Are P waves like crocuses?

I mean it’s spring. It’s St. Patrick’s Day. Flowers are popping up. Do P waves pop up too?

My driveway

I suppose ST waves are popping up too…

50’s y.o. man with Chest Pain

Rate is low 60’s. Rhythm is interesting. There is some irregularity. We do see P waves; let’s zoom in on the second half of the image.

The first PR is about 5mm, the second PR looks to be 6mm, the third PR looks like 7mm, the 4th PR drops. The rhythm therefore is a Mobitz I, aka Wenckebach block.

Axis is normal. QRS is narrow. There are q waves inferiorly. Along with the inferior q’s there’s pretty clear ST elevation inferiorly along with reciprocal STD in aVL.

Take-homes from this Inferior STEMI with Wenckebach? First off is that there may be two problems on an EKG so be systematic. This time the Wenckebach isn’t clinically that significant, but the next time it could be a Mobitz II or third degree. Next off is that don’t assume that it won’t become that. I know that classic teaching is that Wenckebach is fine, but inferior STEMI’s can affect the conducting system, and if that effect increases we could certainly see a higher grade block. While everyone picked up the STEMI, there was some disagreement on the type of block. Either way the assumption has to be that the STEMI is playing a role, so certainly optimize treatment of the STEMI.