Lead II: Upright P waves visible at the end of the T wave

aVL: Upright P waves (red arrows) could easily be mistaken for inverted T waves (blue arrows)

In patients with a regular narrow complex tachycardia and a long R-P interval, our differentials include:

Focal atrial tachycardia (FAT)
Atypical AVNRT
Permanent junctional reciprocating tachycardia (PJRT)
Atypical AVNRT and PJRT both produce retrograde P waves from a focus near the AV node – we would therefore expect a negative P wave axis in inferior leads, which is not the case here. An abnormal P wave axis here with an upright P wave in lead II suggests FAT as the most likely rhythm.

A 78-year-old man with a history of coronary artery bypass surgery presents to the emergency department with symptoms of dizziness and palpitations. He has a history of tobacco use, diabetes mellitus, and hypertension. His medications include metoprolol succinate, lisinopril, aspirin, and atorvastatin. Upon arrival at the emergency department, the patient's blood pressure is 80/45 mm Hg with a heart rate of 180 bpm. He appears mildly distressed. An electrocardiogram (ECG) is obtained..

What is ECG diagnosis ?

#ecginterpretation #doctor #cardiologists #HeartHealth #ekg

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25-year-old female with ‘palpitations’. BP 117/72, GCS 15.

Regular narrow complex tachycardia, rate 132 bpm
Slight right axis deviation
Dominant R wave in V1 meets voltage criteria for right ventricular hypertrophy (RVH)
Pseudo R’ waves in the terminal portion of the QRS in V1, an isoelectric baseline, and lack of flutter waves in V1 point towards this rhythm being an AV nodal re-entry tachycardia (AVNRT)
No rate-related ischaemia
There is one other feature on this ECG that suggests this patient has a congenital structural abnormality, can you spot it?

Crochetage sign: Notching at the apex of the R wave in inferior leads. When present in all three inferior leads, this sign is highly specific for secundum ASD

Notching near the apex of the R wave in inferior leads is known as Crochetage sign
The presence of this sign in all three inferior leads has a 92-100% specificity for the diagnosis of a secundum atrial septal defect (ASD)

What is your interpretation?

Shortly after the above ECG was taken, the patient spontaneously reverted into sinus rhythm and a repeat ECG was taken:

Normal sinus rhythm, rate 84 bpm
Multiple premature atrial complexes (PACs) — 2nd and 10th beat
Features of secundum ASD are again seen — Crochetage sign in all three inferior leads, slight RAD and dominant R wave in V1

OUTCOME
This patient self-reverted in and out of AVNRT multiple times during her stay in the emergency department. When in sinus rhythm she had frequent PACs, which reduced following the administration of metoprolol. She subsequently remained in sinus rhythm and was referred for formal TTE and evaluation for definitive repair of secundum

Pseudo R’ waves in AVNRT

Crochetage sign: Notching at the apex of the R wave in inferior leads. When present in all three inferior leads, this sign is highly specific for secundum ASD

Differential diagnosis for regular narrow complex tachycardia

🔬 سؤال اليوم لأطباء القلب:
في مريض لديه HCM، أي ECG pattern قد يشير إلى apical hypertrophic cardiomyopathy حتى عندما يكون الـEcho غير حاسم؟ 🤔

🚨 سؤال اليوم لأطباء القلب:
مريض لديه syncope + bifascicular block… أي ECG finding إضافي يجعلك أكثر قلقًا من وجود intermittent high-grade AV block؟ ⚠️

🩺 سؤال اليوم لأطباء القلب:
ما الـECG clue الذي قد يساعدك في التفريق بين AVNRT وorthodromic AVRT عندما تكون الـP waves غير واضحة؟ 🤔

🔥 سؤال اليوم لأطباء القلب:
مريض لديه ST elevation، لكن الـcoronary angiogram طبيعي… أي ECG pattern قد يجعلك تفكر في Takotsubo syndrome بدل STEMI؟ 🧐