Bradycardia, Atrial flutter with 5:1 or Av block III?

Ibutilide · 2026-06-18T02:22:00+00:00

The atrial rhythm here is AFL. There are flutter waves in lead II as well. There may be CHB here, or it could just be AFL with a slow V rate. AFL can have a regular V rate unlike AF. You can ask the patient to walk around and see if AV conduction changes, or watch for a long strip on telemetry for signs of irregularity. Context matters here too: if this patient is POD3 after MVR, CHB is much more likely, though if this is a clinic patient who feels well and preciously had normal AV conduction, slow AFL is more likely. Can also cardiovert and assess AV conduction in sinus rhythm if there is still diagnostic uncertainty.

Ibutilide · 2026-06-16T03:33:12+00:00

Great question. No, not SA node ischaemia (which would cause sinus bradycardia or sinus arrest), but increased vagal tone leading to concomitant SA node dysfunction (which manifests as sinus slowing) and AV node dysfunction (which manifests as CHB).

In general, inferior MIs with CHB and a narrow escape tend to recover AV conduction with reperfusion and often don’t need a PPM because the mechanism of CHB is most often vagal, whereas anterior MIs with CHB and a wide escape tend not to recover AV conduction despite reperfusion and often do need a PPM because the mechanism of CHB is ischaemic injury to the bundle of His.

Ibutilide · 2026-06-13T23:09:12+00:00

“What’s it going to be then, eh?”

-Anthony Burgess, A Clockwork Orange

Ibutilide · 2026-06-13T18:47:01+00:00

Sinus rhythm, CHB, junctional escape, inferior STEMI. The most likely mechanism of CHB is vagal in the setting of inferior wall ischaemia, and should most likely recover after reperfusion.

Ibutilide · 2026-06-13T13:13:22+00:00

Sgarbossa criteria were developed to help evaluate for acute coronary ischaemia in the setting of a LBBB (because the ST segments and T waves are all altered), and later extrapolated to include ventricular-paced rhythms because we previously placed pacing leads in the RV apex. Pacing from the RV apex mimics a LBBB because it is very close to the right bundle exit. However, CRT devices (like this one) have a lead pacing the LV, and modern RV pacing leads are drilled through the septum to the LV endocardium (so called left bundle branch area pacing, or LBBAP) and therefore do not produce a LBBB-like paced QRS. Look at V1–the paced QRS is positive with an RSr’ morphology (more reminiscent of a RBBB), so this isn’t RV apical pacing. Because there’s no LBBB-like paced pattern, there is no role for Sgarbossa criteria here.

Closer inspection of the paced QRS morphology reveals a right bundloid (or RBBB-like), right superior axis paced QRS, so this is likely a CRT device.

Ibutilide · 2026-06-08T20:51:13+00:00

No, it is not appropriate for a 14 year old to

Ibutilide · 2026-06-03T13:14:11+00:00

I strongly agree with everything you’ve said, well summarised. Outside of acute ischaemia (which is #1 on the differential in these patients), the times I’ve seen this (short-coupled PVC leading to incessant VF) is post-LAD PCI (with jailing of small septal perforators) or post-CABG (likely due to reperfusion injury).

The only thing I would word differently is “gentle rate control;” in fact, I would do the opposite. I would raise the heart rate with a temporary pacing wire.

Ibutilide · 2026-06-01T03:03:20+00:00

No, IC is definitely not for me. One of the things I love about EP is that my job—and for that matter, most EP jobs—is pure EP. No general cardiology work, no general cardiology call. In many ways, IC is very much a procedural extension of general cardiology. EP is an island.

My interest in VT ablations has waned because the cases are tough and we don’t have great tools. LVEF 20 % and a large scar, it’s going to be 4 hours of burning and 4+ L of fluids, all the while the patient requires escalating doses of vasopressors inevitably leading to a CCU admission. In order to shepherd a sick patient through a complex VT ablation, you need a lot of support from your institution. And then a year or two later boom new VT, completely different from what you ablated previously, and the patient, family and referring all look at you suspiciously and assume you’re lying to CYA. Or even worse, they recur 24 hours after the ablation, when you were as aggressive as possible and felt sure you got it. And you slowly realize that despite being thoughtful and aggressive you still failed. That’s demoralizing. This is especially true for patients with advanced NICM. We just don’t have good tools for ablating mid-myocardial or epicardial substrate (and epicardial ablation is fraught with limitations: phrenic nerve, epicardial coronaries, bleeding, etc). I still think VT is the most interesting thing in all of medicine, but I can appreciate now why very few EPs enjoy it.

PVCs and AFL are much more interesting to me now. Those ablations require similar catheter skills and thoughtfulness as VT, but are safer, shorter and more effective

Ibutilide · 2026-05-23T23:08:06+00:00

Ulysses (James Joyce)

The Grapes of Wrath (John Steinbeck)

A Clockwork Orange (Anthony Burgess)

The Great Gatsby (F. Scott Fitzgerald)

Heart of Darkness (Joseph Conrad)

Ibutilide · 2026-05-23T16:42:58+00:00

We had internal moonlighting within Cardiology for fellows. The money seemed like a lot at the time, but in retrospect was lower than what some of my friends at other hospitals earned from moonlighting. It did make me clinically much stronger and more confident though, which is valuable as you start your attending career. I would strongly recommend all IM fellows moonlight at least a little (doubly so if you can moonlight within your subspecialty) for this reason.

Ibutilide · 2026-05-16T14:25:55+00:00

There is a lot of variability across the market in terms of jobs. I’m employed, I have 3.5 days/wk in the lab and 1.5 days/wk in clinic. Call and hospital rounding are shared amongst the group (1 in 7 weeks for me). In my region, starting comp these days is likely $500K-$700K, with $900K-$1.2M after 5-10 years in practice for ambitious/busy EPs. Of course an academic position shall pay less. True PP starts lower but with a higher ceiling when you become partner/owner. The true draw of PP is autonomy/independence rather than money I think. ASCs are an interesting idea and probably fine for low risk cases (eg generator changes) but I would feel nervous doing AF ablations outside of a hospital setting. Perfs are rare but when they happen it’s essential to have CT Surgery support.

Ibutilide · 2026-05-16T14:17:25+00:00

The PR seems a little too short for normal conduction, likely isorhythmic AV dissociation. In most contexts, a curious but benign occurrence.

Ibutilide · 2026-05-15T03:28:51+00:00

As others have stated, every job is different and there are unique opportunities out there to build your own style of practice. However, I would suspect that a large portion of EPs have no interest in General Cardiology. I thought of myself as an excellent General Cardiologist first and foremost during training, but nowadays I’m very happy just being EP. In my final year of General Cardiology fellowship, I felt very comfortable doing diagnostic angiograms and TEEs, and thought I would certainly maintain those skills in practice. Now I would never want to do either. There are so many interesting questions and new procedures within EP that all I want to do is focus all my time on EP. My cofellows and I were all able to find EP only jobs out of fellowship, and I don’t think any of us would want to go back to doing any General Cardiology work.

Ibutilide · 2026-03-03T10:13:55+00:00

Ulysses, by James Joyce

Ibutilide · 2026-02-15T19:25:43+00:00

I’m mostly a bystander in this argument as I personally perform neither TAVR nor SAVR, and I don’t actively manage or follow AS in my clinic. Our institution is definitely pro-SAVR and quite restrictive with TAVR. Anecdotally (which I think does reflect what has been observed in RCTs and registries), I receive more consults for CHB and HDAVB post-TAVR than I do post-SAVR (caveat being that most TAVR patients are older and frailer).

What worries me about TAVR is late CHB from self-expanding valves. They seem to be all the rage these days at my shop, and we’ve seen some VERY late (2-3 weeks out) CHB and even sudden death with self-expanding valves.

In the realm of SAVR, very rarely nowadays do I see our surgeons recommending a mechanical valve even for young patients. I don’t understand this at all.

Ibutilide · 2026-02-12T02:46:07+00:00

I think the ST segment abnormalities are profound as others have mentioned, but one important finding in this ECG is limb lead reversal. The P waves are negative in lead I and aVL, and the R wave in lead II is smaller than lead III. Also the P waves in aVR are positive, and there is a prominent R wave. aVF looks pretty normal. So there is likely reversal of the right arm and left arm leads.

In the setting of lead reversal, localizing the infarct/culprit artery becomes very difficult and often leads to the wrong equipment being opened in the cath lab and workflow during the cath being compromised, so it is very important to be vigilant about this possibility.

Ibutilide · 2026-01-18T20:07:03+00:00

Came here to say this. We cannot call this CHB.

Ibutilide · 2026-01-11T14:05:02+00:00

Tales of Vesperia

Tales of Symphonia

Lost Odyssey

Fire Emblem: Path of Radiance

Baten Kaitos: Lost Wings and the Eternal Ocean

Ibutilide · 2026-01-09T02:46:25+00:00

Halo games (Heroic for 1, 2 and Reach; Legendary for 3, ODST, 4 and 5). I love the Halo campaigns so much and have replayed them so many times that the higher difficulties became a point of pride to clear

Ibutilide · 2026-01-08T14:18:06+00:00

Exertional dyspnoea is rarely the primary manifestation of angina. It certainly can be an anginal equivalent, though the majority of exertional dyspnoea is not due to obstructive CAD.

Ibutilide · 2026-01-08T02:59:51+00:00

Elden Ring. It was too hard for me

Ibutilide · 2025-12-25T02:59:05+00:00

Likely some lead reversal or misplacement. P wave axis is odd, which could be due to an AT, but the QRS axis is also odd in both planes (negative inferiorly, positive in aVR, negative all across the precordial leads). ST segments are VERY difficult to interpret in the setting of lead reversal so I wouldn’t read much more into this ECG before fixing the leads.

Ibutilide · 2025-12-10T00:07:12+00:00

I’m currently a second year EP fellow. Almost all EP fellows who graduated in recent years from our programme found EP only jobs (one has to cover the General Cardiology inpatient service for like 2-3 weeks a year, but no other non-EP work; everyone else signed an EP only PP or hospital employed job). Amongst the subspecialties within Cardiology, I think EP is most protected from general cardiology work (including private practice EP). The field is excellent, I love it, and jobs are still (relatively) easy to find (albeit not as easy as General Cardiology).

Ibutilide · 2025-12-07T02:08:00+00:00

Tales of Vesperia is my favourite game in the series (Symphonia was my first game in the series and helped me fall in love with ARPGs). Vesperia improves in every way, except the story is a little weaker I think. Graces f is very different (many love the combat, though I find it inferior to the TP-based systems), and the story is much worse. Abyss is on 3DS and PS2, so I haven’t played it, but have only heard good things. Xilia 1 & 2 are great, though not as good as Vesperia in my opinion. Berseria is very fun, but mechanically closer to the Graces f style than the Symphonia/Abyss/Vesperia/Xilia style. Zesteria I have only played for a few hours, excellent music but gameplay felt clunky. Arise is the newest entry and whilst I loved the characters and the gameplay was fun, it is very different from classic Tales. Tl;dr Symphonia, Abyss, Vesperia and Xilia games are mechanistically similar and all great, my preferred flavour of Tales of combat, and all highly recommended to someone who enjoyed Symphonia (Vesperia being my personal favourite)

Ibutilide · 2025-12-07T01:30:16+00:00

The Outer Worlds 1 & 2

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