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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Comments
Vince DiGiulio
The 360 Degree Heart – Part II
It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
2014-10-21 14:00:37
Bryan
The 360 Degree Heart – Part II
I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
2014-10-21 13:43:29
The 360 Degree Heart – Part II | EMS 12 Lead
The 360 Degree Heart – Part I
[…] first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane […]
2014-10-21 12:50:56
Eric Strong
Axis Determination – Part VI
This is a great discussion of axis determination. One minor suggestion: I think it's potentially misleading to refer to an axis between 0 and -30 as "physiologic left axis deviation", since "axis devitation" implies deviation from normal, and axes between 0 and -30 are perfectly normal, (depending on age and body habitus). It may be…
2014-10-05 17:09:00
Ian
Right ventricular infarction – Part I
Can you give me a little more info on hypervagotonia? I googled around for some info but there doesn't seem to be much info and it's a term I've never heard before. Thanks!
2014-10-05 15:09:24

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