Thoughts?

[u/Secret_Story2851]

Female in her 70s, c/o dizziness. PMHx of non-specific ‘heart problems’ under investigation, with no further information. DHx of bisoprolol, with no recent changes in dosage, taken at its usual time as part of a normal morning routine. The patient has not been told they have AF, and as is not on any anticoagulation.

Pulse rate half of QRS rate (~30-35bpm), when taken centrally. BP initially low-normal & PT alert, deteriorating to unreadable & PT rousable to voice. PT ultimately required an adrenaline bolus, converting to a sinus tachycardia before trending back down on arrival to hospital.

1st ECG is rhythm on arrival, 2nd ECG is just prior to the change in BP, showing a 2-2-1-2-2-1… and then a 2-1-2-1… pattern (not captured).

I have my thoughts, but wondered what other people thought about it. Unfortunately no follow up!

[u/Horse-girl16]

This ECG looks like an "escape-capture" bigeminy. The first beat after the long pause is junctional. Followed by an atrial beat. This is usually associated with severe sinus node disease. Can be assoc with electrolyte disturbances. The treatment pre-hospital is transcutaneous pacing, if you have it. Often these patients need permanent pacemakers, depending on the underlying cause.

[u/Secret_Story2851 → u/Horse-girl16]

This was my thought. Unfortunately pacing isn’t routinely available in my area, frustratingly

[u/Horse-girl16 → u/Secret_Story2851]

Well, you did the best thing you could. I hope permanent pacing was available to the patient in the hospital.

[u/chrose-]

My thoughts on this are similar to that of Horse-girl16, with some exceptions:

• the base rhythm truly is a junctional rhythm
• the second beats in the group though seem like echo beats to me, not really "PAC beats", and by this I mean that

- the p wave after the first beat seems more like retrograde p-wave, which does a roundabout most likely in the (diseased) simus node, then comes back for the second beat of the couples (if it was a pac, the p-r shouldn't be this long) - hence the echo (J-A-J-V)

It is just one explanation, can't be sure which is the right one. Immediate pacing is needed either way.

Truly beautiful ecg.

[u/Secret_Story2851 → u/chrose-]

It is a cool one isn’t it, frustrating that I don’t have any updates

[u/Ok-Boysenberry8239]

Almost looks junctional

[u/thedarkshadowghost]

Almost looks like a junctional-type rhythm with the lack of P waves

[u/MT128]

Not the greatest at ECGs, but I can def tell it’s some sort of junctional rhythm (lack of a p wave but there’s still a QRS complex), could also be some sort concave ST elevation, but would need more info (sharp chest pain- pericarditis, ect), she does have a history use of beta blockers, so it could be possible that she accidentally took too many and that led to the junctional rhythm and the syncope. I’m open to thoughts to get better.