of Mountains and T waves

How are Mountains unlike T waves?


They’re allowed to have extra bumps!

I went on an Alaskan Cruise, purely for the educational content of the conference that was on-board.  Hopefully should have some podcast material at least.

Let’s look at last week’s EKG:

~70 y.o. man with improving SOB

Starting with rate, we see a regular rate with R-R interval about 4 big boxes wide so rate is about 80.  While it is regular, the question is whether there are P waves.  There certainly aren’t P waves in their expected position just before the QRS.  Let’s come back to the rhythm and assess the rest of the EKG to look for additional clues.  Axis is up in I and down in aVF so actually a left axis.  QRS is overall narrow however, this eliminates a ventricular source of the rhythm, it has to be at the junction or above.

Let’s zoom in on the T waves, looking at the rhythm strip with V1, II, and V5.


There’s actually extra bumps and inflection points in the T waves.


What do extra bumps and inflection points in the T waves usually mean?  Little lost P waves of course.  In this case the P waves immediately follow the QRS.  We don’t see them in the T-Q segment so this does not appear to be a block, rather the P waves are retrograde.  This patient has an accelerated junctional rhythm.  Why does he have an accelerated junctional rhythm?  Who knows.  This can be normal in highly tuned athletes.  It’s probably not normal in our patient.  His electrolytes were normal though.  It would likely merit a call to the cardiologist who I doubt would be super interested if the patient’s not having syncope or bradycardia.  In this case it seemed to be more of an incidental finding.

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