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

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 ). The 2019 ESC Guidelines for the management of patients with supraventricular tachycardia indicated that IV Amiodarone should not be considered in these populations.

AFIB 104

AFIB Atrial Fibrillation Tachycardia Blog 104

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

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

MAY 7, 2024

The two ECGs above were texted to me with the text: "Young Guy came in in SVT but now in and out of irregular wide complex tachycardia. -- not sure if polymorphic VT vs. a fib with WPW." FINAL Points in Today's CASE: Even though the SPERRI value during AFib in today's case was not below 250 msec. Definitely atrial fibrillation.

Atrial Fibrillation 132

Atrial Fibrillation AFIB Ablation Chest Pain 132

Dr. Smith's ECG Blog

MARCH 7, 2024

There were times when it would be usurped by sinus tachycardia, then return to this rhythm. This does NOT seem irregularly irregular enough for AFib … Instead — there is almost “group beating” with “Wenckebach periodicity”. CT of chest showed the bullet path through his right lung but nowhere near his heart. There is a wide complex.

Hemorrhage 127

Hemorrhage Chest Pain Article AFIB 127

Dr. Smith's ECG Blog

JULY 5, 2024

There is a regular wide complex tachycardia. Remember : Adenosine is safe in Regular Wide Complex Tachycardia. Rather, from this one: Very Fast Very Wide Complex Tachycardia Ideally, one would cardiovert. An older patient with no previous medical history arrived at triage complaining of SOB. If it is VT, there will be no effect.

Atrial Flutter 114

Atrial Flutter Tachycardia Atrial Fibrillation AFIB 114

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

This strip was obtained: Apparent Wide Complex Tachycardia at a rate of 280 What do you think? Troponins 34>33>43, likely secondary to myocardial injury from tachycardia. Is longterm endurance-training a risk factor for AFib and AFlutter? == Why is Today's Initial Rhythm AFlutter? What do you want to do?

Atrial Flutter 65

Atrial Flutter Exercise AFIB Tachycardia 65

Dr. Smith's ECG Blog

AUGUST 13, 2020

His previous echo one month prior shows the same thing: “consistent with old infarct in LAD vascular territory, with EF 45%” "I think there is something else causing his tachycardia which is exaggerating his EKG findings and mimicking an acute myocardial infarction." The patient spontaneously converted back to sinus tachycardia.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

DECEMBER 16, 2018

Wide-complex tachycardia: VT or aberrant, or "other?" A wide-complex tachycardia in an older patient must immediately suggest ventricular tachycardia. Sinus tachycardia with aberrancy was unlikely as the rate was consistently 150 bpm, without spontaneous variation. And indeed the QRS morphology strongly supported VT (e.g.

Tachycardia 52

Tachycardia Atrial Flutter AFIB Atrial Fibrillation 52

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

JUNE 14, 2024

The team immediately paged cardiology, concerned for polymorphic ventricular tachycardia. Since sinus conducted QRS complexes cannot co-exist together with ventricular tachycardia, this must all be artifact. The rhythm terminated before it could be captured on 12-lead. Upon questioning, the patient reported palpitations.

Atrial Fibrillation 82

Atrial Fibrillation Tachycardia Blog Chest Pain 82

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. The Initial ECG in Today's Case: As per Dr. Meyers — the initial ECG in today's case shows sinus tachycardia with bifascicular block ( = RBBB/LAHB ). Sinus Tachycardia ( common in any trauma patient. ).

Tachycardia 116

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia 116

Dr. Smith's ECG Blog

APRIL 23, 2019

Or are they due to ventricular tachycardia (VT). Within about an hour, he spontaneously converted to sinus rhythm: == My Comment by K EN G RAUER, MD ( 4/23/2019 ): == Interesting rhythm — in which the tachycardia alternates from a wide to narrow QRS complex. There are no P-waves. Sinus P waves are absent.

Tachycardia 52

Tachycardia AFIB Atrial Flutter 52

Dr. Smith's ECG Blog

DECEMBER 23, 2019

Initial ECG in the ED: Presenting ECG : Wide-complex tachycardia at a rate about 200. This is overwhelmingly likely to be ventricular tachycardia, even if only age and medical history are considered. Nevertheless, the widths of both the QRS complex and the RS duration are similar in both the old ECG and the tachycardia.

Tachycardia 52

Tachycardia Atrial Flutter Cardiomyopathy Atrial Fibrillation 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

Multifocal Atrial Tachycardia 2. 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. The rhythm is indeed irregularly irregular, so atrial fibrillation must be considered. Sinus with multifocal PACs 3. GET a 12-lead!

Atrial Fibrillation 52

Atrial Fibrillation Tachycardia Arrhythmia Pulmonary 52

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 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. Many patients have a T achy- B rady syndrome in which tachyarrhythmias ( most commonly rapid AFib ) alternate with periods of bradycardia. second in duration.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Bradycardia Pacemaker 52

Dr. Smith's ECG Blog

APRIL 24, 2022

The ECG there reportedly showed an irregular tachycardia, and the patient was immediately referred to the emergency room. Here is her ECG on arrival: There is a wide complex tachycardia that is irregularly irregular (this is difficult to determine at these very high rates). Vitals were within normal limits other than heart rate.

AFIB 52

AFIB Tachycardia Atrial Fibrillation Blog 52

EMS 12-Lead

APRIL 28, 2022

Initial vital signs include: NIBP 99/58 HR 150-160 (trend) RR 10 (spontaneous, but shallow) SpO2 86 (RA) BBS CTA The initial rhythm strip is attached: Figure 1 There is a wide complex tachycardia of varying morphology, amplitude, and R-R cycle length. The rS configuration in Lead I displays a persistent rightward axis.

Tachycardia 52

Tachycardia AFIB Arrhythmia Coronary Artery Bypass Graft 52

Dr. Smith's ECG Blog

JANUARY 15, 2024

We can see enough to make out that the rhythm is sinus tachycardia. Tachycardia is unusual for OMI, unless the patient is in cardiogenic shock (or getting close). A bedside ultrasound should be done to assess volume and other etiologies of tachycardia, but if no cause of type 2 MI is found, the cath lab should be activated NOW.

Chest Pain 65

Chest Pain Blog Arrhythmia Critical Care 65

Dr. Smith's ECG Blog

OCTOBER 10, 2022

I sent it to 2 of my ECG nerd colleagues with no clinical information whatsoever, who instantly said: "Looks like afib with subendocardial ischemia and right heart strain pattern." "I Tachycardia is of course, quite common in patients following cardiac arrest. The rhythm is rapid AFib. ECG #2 shows restoration of sinus rhythm.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

AUGUST 17, 2022

ACUTE MI (I allowed Acute MI to be in the report because I knew there would be an elevated troponin from ischemia, which is the definition of acute MI -- but in this case it would most likely be a Type 2 MI from tachycardia) There is also LA-RA lead reversal. The rhythm is rapid AFib. The QRS complex in lead I looks "funny".

Atrial Fibrillation 52

Atrial Fibrillation Ischemia AFIB Tachycardia 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

2) Tachycardia to this degree can cause ST segment changes in several ways. First , there can simply be diffuse ST depressions (which obligates reciprocal STE in aVR) associated with tachycardia which are not indicative of ischemia. Sometimes you must correct the rhythm to see what lies underneath. Is this inferor STEMI?

Ischemia 52

Ischemia Atrial Flutter Arrhythmia Tachycardia 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 ). But there are 3 other wide beats in the tachycardia that begins with beat #6 ( = beats #7; 13,14 ).

Cardiac Arrest 69

Cardiac Arrest Cardiomyopathy Arrhythmia Atrial Fibrillation 69

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

NOVEMBER 25, 2022

As we've discussed on numerous other posts in Dr. Smith's ECG Blog ( See My Comment at the bottom of the page in the May 5, 2022 post) — a growing number of conditions other than Brugada Syndrome have been found to temporarily produce a Brugada-1 ECG pattern. Sinus Tachycardia ( common in any trauma patient. ).

Arrhythmia 52

Arrhythmia Blog Chest Pain Cardiac Arrest 52

Dr. Smith's ECG Blog

OCTOBER 28, 2023

See this even more interesting and more dramatic and fascinating case: History of Hypertrophic Cardiomyopathy (HOCM), with Tachycardia and High Lactate = My Comment by K EN G RAUER, MD ( 10/28 /2023 ): = QUESTION: For clarity in Figure-1 — I've reproduced today's ECG without the long lead rhythm strip. Abnormal ST-T wave abnormalities.

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Preserved Ejection Fraction Sudden Cardiac Death Heart Failure Chest Pain 58

Dr. Smith's ECG Blog

MARCH 6, 2020

Here was his ED ECG: There is sinus tachycardia (rate about 114) with nonspecific ST-T abnormalities. An ECG was recorded: This shows a regular narrow complex tachycardia at a rate of about 160. See my quick review of atrial tachycardia below) The tachycardia spontaneously resolved. BP:143/99, Pulse 109, Temp 37.2 °C

Heart Failure 52

Heart Failure Tachycardia Atrial Flutter Cardiomyopathy 52

Ken Grauer, MD

JANUARY 10, 2025

As always I favor the P s , Q s , 3 R Approach ( See ECG Blog #185 ). For more on the concept of fusion beats See ECG Blog #128 and Blog #129 ). The risk of developing TiCM depends not only on the type of tachycardia but also on the duration and the rate of the tachycardia. The QRS measures 0.12

Blog 168

Blog Tachycardia Heart Disease AFIB 168

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

At the end of Dr. Meyers' discussion — he lists more than 20 links to cases that we've presented related to this entity on Dr. Smith's ECG Blog. Meyers serves as one more reminder of an entity that we need not to miss = Acute PE ( P ulmonary E mbolism ).

Chest Pain 114

Chest Pain Embolism Pulmonary Tachycardia 114

Dr. Smith's ECG Blog

JANUARY 26, 2025

Figure-1: While at first glance the rhythm in Figure-1 might be mistaken for sinus tachycardia in fact, this is not the rhythm. If the upright deflection in lead V1 was a single sinus P wave then the PR interval would be longer-than-expected for this to be sinus tachycardia. Figure-1: The initial ECG in today's case.

Atrial Flutter 67

Atrial Flutter Tachycardia AFIB Hospital 67