CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 7, August 2012
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Answer
This elderly woman has atrial tachycardia with AV block due to digitalis excess. We’ve seen a number of examples in the past of
bi-level AV block – the concept being that alternating impulses are blocked ‘high’ in the AV junction and the potentially conductible
stimuli can block it at a (functionally) lower level.
The ladder diagram is my answer for this puzzler. There is some irregularity of the P–P cycle with an average rate of 187 per min.
Clearly, many P waves are not conducted.
I interpret this to represent 2:1 transmission with alternating impulses blocked ‘high’ and the potentially conductible stimuli showing
gradual prolongation (Wenckebach block) until the stimulus encounters refractoriness and is not conducted. This resulting pause
permits the next P wave, which previously had not been conductible, to now become the affective stimulus – leapfrog Wenckebach.
Is the concept clear? Any disagreements?
William Nelson ECG quiz
