Discussion for 90 year old male CC: Chest pain– Revisited

We are revisiting the Discussion for 90 year old male CC: Chest pain.  You may wish to review the case.

You may recall we pointed out that the VT appeared be regularly irregular, with alternating cycle lengths:

What follows is a "Guest Post" by Jason Roediger, CCT/CRAT, and Ken Grauer, M.D. (www.kg-ekgpress.com):

"The rhythm represents VT for all of the morphologic reasons discussed in your explanation. The reason for the repetitive regular irregularity of this ventricular rhythm is that the tracing represents VT with retrograde 3:2 Wenckebach Exit block out of the ventricular focus. The discharge rate of the ectopic ventricular focus is ~240/minute.

This results in a manifest ventricular rate that is about 2/3 the presumed discharge rate and reduces the manifest rate to ~160/minute. Note the characteristic Wenckebach periodicity conducting retrograde (with a 3:2 ratio) out of the ventricular focus in the laddergram below. FINAL point: in addition to the bizarre marked axis deviation, the entirely negative QRS in V6 with delayed nadir and other morphologic clues you state in support of the diagnosis of VT-WPW can be ruled out by the negative QS complexes in V4-V6 (Brugada)."

 

Many thanks to Jason and Ken for their insightful analysis. We are always learning!

 

 

 

 

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Jewel
53 Year Old Male: Severe Leg Pain
Hmm it appears like your site ate my first comment (it was extremely long) so I guess I'll just sum it up what I wrote and say, I'm thoroughly enjoying your blog. I as well am an aspiring blog writer but I'm still new to the whole thing. Do you have any helpful hints for…
2014-08-31 17:51:28
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14

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