ECG QUIZ Luc DE ROY Brussels Belgium Disclosure in relation to this topic: none

TEST EXAMPLE What is the colour of this rectangle? 1. Blue? 2. Red? 3. Purple? 4. Green? 5. Yellow? 6. 1 and 3? 7. Any of these? MORE THAN ONE ANSWER IS POSSIBLE

Holter monitoring Is this: 1. Atrial tachycardia 2. AV nodal tachycardia? 3. AV tachycardia on an accessory pathway 4. Can be any of these

And now which seems the most likely? 1. Acessory pathway? 2. Atrial tachycardia? 3. Automatic junctional tachycardia? 4. Slow/ slow AV nodal tachycardia 5. Slow/ fast AV nodal tachycardia? 6. none of these

And now which remain the most likely? 1. Accessory pathway? 2. Atrial tachycardia? 3. Automatic junctional tachycardia? 4. S/S AV nodal tachycardia? 5. Slow/Fast AV nodal tachycardia? 6. any of these

S/S AV nodal Tachycardia 160 ms 250 ms Where is the tachycardia stopping? 1. In the antegrade slow pathway? 2. In the retrograde slow pathway?

320 ms 470 ms 160 ms 310 ms 160 ms 160 ms Where is the tachycardia stopping? 1. In the antegrade slow pathway? 2. In the retrograde slow pathway?

P P P Why the diagnosis of S/S AV nodal tachycardia is the most likely? 1. Acessory pathway? Block in the AP while slowing in the AV node 2. Atrial tachycardia? Slowing of the rate with constant R-P interval 3. Automatic junctional tachycardia? No reason to stop the tachycardia with the absence of a P wave 4. S/S AV nodal tachycardia? Can block on either slow pathway by vagal tone 5. Slow/Fast AV nodal tachycardia? This type of tachycardia has rarely a long retrograde RP

And now this! The same patient! 175 bpm

Is this a: 1. S/S AVNRT? 2. S/F AVNRT? 3. F/S AVNRT? 4. Another tachycardia? 5. CC W Isthmus Atrial Flutter?

F/S AVNRT H H H A A HALO 4-1 = CSp -CSm

Nakagawa H, Jackman W Circ 2007

What is your diagnosis? 1. AF and excessive rate lowering drugs? 2. AF and AV node conduction block? 3. AF and physiologic slow ventricular response? 4. AF and paroxysmal infranodal bloc?

And now what? 1. Excessive rate lowering drugs? 2. Paroxysmal AV node conduction block? 3. Excessive vagal response? 4. Paroxysmal infranodal bloc?

Why does this block occur? 1. Excessive sympathetic tone? 2. Paroxysmal randomly occuring conduction block? 3. Influence on the His/ Purkinje system? 4. Excessive vagal tone?

720 ms 720 ms Why does this block occur? 1. Excessive sympathetic tone? 2. Randomly occuring conduction block? 3. Influence on the His/ Purkinje system? 4. Excessive vagal tone?

PP=720 ms PP=720 ms PR=200 ms Final diagnosis: Paroxysmal infranodal block Major conduction disturbances in the His/Purkinje system: * RBBB * Slow broad QRS escape rhythm * normal PR interval * initiation by a supraventricular ectopy (phase 4 block)

Lee S, Wellens H, Josephson M HR 2009

What is this? 1. SR and LBBB 2. Accelerated idioventricular rhythm 3. Preexcitation 4. Slow ventricular tachycardia

What is this? Location of the AP? 1. SR and LBBB 2. Accelerated idioventricular rhythm 3. Preexcitation 4. Slow ventricular tachycardia 1. Left lateral? 2. Posteroseptal? 3. Anteroseptal? 4. Right lateral?

What is going on? 1. Sinus rhythm with spontaneous disappearance of the preexcitation? 2. Orthodromic AV reciprocating tachycardia? 3. Atrial tachycardia? 4. Ventricular tachycardia?

What is going on? 1. Spontaneous disappearance of the preexcitation? 2. Orthodromic AV reciprocating tachycardia? 3. Atrial tachycardia? 4. Ventricular tachycardia?

IV AJMALINE How does this tachycardia start? 1. With an extrasystole? 2. Due to a change in the accessory pathway? 3. Due to slowing in the right bundle? 4. With a junctional beat? 5. Can be due to 2 and 3?

AJMALINE Why does this tachycardia start? 1. With an extrasystole? 2. Due to a change in the accessory pathway? 3. Due to slowing in the right bundle? 4. With a junctional beat? 5. Can be due to 2 and 3?

AJMALINE Sinus beat

Is this: 1. Ventricular tachycardia? 2. Supraventricular tachycardia with aberrant conduction?

Favours Ventricular Tachycardia QRS width: 186 ms North west axis Left rabbit ear QS in lead V6 Monophasic R in avr

SINUS RHYTHM QRS width: 165 ms North west axis Left rabbit ear rs in lead V6 qr in avr

Now, what could it be? 1. Ventricular tachycardia? 2. Supraventricular tachycardia with aberrant conduction?

AV Dissociation

BUNDLE BRANCH REENTRANT VENTRICULAR TACHYCARDIA with a RBBB pattern AV Disociation

Phlips T, Ramchurn H and De Roy L in press

CL + 500 ms * * * * * What is your diagnosis? 1. Complete AV bloc? 2. Atrioventricular dissociation? 3. Normal AV conduction? 4. 2 and 3?

Continuous strip

What is the most likely diagnosis? 1. Normal conducted sinus beats with frequent SV ectopic beats? 2. Accelerated junctional rhythm? 3. Junctional ectopic tachycardia? 4. Junctional escape rhythm? 5. Something else

CL: ± 500 ms CL: ± 500 ms CL: ± 600 ms E E E c c E c c E c c E E E Junctional ectopic tachycardia and sinus capture beats during CL variations responsible for exit blocks or resetting of the ectopic focus.