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Old 01-16-2014, 17:41   #16
Sdiver
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Here's the moment you've all been waiting for .... the answer.

In addition to the obvious STEMI, which is indeed an Inferior wall MI (as seen in leads II, III, and aVF, at least 3, possibly 4 mm elevation) this was/is a 2nd degree type I AVB, with 2:1 conduction and periods of 3:2, otherwise known as wenckebach.

Here's the same strip with marks pointing out the P-waves that "march out" with regularity. In lead I, you can see the P waves sitting on the down-ward slope of the T-wave with a dropped QRS. But the next p-wave associated with a QRS is right on time and on target.

Also, look at leads V1-V6. Notice anything "extra" ???
Is that a PVC or a PAC ???
Does it make a difference in your interpretation ???
Should you be concerned about it ???

Yes, the main focus is the STEMI and this person should be in a Cath-Lab ASAP, but as Adel pointed out, this is the kind of strip that one needs to slow down, take your time and hit the basics.

Heart blocks are a bitch to read sometimes. Everyone can pick out a 1st degree, and 3rds are relatively "easy", it's the two different types of 2nd degrees that throw people off.
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Last edited by Sdiver; 01-16-2014 at 17:52.
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Old 01-16-2014, 17:49   #17
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What are the types of heart block?

First-degree heart block (also called first-degree AV block). The electrical impulses are slowed as they pass through the conduction system, but all of them successfully reach the ventricles. First-degree heart block rarely causes any symptoms or problems, and well-trained athletes may have this. Medications can contribute to the condition. No treatment is generally necessary for first degree heart block.

Type I second-degree heart block (also known as Mobitz Type I second-degree AV block or Wenckebach AV block). In this condition, the electrical impulses are delayed further and further with each heartbeat until a beat is skipped entirely. The condition generally is not as serious as type II second-degree heart block, but it sometimes causes dizziness and/or other symptoms. Normal people may sometimes have this when they are sleeping.
Type II second-degree heart block (Mobitz Type II second-degree AV block) is also a condition in which some of the electrical impulses are unable to reach the ventricles. This condition is less common than Type I, but is generally more serious. In some cases, a pacemaker is implanted to treat the abnormally slow heartbeat that may result from this condition.

Third-degree heart block (also known as complete heart block or complete AV block) is when none of the electrical impulses can reach the ventricles. When the ventricles, (lower chambers), do not receive electrical impulses from the atria (upper chambers), they may generate some impulses on their own called functional or ventricular escape beats. Ventricular escape beats, natural backup signals, usually are very slow, however, and cannot generate the signals needed to maintain full functioning of the heart muscle.

Bundle Branch Block is when electrical impulses are slowed or blocked as they travel through specialized conducting tissue in the ventricles.

http://arrhythmia.org/heartblock.html
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Old 01-17-2014, 00:06   #18
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As far as the STEMI goes I recall someone telling me that without S/Sx that elevated ST can be indicative of PRIOR MI. That once damage has been done it's permanent and therefore shows up on an EKG.

Again I've been out of the game for awhile and as I gain more FOG status with each day, my CRS keeps actin' up.
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Old 01-17-2014, 07:51   #19
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Thanks for the tutorial SDiver. Great exercise for the ol' noggin to think about things that I haven't thought about in years. Good therapy for the CRS syndrome too.
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Old 12-13-2015, 23:33   #20
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Quote:
Originally Posted by miclo18d View Post
As far as the STEMI goes I recall someone telling me that without S/Sx that elevated ST can be indicative of PRIOR MI. That once damage has been done it's permanent and therefore shows up on an EKG.

Again I've been out of the game for awhile and as I gain more FOG status with each day, my CRS keeps actin' up.
Your post got me thinking about persistence of ST segment changes post MI and I found this abstract about it.

http://www.ncbi.nlm.nih.gov/pubmed/1124714

Their conclusions were..."We concluded that (1) the natural history of S-T segment elevation after myocardial infarction is resolution within 2 weeks in 95 percent of inferior but in only 40 percent of anterior infarctions; (2) S-T segment elevation persisting more than 2 weeks after myocardial infarction does not resolve; (3) persistent S-T segment elevation is associated with clinically more severe myocardial infarction; and (4) in patients with coronary artery disease, persistent S-T segment elevation after myocardial infarction is a specific but insensitive index of advanced asynergy."
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Old 12-14-2015, 07:17   #21
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Great ECG and discussion!

It looks like the elevation is greater in III than II, which would definitely make me want to get a right sided ECG to evaluate for the inferior AMI (often a more proximal lesion of the right coronary artery). With the heart block and brady, thinking it is a right coronary artery lesion since in 80% of the population, this arterty feeds the AV Node.
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Old 05-09-2017, 03:24   #22
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Extreme Sinus Bradycardia; 3rd Degree (Complete) Heart block w/ Inferior/lateral STEMI.

HR seems to be less than 40.
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Old 05-15-2017, 16:56   #23
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Sinus bradycardia with 1st degree AV block and premature junctional contractions.
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