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Practice ECG 5
There is a P-mitrale in lead II. The biphasic P in V1 is also consistent with LAE. Are there any ectopic beats on this ECG? Yes, beats 7 to 10 have different morphologies from the regular SA nodal beats. Beat 7's P is premature and falls on the T of beat 6. This makes the T wave of beat 6 appear taller and more peaked. Beat 10 is transmitted down an abnormal pathway giving it that bizarre appearance (aberrant conduction, to be reviewed later).
What is the rhythm? It is NSR with a short episode of atrial ectopy. You cannot say that this is a wandering atrial pacemaker, even though there are up to five different P wave morphologies, because the predominant rhythm is NSR. The tenth beat is an abnormally conducted supraventricular beat. Note the abnormal looking T wave preceding it, caused by the P falling on the T, and the fact that the morphology of the QRS complex in the aberrancy is similar to the normally transmitted beat. As usually occurs in an aberrantly conducted beat, repolarization occurs along an abnormal pathway, causing ST and T wave abnormalities.
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