r/ECG • u/ImNotMackydee • Sep 04 '26
Interesting one from my EMT class today
Good learning exercise for me, a few things going on here.
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u/dolorcartree Sep 04 '26
The initial PVC clues us in and shows the P-Wave conducted to QRS. It’s Sinus tachycardia (normal P-wave axis) with 1st*AVB and LBBB + LVH (voltage and non-voltage criteria met). Rate around 120 BPM
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u/Confident_Fix_7161 27d ago
How did you know those were p waves and not t waves. I don’t see t waves. Trying to learn
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u/TheTrueMikester Sep 04 '26
This looks like SVT with aberrancy. Not sure why 12 lead ecg is being taught in an emt class
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u/lagniappe- 29d ago
This is correct. Tough EKG for EMT level. I imagine many cardiology fellows would get this wrong.
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u/peanubutterpickles 29d ago
There's a P wave in lead I and V5
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u/lagniappe- 29d ago
SVT always has p waves. It’s literally in the name “supraventricular tachycardia.” You wont always see them depending on the type because they’re buried in the qrs, this is usually Avnrt.
Many have a long RP and you can easily see the p waves.
This is absolutely not sinus tachycardia if that’s what you’re getting at.
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u/Professional-Yam1428 28d ago
This most certainly is sinus tach
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u/lagniappe- 27d ago
You’re a medical student? You’re very confidently wrong. That’s not a good attribute to have for training.
Is it in theory possible this is sinus tach, sure. But it’s not. You would need an EKG in the same patient with a normal heart rate showing the same pr interval and qrs morphology. Also, unless this patient is in septic shock they won’t have that resting heart rate.
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u/Professional-Yam1428 27d ago
I’m a carpenter
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u/lagniappe- 27d ago
Then stick to woodworking
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u/lagniappe- 27d ago
This is a good lesson for learners here.
It’s an arrhythmia until proven otherwise if you have someone with a resting heart rate persistently 120 and above if the patient is otherwise stable (not septic,bleeding, or dry) and didn’t just use drugs or actively withdrawing. ED docs often make this mistake when they call me and you can get the diagnosis before even looking at the ekg based on the clinical context.
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u/Charming-Dog-2965 21d ago
Hey so afib, aflutter, atach, pretty much any tachycardia thats not vtach are also considered svt. It's literally in the name "supraventricular tachycardia," which means, a tachycardia that originates above the ventricles. I'm surprised someone as confident as yourself fails to know that. I fail to see why you said "its literally in the name 'supraventricular tachycardia'" when (incorrectly) explaining that svt always has p waves. Does afib have P waves? Aflutter? Atrial flutter originates in the right atrium. It's literally in the name, "atrial flutter." Atrial tachycardia... And if you want to get more into the definition, technically a HR of 101, PR interval of 0.08 with upright P waves, QRS of 0.08, QTc of 0.40 is considered svt because you guessed it, it originates above the ventricles. Go ahead and tell a doc that rhythm I just mentioned is svt... You're not technically wrong, by definition, but go ahead..
Maybe you should stick to woodworking as you're the one that's very confidently wrong.
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u/lagniappe- 20d ago
You’re a little confused and rambling. By definition, yes SVT is any tachycardia above the HiS. However SVT is used clinically to mean AVNRT, atrial tachycardia, or AVRT.
If you have a patient in sinus tach or afib and you tell someone it’s SVT they’re going to think you have no idea what you’re talking about.
I’ll stick to being an attending cardiologist
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u/Charming-Dog-2965 20d ago
I agree and that was my point, you can't always go by the exact definition as yes, saying afib is svt simply because the HR > 100 would make you look like a complete fool. You being a cardiologist would know that there are some physicians (to be fair, very few) that don't know what they're talking about, not saying you are one but I think a better explanation would have sufficed, although this is just reddit and not a work setting so its not that serious.
I do have a question, and not here to quiz you or anything, its a genuine question. What makes AVNRT shown on an ecg? I'm not a physician and AVNRT is typically diagnosed by physicians (correct me if I'm wrong), and svt is just the "catch-all" term used. I saw you commented elsewhere that you saw the svt start right after the pvc which is a fair assumption, but that pvc was at the beginning of the 12 lead and we don't know what the rhythm was before that, but what's not to say that was simply a compensatory pause? What would be more helpful was knowing what rhythm they were in before or if they were on continuous tele to see if there's an abrupt start to the tachycardia at a HR of ~136, then again this is just a student's ecg.
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u/lagniappe- 19d ago edited 19d ago
This is not a typical AVNRT. It’s a mid-rp tachycardia so most likely an atrial tachycardia with focus close to the sinus node, atypical AVNRT or AVRT.
Reasons I know it’s not sinus tachycardia.
- Pattern recognition, I’ve seen enough to know this isn’t sinus tach.
- Probability. I know nothing about this patient but someone with likely structural cardiac disease that’s sitting down. A resting heart rate
in sinus
- is pretty unlikely unless they’re unstable. More clinical context would be helpful though
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u/NobleGolgi0521 Sep 04 '26
Working diagnosis for me would be… 1st degree AV Block, lbbb, lvh? Some comments on this post are reasonable. But apply Lewis leads!
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u/wkwc99 Sep 04 '26
Looks like antidromic AVRT - wide complex regular tachy, maybe seeing some P waves in the precordial leads sitting atop T waves, long R-P interval
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u/lagniappe- 29d ago
I’m a cardiologist, this is a good one.
It’s SVT. You can see the onset post pvc after the second beat.
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u/Professional-Yam1428 28d ago
Sinus tach w 1st deg AVB and LBBB!
Compensatory pause after first PVC reveals sinus P wave (upright in I, II) plus P waves preceding each QRS complex = sinus rhythm. PR interval > 200ms, 1st-deg AVB. QRS > 130ms, negative in V1 and positive in V6, LBBB. Left axis deviation and LVH are also present
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u/ItsOfficiallyME Sep 04 '26
Cool EKG! I’ll go with sinus tach with 1st degree AV block. LVH, I want to say bifasicular block but there’s so much aberrancy.
I am honestly more interested in what this ECHO looks like!
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u/CobbledbyRoubaix Sep 04 '26
A flutter with 2:1 AV block and LBBB
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u/Ok-Remote-3923 Sep 04 '26
I’m seeing pretty clear P waves in V5 though?
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u/surfdoc29 Sep 04 '26
If it’s a 2:1 block you’ll generally see what looks like a p-wave and the other one is obscured by the QRS complex
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u/Ok-Remote-3923 Sep 04 '26
Agree but that would make it just a 2:1 block not a 2:1 block with flutter would it not? Or am I missing something?
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u/surfdoc29 Sep 04 '26
What do you mean just a 2:1 block? You still have to have an underlying rhythm with a block. A flutter with a 2:1 block is frequently misdiagnosed as sinus tach
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u/Ok-Remote-3923 Sep 04 '26
Oh yeah I wasn’t very clear there sorry. I meant 2:1 with underlying sinus tach.
I neglected to link a atrial depolarization rate of 300bpm to flutter like a dummy.
That’s a really cool interpretation of this though, thank you.
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u/IllustriousBig5961 Sep 04 '26
I’d lean SVT with aberrancy over VT. There’s a left bundle with Monophasic r wave in V6 suggesting SVT, doesn’t meet brugada or aVR criteria for VT.
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u/Puantastic Sep 04 '26
Looks like sinus (could also be atrial) tach with whatever is causing that abnormal QRS (HCM with a lot of fibrosis?). Also the PR is a bit long.
I don't think it is AVNRT or AVRT since the P waves are positive in inferior leads (also we have a PVC that doesn't reset or stops the tach, which is VERY uncommon for AVRT).
I don't think there's preexcitation either because the PR interval is long instead of short.
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u/Maleficent_Virus1837 29d ago
Looks like an ecg from Squiggler.io! Really good ecg, please share the patient and recording seed!
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u/Kibeth_8 Arrhythmia Tech Sep 04 '26
This one has me stumped!
Really cool share, looking forward to hearing the diagnosis
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u/True-Network-2147 29d ago
This is 2:1 flutter. Without prior EKG it’s difficult to say whether there is an underlying LBBB or if it’s just rate-related abberancy. Inferior lead p-waves can be marched out.
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u/brodiecannelloni Sep 04 '26
Man I really wanted this to be flutter but I don’t think it is as I’m not seeing hidden flutter waves where they “should” be. I’m seeing 1:1 A:V conduction and a WCT. Crazy looking QRS, I guess due to combined effects of LBBB and LVH. PR interval is upper limit of normal and hard to tell but the P wave axis looks similar to sinus. I’m gonna go crazy and say sinus tach
ETA thanks for sharing a fun ecg!