularly irregular enough for AFib … Instead — there is almost “group beating” with “Wenckebach periodicity”. The QRS is VERY wide — and the very wide Q in lead I ( showing marked axis deviation ) certainly suggest a ventricular etiology.

Hemorrhage 114

Hemorrhage Chest Pain AFIB Article 114

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

ECG Cases

FEBRUARY 28, 2022

Jesse McLaren explains his AFIB mnemonic for approach to atrial fibrillation that involves 4 questions: 1. and runs through 10 cases to elucidate the nuances of atrial fibrillation management on this ECG Cases blog. Is it atrial fibrillation? Does the patient need an anticoagulant started in the ED?

Atrial Fibrillation 52

Atrial Fibrillation AFIB Blog Atrial Flutter 52

Dr. Smith's ECG Blog

JULY 14, 2024

The rhythm in both tracings in Case #2 shows AFib with a controlled ventricular response ( with a PVC in the 2nd tracing ). Presumably the AFib is not a new rhythm — since new-onset AFib is usually associated with a rapid ventricular response.

AFIB 74

AFIB Stents Stent Chest Pain 74

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 ).

Blog 78

Blog Chest Pain AFIB STEMI 78

Dr. Smith's ECG Blog

AUGUST 18, 2024

As per Dr. Meyers — the underlying rhythm is either slow AFib or a junctional escape rhythm ( There is a fairly-but- not -completely regular underlying bradycardic rhythm — with narrow QRS — and no P waves ).

Pacemaker 90

Pacemaker AFIB Atrial Fibrillation 90

Dr. Smith's ECG Blog

JUNE 14, 2024

. == Links to Examples of ARTIFACT: What follows below is an expanding list of technical "misadventures" — most from Dr. Smith's ECG Blog — some from other sources ( NOTE: As I did not previously keep track of these — there are additional examples of artifact sprinkled through Dr. Smith's ECG Blog that I have not yet included here. ).

Atrial Fibrillation 76

Atrial Fibrillation Tachycardia Chest Pain Blog 76

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 114

Chest Pain Cardiomyopathy Blog AFIB 114

Ken Grauer, MD

MARCH 12, 2023

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 ). Among the fast Supraventricular Rhythms: This is not AFib — because the rhythm is regular.

Blog 78

Blog Atrial Flutter Arrhythmia AFIB 78

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

MARCH 28, 2024

I don’t see evidence of retrograde atrial activity during the WCT — but usually with the “almost regular AFib rhythms” — you can when you measure pick up some slight differences — so my hunch is that the initial ECG is a REENTRY SVT rhythm, that then breaks down to AFib. Theoretically — this can occur with BOTH AVNRT and AVRT.

Tachycardia 121

Tachycardia Atrial Fibrillation AFIB Atrial Flutter 121

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

This is written by Magnus Nossen, with some edits by Smith This ECG diagnosis will be obvious to the majority of the readers of this blog. Thoughts about Today's CASE: On occasion — a patient may present for acute care because of CP ( C hest P ain ) due solely to a tachyarrhythmia ( including new AFib, a reentry SVT or VT ).

Chest Pain 89

Chest Pain Atrial Fibrillation AFIB Myocardial Infarction 89

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

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 ). Could there be HCM? What else?

Chest Pain 52

Chest Pain AFIB Blog Atrial Fibrillation 52

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 71

Cardiac Arrest Blog Atrial Fibrillation AFIB 71

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 QRS complex in lead I looks "funny".

Atrial Fibrillation 52

Atrial Fibrillation Ischemia AFIB Tachycardia 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 66

Chest Pain Blog Critical Care Arrhythmia 66

Dr. Sanjay Gupta

DECEMBER 19, 2022

Conditions such as AFib are often said to be associated with stroke as a consequence of cardioembolism. I hope you found this blog useful. Keywords: Cryptogenic strokes; AF; Afib; PFO; stroke; blood clots; thrombophilia; Antiphospholipid syndrome. This is called cardioembolism. This is the link to the video.

Stroke 52

Stroke Strokes Blood Clot AFIB 52

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. What are the ECG Findings of Cardiac Contusion?

Tachycardia 106

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 106

Dr. Smith's ECG Blog

DECEMBER 16, 2018

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. The underlying rhythm is AFib ( irregularly irregular QRS without P waves ). Note QRS widening for beats #14-thru-18 in ECG #3.

Tachycardia 52

Tachycardia Atrial Flutter AFIB Atrial Fibrillation 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 Coronary Artery Disease 52

Dr. Smith's ECG Blog

MARCH 6, 2020

I focus My Comment on determination of the e tiology of this patient’s tachyarrhythmia — and compare it to other SVT rhythms previously published in Dr. Smith’s ECG Blog. E CG # 2 in Figure-1 is from the October 16, 2019 post on Dr. Smith’s Blog. E CG # 3 in Figure-1 is the 4th tracing shown above from T oday’s C ase.

Heart Failure 52

Heart Failure Tachycardia Atrial Flutter Cardiomyopathy 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

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 77

Preserved Ejection Fraction Sudden Cardiac Death Heart Failure Chest Pain 77

Dr. Smith's ECG Blog

MAY 7, 2024

Since the ventricular response in ECG #2 is comparable to the rate range for any patient who develops new-onset AFib — definitive diagnosis of WPW was not made in today's case until the 3rd ECG was obtained. FINAL Points in Today's CASE: Even though the SPERRI value during AFib in today's case was not below 250 msec.

Atrial Fibrillation 116

Atrial Fibrillation AFIB Ablation Chest Pain 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 95

Atrial Flutter Tachycardia Atrial Fibrillation AFIB 95

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 19, 2020

Resuscitation was initiated and this ECG was obtained: Likely AFib (irregularly irregular) with bradycardia. STD in V2 from posterior MI can "pull down" the STE in V1 and negate it. On arrival in the ED, she was profoundly hypotensive, nearly obtunded, and bradycardic. Figure-2: ECG #2 — recorded on arrival in the ED ( See text ).

Bradycardia 52

Bradycardia STEMI AFIB Pacemaker 52

Dr. Sanjay Gupta

JANUARY 17, 2022

The first thing I want to say is that unfortunately the practice of modern day medicine is largely servile to clinical guidelines. We decide how to treat a patient based on how someone else (i.e whoever wrote the guideline) tells us how to manage the patient.

Dementia 52

Dementia Ablation Risk Factors Atrial Fibrillation 52

Dr. Smith's ECG Blog

FEBRUARY 18, 2024

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. 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 ).

Pacemaker 89

Pacemaker Blog Atrial Fibrillation Electrophysiology 89

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

Meyers, awareness that this patient had just been started on Flecainide for treatment of AFib, but without concomitant use of an AV nodal blocking agent — greatly increases the likelihood that the SVT rhythm in ECG #1 is the result of a proarrhythmic effect of Flecainide ( ie, conversion of AFib to AFlutter with 1:1 AV conduction ).

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 52