A Wide Complex Rhythm in an Intoxicated Patient

This patient presented with altered mental status and was thought to be intoxicated.  He did not have any other apparent medical issues.I ' m not certain why an ECG was recorded, but it was:The computer and the overreading physician diagnosed" Sinus rhythm with LVH. "What is it?This is an accelerated idioventricular rhythm (AIVR).  There is also isorhythmic dissociation (P-waves and QRS co-incidentally going the same rate, but without the P-waves consistently conducting through the AV node because frequently the ventricular rhythm usurps it (comes too early for the P-wave to conduct).I point out the salient features on the annotated image below:There is a wide QRS that is at regular intervals at a rate of about 65.They are either not preceded by a P-wave, or by a P-wave that is too close to be conducting.Black arrows points to normal P-wave that conducts to a normal QRS.Green Arrows point to upright sinus beats that are close to the QRS and create a " fusion " beat, in which the ventricular beat and the normal beat meet up (fuse) and create a hybrid QRS that is longer than a normal one, but shorter than the idioventricular ones.Red Arrowspoint to retrograde P-waves.  The idioventricular rhythm conducts up the AV node to the atrium, creating an upside down P-wave after the QRS.Blue arrows point to upright P-waves that are within or after the QRS; they occurred too late to affect the QRS (they did not fuse).See below how this resembles WPW and why it is not WPW.A...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs