VAQ 2010.1

LITFL link for this question

A 64 year old man is being evaluated in your emergency department after an episode of chest pain which has now resolved.

a. Describe and interpret his ECG (100%)

This ECG shows second degree heart block (Wenkebach). Although this can be a relatively benign arrhythmia, in a symptomatic patient it is of more concern from ischaemia. Considerations other than ischaemia are electrolyte disorder, cardioactive drug toxicity (CCB, digoxin, beta blocker particularly), myopericarditis, and an incidental finding.

Important bits in bold

  • Rate – 60 between conducted beats; 35 between pauses (either will do or average over ECG but need to explain what using)
  • Rhythm – lengthening PR then drop consistent with type I (Wenkebach) second degree HB (Mobitz II also accepted in exam in view of irregularilty)
  • Axis – normal


  • P – unremarkable
  • Q – n/a
  • R – no diagnostic features
  • S – no diagnostic
  • T – unremarkable
  • U – not seen


  • PR – progressive prolongation until drop
  • QRS – narrow
  • ST- slight ST elevation with J point elevation in inferior and praecordial leads; appearance suggests benign early repolarisation
  • QTc – less than half R’R

Overall unremarkable ECG other than

  • non coronary artery distribution ST elevation
    • likely BER
    • consider serial ECG
    • consider ischaemia, pericarditis, myocarditis (at least one other cause suggested)
  • 2nd degree Wenkebach HB
    • consider serial ECG
    • AV nodal ischaemia – can be RCA or LCA supply so corroborating ECG changes unpredictable
    • check drug history (CCB, digoxin, beta blocker – with therapeutic use and overdose), electrolytes

Worth reading the slightly convoluted report on this (linked above)

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