Rhythm Strips, Many Are Beyond Imagination!

Frank Yanowitz, MD
Professor of Medicine (Retired)
University of Utah School of Medicine

From my ECG collection and the amazing collection of my late friend and colleague, Dr. Alan E. Lindsay
http://ecg.utah.edu
 Instructions
http://ecg.utah.edu

• Each ECG slide is open to your interpretations and thoughts.

• Each ECG slide will be followed by the same ECG tracings but with my
interpretation and teaching points.

• I sometimes make mistakes…….., so if you have an issue with my

interpretation, please let me know (via the website).

• Don’t be afraid to use calipers to measure RR and PP intervals:

• Some of these ECGs are very old; I am also very old.

(be gentle)
 Ventricular ectopy vs. Supraventricular with aberrancy
1. Search for the P (‘Cherchez le P’) on the T (it’s sexier to look in French)
2. Measure the pause (assumes P-P intervals are all the same)
– Compensatory vs. non-compensatory (i.e., complete or incomplete)
– Ask: has the sinus node been reset or not ?
– PACs more likely to reset the sinus; PVC’s less likely to reset sinus (unless retrograde conduction)
– Works best at faster sinus rates (>75 bpm, to avoid vagal tone fluctuations)
– Use calipers to measure PP intervals
3. Consider the QRS morphology (especially in lead V1): RBBB 50:50 LV 50:50

4. Wide monomorphic QRS tachycardias: rsR’ ectopy

– Is there AV dissociation?
• Look for fusions and/or captures
– Look at QRS morphology in lead V1 (RV vs. LV origin)
– QRS axis: If in the NW Quadrant (-91 to 180 degrees) most likely ventricular origin)
– Consider 4-Step Brugada rules (see 2018 PDF Outline, p43)
• (usually unnecessary)
 (Slower HR)

(Longer RP)

a
V1

b
V1

c
V1

1. ‘Cherchez le P’
 FLB Morphology in lead V1
Is the QRS mostly up-going (A) or down-going (B)?

Up-going (+) QRS indicates

movement from LV to RV
LV It
rSR’ 50:50 depends
ectopy
A Classic RBBB

Down-going (-) QRS indicates

movement from RV to LV

B
 Wide QRS Tachycardias JACC EP 2017;3:669-77

Features favoring VT Features favoring SVT

• AV dissociation • rSR’ triphasic (RBBB-like) in V1
• With fusions & captures
• LBBB-like in V1 with narrow r,
• QRS width >0.16 s
• NW QRS Quadrant axis (90° - 180°)
smooth, rapid S downstroke,
• RBBB-like with notched R in V1 and
and nadir <60 ms from QRS
1st peak greater than 2nd peak (#4) onset
• LBBB-like in V1-2 with any one of: a) • QRS in V6 with intrinsicoid
fat R, b)notched downstroke of S deflection <50 ms and/or
wave, or c) delayed S nadir (60 ms
after QRS onset) triphasic qRs pattern in RBBB
• Initial R in aVR and/or width of –like tachycardias
initial R or Q >40 ms

rSR’ Classic RBBB ? LV ectopy ?

 A.

B.

C.

1.
 A.

NSR (90 bpm); 3rd degree AV block (complete AV Dissociation); junctional escape rhythm with LBBB

B.

Looks like a- utter, but actually it’s a- b with moderate-fast ventricular response. Note the irregularly
irregular ventricular response. Note peak-to-peak di erences in the ‘ utter-like’ brillation waves.

C.

1b. Atrial brillation, rapid ventricular response with atypical RBBB morphology
fi
fl
fi
ff
fl
fi
 A.

B.

C.

2.
 *
A.

NSR (3 Beats), one PVC, sinus beat followed by onset of ectopic atrial tachycardia (*)

B.

Atrial sensed (NSR) right ventricular paced rhythm. Note: QRS morphology in V1 suggests RV ectopy

C.

NSR with 2 late onset (end-diastolic) left ventricular PVCs with complete compensatory pause. Note: the
2b. PVC morphology in V1 suggests LV origin (moving from posterior to anterior direction)
 A.

B.

C.

3.
 A.

HR = 200 bpm: Atrial utter (or ectopic atrial tachycardia) with 2:1 AV conduction delay

B.

NSR (~85 bpm) with 2nd degree AV block (type II) and RBBB; the block is either in His bundle or
there is intermittent block in the left bundle (i.e., bilateral bundle branch disease)

C.

NSR with 2 aberrantly conducted PACs (RBBB); the pause is incomplete (i.e., PACs reset the sinus)
3b.
fl
 A. V1

B.

C.

4.
 ?

A. V1

2nd degree SA block; note the pause with the missing sinus P is 2x the basic PP interval

B.

NSR with nonsustained VT; note the fusion beat at the onset (*). The VT is from LV (from posterior LV
chamber moving towards anterior RV in lead V1)

C.

NSR; 2nd degree AV block (type I) and RBBB; the block is likely in AV node (Ca++ channel)

4b.
 A.

B.

V1
C.

5.
 * *

A.

Incomplete AV dissociation; ventricular paced rhythm competing with NSR; note sinus captures (*)

B. * *

NSR with 2 PVCs, one is interpolated, sinus P (*), and one has complete compensatory pause

V1 * * *
C.

5b. Sinus bradycardia with 3 PVCs; note the PVCs have retrograde P waves (*) that reset the sinus!
 V1
A.

V1

B.

V1
C.

6.
 * * * *

V1
A.
Sinus bradycardia (~50 bpm) with intermittent RV pacing (77bpm *) interrupted by sinus captures

V1

B.
Atrial brillation with intermittent rate-dependent RBBB aberrancy (rsR’)

V1
C.

6b. Third degree AV block; sinus rhythm (99 bpm); junctional escape rhythm (50 bpm) with RBBB
fi
 A
V1

V1

7.
 * * *
A
V1
Atrial brillation, slow ventricular response with junctional escapes (note regular RR intervals *)

Atrial brillation, rapid ventricular response with rate-related LBBB aberrancy. (This is not VT)

V1

7b. Atrial utter with 2:1 and 4:1 AV block; note the regular irregularity! (don’t be fooled; it’s not a- b)
fl
fi
fi
fi
 V1

A.

B.

V1

II
C.

8.
 V1 * *

A.

Incomplete AV dissociation due to accelerated J-rhythm (85 bpm); two sinus captures with RBBB aberrancy (*)

B.

V1

NSR (75 bpm) with 2nd degree AV block (type I) and one PVC (*); also anteroseptal STEMI.

II
C.
* * *

Sinus rhythm; three nonconducted PACs (*) in a pattern of bigeminy. Nonconducted PACs are the
8b. most frequent causes of unexpected pauses. Always search for the P (Cherchez le P)!
 A.

V1

B.

V1

C.

9.
 * * * * *

A.

* * * * * *
V1
High grade 2nd degree AV block (type I) with sinus captures (*) and junctional escapes (*)

B. * *

V1
2nd degree AVB (type I) with bradycardia dependent LBBB (*) aberrancy after the pause.

C.

9b. SVT with RBBB (the morphology of rsR’ in V1 is very good odds of a supraventricular rhythm!
 A

B
V1

10.
 A

Sinus bradycardia; now, that wasn’t very di cult!

B
V1
Sinus rhythm with late onset PVCs from LV (note + direction in V1 indicates coming from LV)

* * * *

10b.
Sinus rhythm with PAC’s in a pattern of bigeminy (*) that have LBBB aberrancy
ffi
 A.

B.

C.

11.
 Short
Long cycle cycle

A.

Atrial b with one aberrantly conducted QRS (RBBB). These were originally called Ashman beats!

B.

NSR (85 bpm) with 2nd degree AV block (Type I)

C.
* *

11b. NSR with conducted (*) and nonconducted (*) PACs (Cherchez le P)
fi
 V1

A.

B.

C.

12.
 V1 *

A.

Incomplete AV dissociation due to marked sinus bradycardia and a J-esc rhythm (default). Note: one sinus
capture with RBBB aberrancy (*).

B.

Sinus rhythm with PVCs in a pattern of bigeminy. PVCs are from the LV (moving anteriorly in V1)

C.

12b. 2nd degree AV block (type II, infra nodal) with RBBB. The AVB might be in the left bundle. (consider pacemaker).
 V1

A.

V1

B.

C.

13.
 V1 * * *

A.

Atrial brillation with three PVCs from the LV; note QRS morphology with notch on the downstroke (*)

V1 Note
Shorter RR

B. *

NSR and a J-escape rhythm due to high-grade 2nd degree AV block; one sinus capture (*); RBBB

* *
C.

13b. Sinus rhythm with incomplete AV dissoc.; usurping accelerated V-rhythm (RV origin); note two fusion beats (*)
fi
 V1

14.
 * * *
V1
Wow! i.e., 3x
* * *

* * *

* *

* *

Continuous rhythm strip: NSR with premature junctional beats (*) in a parasystolic pattern (i.e., the intervals between the PJCs
have a xed common denominator; the parasystolic ectopic focus in the AV junction res at a xed rate independent of the
sinus and captures the ventricles at di erent coupling intervals from the sinus beats); this is very rarely picked up in today’s
14b. ECG world. Note also the RBBB.
fi
ff
fi
fi
 V1

A.

B.

V1

15.
 V1

A.
* *

Sinus rhythm (~95 bpm) with ventricular parasystole. Note that the PVCs are not xed to the previous sinus
beats but move away (at a slightly faster rate) and eventually result in fusion beats (*) before disappearing.
1x 2x
*

B. * * *

V1

Another example of NSR with ventricular parasystole and fusion beats (*); note the common inter-ectopic
15b. intervals. (the ectopic intervals don’t have to be exact)

fi
 A.

B.

C.

D.
16.
 A.
NSR with 1st degree AVB

B.

Sinus tachycardia with 1st degree AVB (note sinus P waves buried in the T)

C.

NSR with 2nd degree AVB (type I, hidden P waves in T waves) with one PVC

D.
16b. Sinus tachycardia with 2nd degree AVB (type I, hidden P waves in T waves)
 A.

B.
V1

II

C.

17.
 A.
V1

NSR (~100 bpm); 2nd degree AV block (type II) with 3:2 and 2:1 conduction; also LBBB

* *

B.
V1

NSR with 2nd degree AV block (type I) and 2 junctional escapes (*) that end the long pauses.

II

C.

NSR with 2nd degree AV block (type unknown, because in 2:1 block we can’t say)

17b.
 A.

B.

C.

18.
 A.

V1
Atrial utter with marked variable AV block

Sinus P Sinus P

B.
V1

NSR with 2 PVCs (complete pauses) and two PACs (incomplete pauses resetting the sinus)

C.

V1

NSR with 2nd degree AV block (type I) with 3:2 conduction

18b.
fl
 A.

B.

C.

19.
 A.
V1
NSR with 2nd degree AV block (type II) and LBBB (note successive nonconducted P’s)

* *

B.
V1
NSR with 2 PVCs (from the LV) and 2 junctional escapes (*) ending the long pauses

C.

Acute anteroseptal STEMI; NSR interrupted by accelerated ventricular rhythm (LV origin);
19b. note dissociated sinus P waves and one fusion beat (*)
 A.

B.

C.

20.
 *

A. *

NSR interrupted by an isochronic (i.e.,similar HR) accelerated J-rhythm (onset here*); return of NSR
(onset here*) at the end; note AV dissociation during the junctional rhythm).

* * * * *
B.

NSR with 2nd degree AV block (type unknown) because of junctional escapes (*); this is probably type I
because the setting is inferior STEMI which may a ect AV node conduction (CA++ bers)

C.

Sinus tachycardia and 3rd degree AV block (complete AV dissociation)

20b.
ff
fi
 A.

B.

21.
 A.

NSR; 2nd degree AV block (type II) 2:1 and 3:2 conduction; RBBB (V1) and LAFB (lead II); i.e. bifascicular block

* *
B.

J J J J J
NSR with high grade 2nd degree AV block (type I), junctional escape rhythm (J); two sinus captures (*);
note the inverse relationship between RP and subsequent PR in captured beats (indicates type I AV block)
21b.
 swallow

swallow

swallow

45 y.o. man

Lindsay AE
22. Am Heart J 1973;85:679
 swallow
a-tachycadia

a-tachycadia

swallow

swallow

45 y.o. man with swallow- or deglutition-induced ectopic atrial tachycardia (with or w/o RBBB or LBBB aberration

Lindsay AE
22b. Am Heart J 1973;85:679
 A.

Admission ECG

B. 24-hrs later

V1

C.

23.
 A.

Admission ECG

24-hrs later
B. * * *

Inferior STEMI: 2nd degree AV block (type I) with J-escapes (*)

V1
* * S * * *

S S
C. * * * *

23b. Continuous strip: Inferior STEMI: 2nd degree AV block (type I) with J-esc rhythm (*); only 3 sinus captures (S)!
 A.

B.

C.

D.

24.
 * *

A.
Junctional rhythm with retrograde type I AV block; 2 retrograde P’s return to ventricles (*echos) with RBBB aberrancy

B.

NSR (~100 bpm) with 2nd degree (type II) AV block (2:1 and 3:2 conduction); also LBBB

? J J J
C. * *

J-escape rhythm with high-grade type I 2nd degree AVB; 2 (*) sinus captures (shorter RR intervals, in red); PR inversely proportional to RP

*
D.

24b. NSR with 2nd degree AVB (type I) with atrial echo (*); the longest PR allows the P to return retrogradely as an echo beat.
25.
 Nice publication from the team at Intermountain Medical Center
25b.
 A.

B.

C.

26.
 * *

A.

NSR with 2nd degree AVB (type I) with junctional escapes (*).

* * *

B.*

NSR with conducted and nonconducted PACs (*). Nonconducted PACs are the most common causes of an unexpected pause!
That’s why we must always Cherchez le P !

C.

NSR with 2:1 2nd degree AV block (type undetermined because only 2:1 conduction) (probably type I, narrow QRS)
26b.
 A.

B.

C.

27.
 A.

NSR with 2nd degree AV block (type II) and LBBB (note successive nonconducted P’s)

B.

NSR with 3rd degree AV block with complete AV dissociation; junctional escape rhythm

C.

Sinus bradycardia; one PVC followed by slightly faster ectopic atrial rhythm
27b.
 1.

2.
≈

28.
 * * * *
1.

Sinus tachycardia (110 bpm); 2nd degree (type I) AV block with accelerated junctional ‘escapes’ (*)

* *
2.

Sinus tachycardia (110 bpm); 2nd degree (type I) AV block with accelerated junctional ‘escapes’ (*)

maybe open to other interpretations ??

28b.
29. FLB: Theme & Variations
 *
A- b, 1 RBBB aberrancy, and
1 PVC (from the LV *)

A- utter, variable conduction

and one RBBB aberrancy

STEMI; NSR with aberrantly

conducted and normally
conducted PACs; note RBBB
aberrancy after long pause

* * NSR with 1 aberrantly

conducted PAC (*) and one
4 beat SVT where 1st beat
is aberrantly conducted (*).
29a. FLB: Theme & Variations
fl
fi
 I

II

III

DB: Age 19 (courtesy of Dr. Alan Lindsay)

30.
 I

1. Normal sinus rhythm with intermittent

II
WPW preexcitation; note the short PR
and the delta waves in the di erent leads.

III 2. An alternative explanation is that the FLBs

are ‘late’ (end-diastolic) PVCs. In V1 the wide
QRSs are down-going (moving posterior) and
in V6 they are up-going (moving left); i.e., they
are originating in the RV.

DB: Age 19

30b.
ff
 Age 40; long history of paroxysmal tachycardia

31.
 Age 40; long history of paroxysmal tachycardia
Another example of intermittent preexcitation (WPW) alternating with NSR. Note that
31b. the WPW QRSs (red circles) have slightly shorter PR intervals with minimally wider and di erent QRSs.

ff
 II

V2

II

V2

32.
 Another example of intermittent preexcitation (WPW)
alternating with NSR. Note the WPW QRSs
II

V2

II

V2

>300 bpm

32b.
One of the dangers of a fast accessory pathway is atrial brillation with extremely rapid ventricular response.
fi
33.
 A. Accessory path and AV node used resulting
in a short PR and delta wave on the QRS

B. PAC is blocked in the accessory pathway

conducting through AV node with normal QRS

C. and D. illustrate mechanism of AVRT

33b.
34.
 *

Another patient with intermittent WPW preexcitation.

The ladder-diagram begin with the red dotted line. Note that here the sinus uses only the AV node
resulting in a normal QRS (*). The next QRS shows preexcitation with a short PR and wide QRS. The
next QRS is normal, but a PAC (black arrow) initiates AVRT as illustrated in the ladder diagram.

34b.
 V1

CCU continuous rhythm strips

35.
 V1

CCU continuous rhythm strips: atypical type I 2nd degree AV block; analyzed in the following slides………
35b.
 * *

V1

A. 2nd degree AVB with ventricular escape; B. same with rate related LBBB (as RR shortens); C. fusion beat (ventricular
35c. escape rsR’ + a sinus capture; D. rate-related LBBB with ???
 No explanation needed!

35d.
 170/3 = 57
286/5 = 57 = 107/min
36. 390/7 = 56
 170/3 = 57 Atrial parasystole: ‘X’ indicated the inter-ectopic interval in decimeters;
i.e., 57 decimeters is 570 mm which translates to ~107 bpm)
286/5 = 57 = 107/min
36b. 390/7 = 56
 V1

37.
 V1 *

* *

* *

NSR with frequent PVCs, couplets, and triplets (VT). Fusion beats are also present (*). Ventricular ectopy
is LV origin (moving anterior in direction from the posterior LV)

37b. LV ectopy
 134 = 67 x 2
188 = 63 x 3 Parasystolic ventricular rate = 94 bpm
248 = 62 x 4

38. (courtesy of Dr. Alan Lindsay)

 * * * * *

* * *
* *

134 = 67 x 2
188 = 63 x 3 Parasystolic ventricular rate = 94 bpm
248 = 62 x 4
Ventricular parasystole; note fusion beats (*)

38b. (courtesy of Dr. Alan Lindsay)

39.
 NSR with frequent PACs from a parasystolic focus; note common inter-ectopic interval (~1.1 sec)

39b.
 Why did the HR slow here ??

40.
 *

* *

*
*
* * * * * * *

NSR with frequent PACs:

a. normally conducted (*) Why did the HR slow here ??
b. aberrantly conducted (*) Nonconducted PACs in bigeminy!
c. nonconducted (*) Cherchez le P !
40b.
 II

1. Before Rx
2. After Rx

What was the treatment ?

41.
 II

1. Before Rx utter with 2:1 conduction

1. Atrial
2. Atrial
2. After Rx utter with 1:1 conduction

What was the treatment ?

41b.
fl
fl
 A funny thing happened on the way to the ventricles.

42.
 A funny thing happened on the way to the ventricles.
Top (lead 2): atrial tachycardia with 1:1 conduction

Bottom: (lead V1) (after carotid sinus massage): atrial tachycardia with variable conduction
: RR and/or PP intervals: 180 bpm (carotid massage slowed AV conduction, but didn’t stop the arrhythmia)

42b.
 II

24-y.o. woman with history of paroxysmal tachycardia (on beta-blocker)

43.
 * *

II

24-y.o. woman with history of paroxysmal tachycardia (on beta-blocker)

Ectopic atrial tachycardia with variable AV block (2:1, 3:2, 1:1); several aberrantly conducted QRSs (*);
converting to sinus bradycardia and sinus arrhythmia. Note: long/short rule for aberration (Ashman!)
43b.
 II

44.
 J J J

* * *
II
J J J

* * *

J J J J

* * * ?

Continuous lead II rhythm strip: Sinus tachycardia with conducted ( ) and nonconducted (*) PACs; Junctional escapes
are seen after nonconducted PACs (J).

44b.
45.
 NSR with PACs that result in atrial brillation with a rapid HR response

45b.
Courtesy of PDQ Bach (Dr. Alan Lindsay was a great fan!)
fi
46.
 2 PP

Pretty obvious isn’t it: the sinus res but sometimes doesn’t make it to the atria. In the di erential diagnosis of an
unexpected pause a nonconducted PAC is the most common. Other considerations include marked sinus arrhythmia,
2nd degree AV block (the pause includes a P wave) and 2nd degree SA block which is the diagnosis in this strip! This
diagnosis is suggested when the pause is approximately equal to 2 PP intervals.

Two types of 2nd degree SA block have been described, but without any clinical signi cance (unlike AV block).

46b.
fi
fi
ff
 V1

47.
 * *
*
V1
PP

* *

* *

NSR with 1st degree AV block and 2nd degree SA block; frequent junctional escapes (*); one retrograde P (*);
2nd degree SA block is likely when the PP interval of the pause is ~2x the sinus PP.

47b.
 V1

48.
 ? J J J J

J J J J

Shorter RR

J J J ? J J

V1

NSR with 2nd degree AV block (probably type II) and LBBB. Frequent Junctional escapes present (J); sinus captures are seen
when the RR intervals shorten ( ).

48b.
 II

49.
 B B B B B

B E E B

II

49b. All about junctional premature beats: retrograde P & QRS relationships
 V1 1400 ms

1400 ms

On digoxin

50.
 V1 1400 ms

1400 ms

On digoxin Patient with long standing atrial brillation with 3rd degree AV block at level of AV node (and RBBB):
A. Junctional tachycardia~140 bpm.
B. Junctional tachycardia with varying degrees of exit block to the ventricles (still in a- b)

Conclusion: digoxin toxicity!

50b.
fi
fi
 V1
A.

II

V1

B.

The 3 Fates……..

51.
 *

V1
A.
* *

II

* *
V1 *

B.
The 3 Fates……..of PACs
1. Normally conducted (*)
2. Aberrantly conducted (*)
3. Nonconducted ( )

51b.
 *

A. V1

Before Rx: What’s this? *

V1
B.

After Rx

52.
 *

A. V1

Before Rx: What’s this? NSR, 2:1 AV block and RBBB; a fusion beat (*); 3-beat RV escape rhythm; ending with sinus capture!

V1
B.

After Rx: right ventricular pacing ( ) with retrograde P waves

Note: the fusion beat (*) looks like a normal QRS..but it’s actually
a fusion of the sinus P entering the LV (because of RBBB) at the
same time that the RV escapes (due to the slow HR). The
resultant QRS reflects that the two ventricles are activated
simultaneously!

52b.
 V1

What degree?

53.
 * * *

V1

What degree?
Incomplete AV dissociation (by default) due to to 2nd degree AV block (type I) and junctional escapes; sinus
captures are identi ed (*) by shorter RR intervals compared to the J-escape RR intervals. In type I 2nd degree AVB
there is an inverse relationship between RP and the next PR indicating that the location of the block is in the Ca++
bers of the AV node. Block in His or bundle branches and fascicles of the LBB are all-or-none (Na+ bers)

53b.
fi
fi
fi
 Massage
parlor antics
CSM

CSM
54.
 Massage
parlor antics
CSM

Sinus tachycardia slowing

AVNRT converting to sinus bradycardia (variation in sinus P morphology)

Atrial utter 2:1 AV block slowing markedly, but atrial utter persists

CSM
54b.
Ectopic atrial tachycardia with 1:1 conduction slowing to 2:1 conduction
fl
fl
55.
 * *

* *

Incomplete AV dissociation due to a slightly accelerated junctional rhythm competing with an intermittently faster
normal sinus rhythm (*). Sinus captures are identi ed by slightly shorter RR intervals and normal PR intervals; when
the sinus slows (during sinus arrhythmia) the junction takes over. With two competing pacemakers for ventricular capture
the faster pacemaker is the ‘boss’ of the QRS.

55b.
fi
 Common Mistakes (I)
Common Mistakes All Of Us Sometimes Make

1. Assume all pauses are due to SA node dysfunction

2. Assume all funny looking wide premature beats are PVC’s

56.
 Common Mistakes (I)
Common Mistakes All Of Us Sometimes Make

1. Assume all pauses are due to SA node dysfunction: Nonconducted PAC (*)

* *

2. Assume all funny looking wide premature beats are PVC’s: PACs (*) with RBBB aberrancy

56b.
 Common Mistakes (II)
Common Mistakes All Of Us Sometimes Make

3. Feel comfortable with a regular rhythm in atrial fibrillation:

4. Assume all wide QRS tachycardias are ventricular:

57.
 Common Mistakes (II)
Common Mistakes All Of Us Sometimes Make

3. Feel comfortable with a regular rhythm in atrial fibrillation:

Atrial brillation with complete heart block; accelerated junctional rhythm (consider digoxin toxicity)

4. Assume all wide QRS tachycardias are ventricular:

Atrial brillation with rapid heart rate and rate related LBBB aberrancy

57b.
fi
fi
58. “…and finally, let it never be said that ECG’s lack a sense of humor.”
 7/24/1978

59. (courtesy of Dr. Alan Lindsay)

 V1

60. (courtesy of Dr. Douglas Zipes)

 V1 * * * * *

Continuous rhythm strip: 2nd degree AV block (type I) with right ventricular escapes (*) and incomplete AV
dissociation. In the middle and bottom strips 2nd degree AV block persists; the wide QRS beats are
probably RV escapes (cannot exclude brady-dependent LBBB). The fusion beat ? favors RV escapes!

60b. (courtesy of Dr. Douglas Zipes)

 II

During carotid sinus massage…

61.
 II

During carotid sinus massage…

Marked sinus slowing results in bradycardia-dependent LBBB with varying degrees of ‘completeness’. It is thought that
as the heart rate decreases, escape pacemaker cells living in the left bundle branch start to ‘wake up’, but before they reach
ring threshold the sinus impulse comes into the bundle branch. Conduction slows (or blocks) in the partially depolarized
left bundle and results in varying degrees of LBBB. Brady-induced aberrancy is way less common than tachycardia-aberrancy.

61b.
fi
 III

(courtesy of Dr. Alan Lindsay)

62.
 III

(courtesy of Dr. Alan Lindsay)

NSR with conducted and nonconducted premature junctional beats ( ); also LBBB. The ladder diagram shows
62b. that the PJCs have a parasystolic focus ( xed inter-ectopic interval)
fi
 V1

RR 1000 960 920 900 900 940

1000 1040 1040

63.
 V1

RR 1000 960 920 900 900 940

1000 1040 1040

NSR with tachy-related LBBB. Note that the LBBB occurs when the RR interval (ms) shortens, and goes
away with longer RR intervals. It is typical for the LBBB to disappear at a longer RR that when it rst
appears; i.e., it appeared at 900 ms but disappeared at 1040 ms.

63b.

fi
 V1

Atrial brillation with rate related LBBB. Don’t confuse these WQRS tachycardias with VT; the QRS morphology in V1
shows a rapid downstroke typical of LBBB and not the QRS coming from a RV focus.

64.
fi
V1

65.
 V1

Sinus arrhythmia with rate-related RBBB (appears with slight increase in rate)

65b.
 V1

Mystery Rhythm:
“Escape from the hum-drum, bundle up your cares, fuse into the
multitude, hasten your destiny, but, above all, be critical!” Alan E. Lindsay, MD

66.
 * *
V1

* *

Mystery Rhythm:
“Escape from the hum-drum, bundle up your cares, fuse into the
multitude, hasten your destiny, but, above all, be critical!” Alan E. Lindsay, MD
NSR with 2nd degree AV block (type I); tachy-related LBBB; ventricular escape beats occur after some nonconducted P (*),
and occasional fusion beats (sinus QRS + RV escapes) occur (*). Nonconducted P waves often hidden in ST-T;
note that the escape intervals are xed. The fusion beats have varying morphologies related to how much of the sinus
impulse gets into the right ventricle (i.e., two wrongs sometimes make a right!)
66b.
fi
 V1

Confusion…….??

67.
 V1
*

Confusion…….??
NSR with frequent xed-coupled PVCs (LV origin); also, PACs, many of which fuse to some degree with the PVCs (*).

67b.
fi
 V1

68.
 V1
*
*

NSR with 3 PACs (*), 2 of which are aberrantly conducted (*) and one PVC (from the LV)

68b.
 V1

69.
 * *

V1

NSR with aberrantly conducted PAC(*); another aberrantly conducted PAC initiates atrial brillation with RVR and occasional
aberrantly conducted beats. Episodes of a- b usually are triggered by PACs in pulmonary vein ori ces of the left atrium.

69b.
fi
fi
fi
70.
 A. Atrial brillation with RVR and 4 aberrantly conducted a- b beats (RBBB)
B. NSR (same patient) with aberrantly conducted PAC

70b.
fi
fi
 V1

71.
 V1

NSR with single PVCs and short runs of VT, all from the LV (positive QRS in V1 means coming from the LV)

rSR’ Classic RBBB ? LV ectopy ?

71b.
 *
V1

* *
*

What are these: *

72.
 V1

* *
*

What are these: *

NSR interrupted by runs of VT and ventricular rhythms (from the LV) with occasional fusion beats (*);
note the AV dissociation during the runs (typical of VT).

72b.
 V1

73.
 V1

NSR (~100 bpm) with frequent parasystolic PVCs (note consistent inter-ectopic RR intervals, and fusion with the
sinus beats as the ectopic beats move into the PR interval of the next sinus beats.

73b.
 *

* Why is this PR interval so short??

74.
 2x 1x

1x *

* Why is this PR interval so short??

Parasystolic PVCs with one fusion beat (*); ‘x’ is the inter-ectopic interval. The short PR (*) suggests that
the sinus P did not cause the next QRS, but the QRS is actually a ventricular echo.

74b.
 85 y.o. woman with CHF and chronic atrial fibrillation
1. On Digoxin 0.25 mg/d; K+ 4.0 mEq/L; BUN 50 mg%

75.
 *

* * *

85 y.o. woman with CHF and chronic atrial fibrillation

1. On Digoxin 0.25 mg/d; K+ 4.0 mEq/L; BUN 50 mg%
Atrial brillation with a competing left ventricular rhythm ( xed RR intervals); note the fusion beats (*); in addition
there are 3 xed coupled PVCs from the LV (*) from a slightly di erent LV ectopic focus; the patient has digoxin toxicity.
75b.
fi
fi
fi
ff
 V1

Evolving acute anterior MI

IVR: Isochronic Ventricular Rhythm

76.
 V1
*

Evolving acute anterior MI

IVR: Isochronic Ventricular Rhythm

Two pacemakers, one sinus and one ventricular at approximately the same rate; which ever is faster
76b. controls the ventricles; note the fusion beat (*); during the ventricular rhythm there is AV dissociation.
Hx: 22 y.o. student nurse with recurrent palpitations and one syncopal episode

77.
 * *
V1 *

Hx: 22 y.o. student nurse with recurrent palpitations and one syncopal episode
Short runs of VT (from the LV) with intermittent 2:1 exit block from the VT focus; fusion beats are also present (*)
The red arrow indicates the VT rate (~140 bpm); the blue arrows are 2x the length of the red arrows (2:1 exit block).

77b.
 V1

A.

V1

B.

78.
 V1
* *

A. 2:1

Sinus tachycardia with 2:1 AV block with a competing accelerated ventricular rhythm (from LV) and fusions (*);
note the AV dissociation during the ventricular rhythm.

V1

B.

Same patient: atrial brillation with intermittent LV ectopic beats and rhythm

78b.
fi
 II

79.
 II
*

F F F F

NSR with late (end-diastolic PVCs) suggestive of a parasystolic focus (common inter-ectopic interval)
and fusion beats (F); two PACs (*)
79b.
80.
 Atrial utter with high grade AV block and ventricular escape beats (LV origin)

80b.
fl
 V1

Can you find up to 7 “abnormalities” of impulse formation and/or impulse conduction ?

81.
 V1

1. 2:1 AV block

2. RBBB aberrancy

3. Nonconducted PAC
Can you find up to 7 “abnormalities” of impulse formation and/or impulse conduction ?
4. Brady-dependent LBBB

5. Fusion beat (2 wrongs..)

6. Pacemaker spike

7. Sinus arrhythmia

81b. Answer…..
II (at rest)

(exercise)

82.
II (at rest)

(exercise)

NSR with frequent unifocal, xed coupled PVCs. They disappear with mild exercise (overdrive suppression).

82b.
fi
 V1

83.
 V1

1.

NSR with an accelerated (isochronic) right ventricular rhythm and single PVCs of the same morphology

2.
?

NSR with short run of ventricular tachycardia. ? possible late PVC (di erent focus) with fusion.
83b.
ff
 II

84.
 * * * * *

II

NSR with a competing isochronic ventricular rhythm (nearly same HR); note the fusion beats (*)

84b.
 Patient has a right ventricular artificial pacemaker (pacer spikes
are not easily visualized).

85.
 Patient has a right ventricular artificial pacemaker (pacer spikes
are not easily visualized).

* *

A. NSR; ventricular pacing (*); complete AV dissociation (3rd degree AV block)

B. Ventricular pacing with retrograde VA conduction (retrograde P waves)

85b.
86.
Accelerated junctional rhythm (65 bpm) with AV dissociation; arrows indicate sinus rhythm (60 bpm) which are dissociated.
One atrial sensed - ventricular paced event appears which resets the junctional pacemaker.

86b.
 V1

Atypical ?

87.
 V1

160 240 280 280

Atypical ?
Atypical 2nd degree AV block (type I) due to retrograde concealed conduction in the AV junction.
Normally with the ‘footprints’ of Wenckebach (typical type 1 block), the PR gets longer by smaller increments
and the RR intervals get shorter up to the pause. In this example the RR before the pause is longer.

87b.
 Lindsay A, Schamroth L. (Am J Cardiol 1981; 47:371)

V1

88.
 Lindsay A, Schamroth L. (Am J Cardiol 1981; 47:371)

V1

Abstract
In 1968 Moe and associates postulated multilevel atrioventricular (A-V) block as a mechanism for some forms of the supernormal phase of A-V conduction.
In 1971 Schamroth further postulated that, if this were correct, there would only be odd numbers of sinus P waves between the capturing impulses. This report
presents two cases of sinus rhythm dissociated from junctional escape rhythm (40 bpm) as a result of high grade A-V block. The rhythm is complicated by manifest and

88b. concealed A-V captures during the so-called supernormal phase. There are only odd numbers of P waves between the capturing impulses.
 *

89.
 *

NSR, 2:1 AV block and RBBB; fusion beats (*); RV escape rhythms (RV origin brcause QRS moves posterior in V1;
The fusion between RBBB morphology and RV ectopic morphology creates a normal looking QRS.

89b.
 3 rhythm strips at different times (it’s all about the sinus rate)

V1
A.

B.

C.

90.
 3 rhythm strips at different times (it’s all about the sinus rate)

V1
A.

B.

C.

A. NSR (80 bpm): 3:2 and 4:3 groupings of 2nd degree AV block (type 1)
B. NSR (110 bpm): 2:1 AV block (type 1, because of ‘A’ in same patient)
C. NSR (70 bpm) with 1:1 conduction

90b.
 The AV node is a Ca++ channel conduction system. There is an inverse relationship between the RP
interval (QRS to next P wave) and the subsequent PR interval. This is illustrated in the tracing and graph.
The His bundle, bundle branches and fascicles are Na+ channel conducting bers, and conduction is
all-or-none (e.g., type II AV block).

91. fi
92.
 *

Sinus tachycardia (105 bpm) with 2nd degree AVB; there is a competing slightly accelerated ventricular rhythm with
retrograde conduction into the AV junction preventing sinus beats from entering the ventricles (see ladder diagram).
One sinus beat (*) is able to capture the ventricles. Other sinus beats don’t have opportunities to conduct.

92b.
 Block – Acceleration Dissociation
The accelerated ventricular rhythm makes the ventricles “unavailable” to atrial stimuli

93.
 Block – Acceleration Dissociation
The accelerated ventricular rhythm makes the ventricles “unavailable” to atrial stimuli

*
B

* * *

A NSR (90 bpm) with 3:2 and 2:1 2nd degree AVB (type 1)
B (same patient) NSR (110 bpm); competing accelerated V-rhythm (55 bpm); because of the 2nd degree
AV block most sinus beats don’t have an opportunity to conduct; 3 sinus captures (*) are seen and 1 fusion beat (*)

93b.
94.
Atrial tachycardia with 2nd degree AV block (type 1); note the inverse relationship between RP and PR.

94b.
95.
 NSR with dual AV conduction pathways. The ladder diagram shows P waves using the fast pathway (a) with
normal PR intervals. The PVC (X) conducts retrogradely into the AV junction and blocks (a) but allows sinus
conduction through (b) with very long PR intervals. Rhythms like this are very rare.

95b.
 A

96.
 *
A

NSR with dual antegrade AV pathways. The PVC (*) interrupts the faster pathway allowing the sinus to use
the slow pathway (long PR interval); the long pathway continues to be used because of partial retrograde
conduction (of the sinus P) into the faster pathway.

Transition from the slow AV pathway (long PRs) back to the faster pathway occurs when another PVC (*) causes
one sinus P (arrow) to be blocked; this allows the faster pathway to recover and open up. Notice that the sinus
P wave just before the PVC is responsible for the normal QRS just after the PVC and the following sinus is blocked ( ).
96b.
 Young woman with congenital AV block: Exercise and recovery

97.
 Young woman with congenital AV block: Exercise and recovery

Continuous rhythm strip: At the beginning, during exercise, there is marked 1st degree AV block, transitioning to 2nd
degree with variable AV conduction during recovery after exercise. The AV block is at the level of the AV node because
of the inverse relationship between RP to the next PR interval (type I). The bottom strip (2:1 conduction) shows an example of
ventriculo-phasic sinus arrhythmia (the PP interval surrounding the QRS is shorter the next PP). The mechanism is due to
transient vagal stimulation brought about by the ventricular contractions. (Cherchez le P on le T)

97b.
 II
1.

A.

V1
2.

B.

3.
V1
C.

98.
 II
*
1.

A.
NSR; 2nd degree AV block (type II, infra-nodal); pacemaker escapes; one nonconducted PAC (*)

V1
2.
*

B.NSR with RBBB; 2nd degree AV block (type II, infra-nodal); occasional junctional escaper (*)

* * * *
3.
V1
C.
NSR with LBBB; 2nd degree AV block (type II, infra-nodal) (note consecutive nonconducted P waves)
98b.
 Not all bradyarrhythmias are alike!

99.
 Not all bradyarrhythmias are alike!

A * *

Marked sinus bradycardia with a junctional escape rhythm (incomplete AV dissociation by default, sinus is too slow);
several sinus captures are conducted with RBBB aberration (*).

B * *

NSR with 2nd degree AV block (type I, see last two captures); junctional escapes noted (*)

99b.
 V1

100.
 V1 * *

* * * *

High grade 2nd degree AV block with junctional escapes (*) and sinus captures (note shorter RRs); RBBB

100b.
101.
NSR (75 bpm) with 2nd degree AV block (type I); junctional escapes are present after pauses. Note the escape beats (E)
from the junction (in the His bundle) sometimes look slightly di erent from the QRSs of the sinus rhythm, but still are narrow.
P waves before the junctional escapes are dissociated from the QRS (beat #1 is a junctional escape also).

101b.
ff
 An interesting bigeminy (ambulatory ECG study): …very subtle findings

102.
 An interesting bigeminy (ambulatory ECG study):
Dx: ectopic atrial tachycardia, variable AV block (ectopic P waves very hard to see…but they’re there!)

102b. (Cherchez le P’s)

 ….Enough for now

Stay Up to Date
and
Keep reading ‘lots of ECGs
(or are they EKG’s?)
References:
http://ecg.utah.edu