What do you think of this " Ventricular Bigeminy " ?

Written by Bobby Nicholson MD, with edits by MeyersA woman in her 50s with past medical history of heart failure, prior stroke, atrial fibrillation on Eliquis, lung cancer in remission, and CKD, presented to the emergency department for evaluation of cough and shortness of breath. EKG was obtained in triage and read as ventricular bigeminy. What do you think?On my first read of the EKG, I agreed with the initial interpretation. Pendell Meyers then recommended that I take a second look at the morphology of the QRS complexes. I think it was easiest for me to see in the rhythm strip, but there are clearly P waves in front of every QRS complex.So what is the QRS morphology below?Enlarging a singular beat highlights a clear P wave with a shortened PR interval and slurred upstroke to the R wave. I think it is easy to see now that the QRS is widened because of an accessory conduction pathway. In context of our original EKG, the patient appears to be alternating conduction through the AV node and accessory pathway - a condition previously described as Wolf-Parkinson-White Alternans.[1]If we look at the patient ’s previous EKG on record, we’re able to see that this pattern is not new:Interestingly, the patient does appear to have PVCs in this ECG as well as WPW beats. If we zoom in, we can see a QRS complex with slurred upstroke and shortened PR interval, a PVC which has no slurring to the upstroke of the R wave, followed by another beat down the accessory pathway.If we enlarge le...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs