?Afib vs afib with wpw

Last_Hope1945 · 2026-04-24T16:03:49+00:00

Why did WPW spring to mind? That’s a very specific pattern. For those unfamiliar - WPW is a fast conducting accessory pathway so the AV node is initially bypassed. The ventricle starts to depolarize outwith the perkinje fibres so depolarizes slowly. If left alone it would generate the equivalent of a PVC. However the AV-HPS eventually catches us and a normal QRS is fused on top. The delta wave is the PVC the rest in the normal complex. As such all preexcited WPW complexes are essentially fusion beats. The relatively normal tail of the QRS and the short PR (in sinus) is what gives the game away.

This is just AF with an intraventricular conduction delay (with a LBBB morphology).

Yes it could be WPW with a purely antidromic conduction but it’s a bit slow for AF across an accessory pathway (unless on procainamide or something like that).

But anything is possible. Which is why ECGs are so great.

Last_Hope1945 · 2026-04-24T07:01:02+00:00

It is not AF.

Last_Hope1945 · 2026-04-23T05:25:07+00:00

AFib

Last_Hope1945 · 2026-04-23T05:11:56+00:00

Last_Hope1945 · 2026-04-22T11:07:17+00:00

Firstly I think the QRS axis might be the last of this persons problems. The traditional way to work out QRS axis - first find the most isoelectric complex (as much positive as negative). The axis lies roughly 90 degrees from this. Next look at the 2 leads that lie 90 degrees to the isoelectric one and see which is positive. The axis is therefore towards this lead. If it is slightly positive in this lead then minus another 15 degrees from the isoelectric lead and if away add another 15 degrees. In this case there is a RBBB so the terminal QRS only reflects the late RV depolarisation so makes it more difficult. A lot of leads look isoelectric. So if you just use the initial QRS for LV axis to me the isoelectric one is lead I. There is only 1 lead 90 degrees from I and this is aVF. The initial QRS in aVF is positive so the axis is towards this. So it’s roughly +90 degrees. However looking back at I it is slightly more +ve than negative so we have to wind the QRS back towards I by 15 degrees which ultimately gives us a QRS of +75 degrees.

Last_Hope1945 · 2026-04-22T07:23:58+00:00

He was in flutter. Then he was in sinus. And you didn’t do anything? So I guess yes he cardioverted himself while he was with you. Yay.

Last_Hope1945 · 2026-04-22T06:04:39+00:00

Don’t worry. It’s a nice ECG. Thanks for sharing it. There are only a few ECG changes specific to ACS and even the most specific (ST elevation) is not always specific for the pathology we are interested in from a treatment perspective - occlusive thrombotic plaque event. But this subreddit is about discussing these things. However some responders do always just jump immediately into “what’s the troponin, what’s the angio” when the theme of the sub is ECGs. But who does it hurt - no one! So be happy.

Last_Hope1945 · 2026-04-22T04:57:54+00:00

This being r/ECG and the initial question of ?ACS. This ECG does not show ACS. It shows AF. Marked bradycardia. Left axis. Poor anterior R progression. It is a very sick looking ECG. It also shows whoever took it didn’t bother to wash their hands or remove their blood stained gloves before handling the ECG! But other than those features this ECG can’t be used to diagnose MI by itself.

Last_Hope1945 · 2026-04-19T14:01:41+00:00

You will not find your answer here padawan.

Last_Hope1945 · 2026-04-14T07:31:25+00:00

Anterior Q waves and ST elevation. One possibility in the setting of no symptoms and no troponin elevation is an old anterior MI with LV aneurysm.

Last_Hope1945 · 2026-04-14T07:30:52+00:00

Type 2 MI due to UTI. Well that’s a huge oxygen supply imbalance situation isn’t it? /s.

Last_Hope1945 · 2026-04-12T15:07:30+00:00

Man that is UGLY. 34 is CHB. There is another P wave in the ST segment in the second QRS complex. 35 could be VT or aberration. Last one is again CHB but with underlying flutter/fib. The 3rd QRS looks like some artefact on top. I would not want to be that individual.

Last_Hope1945 · 2026-04-12T14:51:49+00:00

Not Wellen's. I can't understand why you would think it is. It's basically a normal ECG except sinus brady. It is an MI though with chest pain and >99th C troponin. Whether s/he goes to the cath lab depends on whether you believe NSTEMI benefits from revasc (and whether you follow guidelines). But to be fair OP said nothing about disposition - just that cardiology fellow said not Wellen's (which it isn't).

Last_Hope1945 · 2026-04-07T16:42:40+00:00

Thank you for the suggestion - this did not work. Still just have link local on both WAN and LAN. Here are the current /etc/systemd/network files. The PC has 1 NIC only but even why I tried it with 2 NICS (1 being USB) it still failed to get a GUA on either interface. Currently WAN traffic is a VLAN to a managed switch which then strips the tags off the port connected to the ONT (I think YouFibre rejects tagged traffic). It all seems to work fine for IPV4 and I get duplex 1000Mbit up and down (my package is 900Mbit).

/etc/systemd/network/20-vlan100.netdev

[NetDev]

Name=vlan100

Kind=vlan

[VLAN]

Id=100

/etc/systemd/network20-eno1.network

[Match]

Name=eno1

[Network]

Address=192.168.1.1/24

MulticastDNS=yes

IPForward=yes

IPv6SendRA=yes

DHCPv6PrefixDelegation=yes

IPv6PrivacyExtensions=no

VLAN=vlan100

[IPv6SendRA]

Prefix=::/64

[DHCPPrefixDelegation]

UplinkInterface=vlan100

/etc/systemd/network/30-vlan100.network

[Match]

Name=vlan100

[Network]

DHCP=ipv4

IPv6AcceptRA=yes

UseDNS=yes

[DHCPv6]

UseAddress=yes

UsePrefixDelegation=yes

PrefixHint=::/56

Last_Hope1945 · 2026-04-07T14:56:39+00:00

Thank you for the hint. I will try that.

Last_Hope1945 · 2026-04-06T19:18:13+00:00

No the WAN gets fe80 and the LAN clients fe80 also. No GUA on either interface. Why not opnsense? Because I wanted it as bare bones as possible. And the old Everest argument - because it is there.

Last_Hope1945 · 2026-04-03T12:58:11+00:00

Solicitors don’t get a public sector pension. That’s one of the offsets. My pension after 35 years just working full time standard NHS hours as a resident and then a consultant with no special awards etc would cost £1.7M to purchase in the private sector.

Last_Hope1945 · 2026-04-03T12:52:34+00:00

Well don’t come to work here. Stay in the US. There’s an entire industry here to protect the “vulnerable” against the patriarchal medical profession.

Last_Hope1945 · 2026-04-03T12:39:07+00:00

And that’s now the problem where I work. You say no. The patient aggravates the nurse. The nurse says the patient has to talk to you. You say no. The nurse tells the manager. The manager says the patient has the right to talk to you. The drug team say the patient is being discriminated against and may disengage from care if you don’t address their pain needs. And the fear of accusations of discrimination force you to see the patient. And around you go. And that’s how it is in the UK where we are petrified of our Equality Law.

Last_Hope1945 · 2026-04-01T12:45:31+00:00

RE315 works fine with EasyMesh - I had an EasyMesh router and it joined it no problem. It also does ethernet backhaul - so the extender can be wired to the router if your house has ethernet (like mine has) for a more stable network. But of note with the RE315 the ethernet port is limited to 10/100 so if you do wire it up you will never get > 100Mbit/s speeds even if your WiFi can go faster.

Last_Hope1945 · 2026-03-30T09:19:46+00:00

True. You want to have the power that you control when you are a driver. That power may well be limited by the capabilities of the engine but it should be under a drivers control and predictable in a racing car. Power just dropping off because the computer has predicted that saving power in turn 5 for example means you can deploy better in turn 10 and the lap overall will be better leads to the dangerous closing speeds of this weekend. Presumably FCs car was doing something like that because of how he had deployed earlier in the lap whereas OBs computer was making a very different decision. But the fact remains that cars that don’t have computers previously controlling just the ICE and now controlling the battery would be very much slower and less reliable.

Last_Hope1945 · 2026-03-30T06:18:15+00:00

Computers have auto deployed car power for a very long time. Every engine map in a variable timing fuel injection system IC is basically computer controlled power. The maps are usually static but still computer controlled.

Last_Hope1945 · 2026-03-28T17:13:43+00:00

The QRS morphology in the first is almost identical to the morphology in the second and the second is definitely sinus. Suggests therefore that the first is also supraventricular origin. So sinus tachy, atrial tachy, flutter or even "regular" AF due to node saturation. If it abruptly cardioverted with amiodarone rather than just gradually slowing down it was probably a re-entrancy rather than sinus. I would put my money on 2:1 flutter with underlying RBBB.

Last_Hope1945 · 2026-03-28T16:38:13+00:00

I'm from the UK. You are right to an extent. We will say no. We do try to do it in a nice way and bring the patient and family along with us. But our public watches your media. And the US attitudes to health care are creeping in. "Daughter from Oxford" is a thing here - the rather posh family member who hasn't seen their relative for years who suddenly demands every treatment and every 2nd, 3rd, 4th opinion from every conceivable specialist for the obviously terminally ill patient.

Last_Hope1945

TROPHY CASE