AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2641-0419/286
1MD Bait Balev Nesher and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
*Corresponding Author: Jochanan E. Naschitz, MD Bait Balev Nesher and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
Citation: Jochanan E. Naschitz (2022). ECG at the Bedside: Atrial Bigeminy with Alternating long and Short PR Interval. J. Clinical Cardiology and Cardiovascular Interventions, 6(1); DOI:10.31579/2641-0419/286
Copyright: © 2022 Jochanan E. Naschitz, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 14 November 2022 | Accepted: 28 November 2022 | Published: 03 January 2023
Keywords: inter-atrial block; bachmann bundle; atrial bigeminy; left atrial extrasystole
The admission electrocardiogram of an 88-year-old woman, showed sinus rhythm, biphasic P waves in leads II, III, with the terminal vector directed upward, P duration 130 msec, PR interval 200 msec, consistent with advanced inter-atrial block. Next, atrial bigeminy occurred originating in the left atrium and delaying the sinus P waves. With the ectopic P’ measuring 60 msec, the likely path of left atrial stimuli to delaying the sinus node was through Bachmann’s bundle, by retrograde conduction. This means that inter-atrial conduction via Bachmann bundle
An inter-atrial block leads to dispersion of the atrial refractory period and contributes to generating re-entry circuits. This is illustrated by occurrence of transient atrial bigeminy. Intriguingly, P' waves and the P'R interval were shortened during atrial extrasystole, challenging our interpretation of the tracing.
The patient, an 88 year-old woman, was admitted for rehabilitation after recovering from pneumonia and hyponatremia. Her medical history was notable for arterial hypertension, ischemic heart disease, atrial fibrillation, and pulmonary embolism. Her medications, daily doses, were apixaban 10 mg, valsartan 160 mg, furosemide 40 mg, and atorvastatin 10 mg. Upon presentation she was alert, the vital signs and routine laboratory tests (CBC, chemistry, thyrotropin) were unremarkable. The ECG showed sinus rhythm 72 beats per minute, P waves duration 130 msec, biphasic P waves in leads II, III and aVF with the terminal vector directed upward, i.e. characteristic features of inter-atrial block. The PR interval measured 200 msec. The QRS had the right bundle branch block pattern. Deep negative T waves were noticed in leads III and aVF. This ECG was comparable with several tracings recorded a few months ago. Three days after admission, while the patient felt well, the ECG had changed: each regular beat was followed by an atrial ectopic beat (Figures 1 and 2). The P waves, alike in earlier tracings, were consistent with sinus rhythm and showed the morphology of advanced inter-atrial block. In distinction from the latter, the ectopic P’ waves' duration was 50 msec, P' were positive in leads I,II,II and V1-V6, and the P'R interval was 120 msec. The P-P' interval was constant. Atrial bigeminy was diagnosed.
Figure 1: Interatrial block and atrial bigeminy. Notice that ectopic atrial waves are positive in leads II and V1, and negative in aVL.
Figure 2: Details of P and P' are evident under magnification. The strips were taken from Figure 1. The P waves in lead III are biphasic, with an early downward vector followed by the late vector directed upward. The maximal P was duration is 130-140 msec, the PR interval 220 msec. In Lead V1, the large negative terminal deflection of the P waves is notched in a to-and-from pattern. P' in leads III and V1 are positive except the third P' in lead III. The P'P interval is 800 msec.
The following day's tracing showed sinus rhythm, no extrasystole (Figure 3).
Figure 3: Sinus rhythm 74 bpm, inter-atrial block, no ectopic beats. P-P interval 800 msc. alike P’-P intervals on the previous day's tracing.
Discussion
The P waves in this tracing differ from normal atrial activation. Usually, atrial activation begins with impulse generation in or near the sinus node. From here, the activation extends anteriorly toward the lower portion of the right atrium and inferiorly toward the atrio-ventricular node. The left atrium is activated after the onset of right atrial activation by spread of the stimulus usually through Bachmann's bundle. The latter spans from the right atrium to the left atrium close to the right upper pulmonary vein. Activation proceeds in both atria downward, continuing in the left atrium after the right atrial activation is complete. Accordingly, the normal P waves are positive in lead II and usually in leads I, aVL, and aVF. The P wave in the right precordial leads is typically upright but may be biphasic in leads V 1 and V2 with an initial positive followed by a terminal negative deflection. The normal P wave duration's upper limit is 120 msec measured in the lead where the P wave is widest. The terminal negative deflection in Lead V1 is normally less than 0.1 mV in depth. The normal duration of the PR interval is 120-200 msec [1]. Abnormal P waves suggest an abnormal site of impulse formation and an abnormal course of subsequent activation. When conduction from the right to the left atrium is delayed the P wave duration is longer than 120 msec and the P waves in lead II have two humps, the first corresponding to right atrial activation and the second to left atrial activation, i.e. partial inter-atrial block [2]. With advanced inter-atrial block, the right atrial impulse reaches the left atrium late, after traveling down near the atrioventricular junction and then upward across the left atrium; consequently, the P waves in inferior leads are positive at their beginning and turn negative at termination [2,3]. Bayés de Luna et al. [2] classified these types of blocks as either partial block, when the only ECG abnormality is a P wave that equals or exceeds 120 msec or an advanced block, when the P wave duration is ≥120ms and the P wave is biphasic in the inferior leads II, III, and aVF, beginning positive and becoming negative at termination. Advanced inter-atrial block is frequently associated with left atrial enlargement but may manifest independently of left atrial size [4]. Unusual in this tracing in is the notched terminal deflection of the P wave in lead V1. This contrasts to the common smooth terminal component of the P wave in lead V1 both in partial and advanced Bachmann bundle block as well as in the presence of other left atrial pathologies [5].
Inter-atrial conduction delay leads to the dispersion of the atrial refractory periods, facilitating occurrence of re-entrant atrial arrhythmias, especially atrial fibrillation and atrial flutter [6], but also atrial bigeminy [7] as in the proposito. Atrial bigeminy refers to a sequence of at least two atrial ectopic beats, each one following a sinus beat with a fixed coupling interval. The ectopic beats can be generated from any atrial site. Focal automatism or re-entrant mechanisms may be the mechanisms of atrial ectopy [8]. The combination of a positive P’ in lead V1 with a negative or isoelectric P’ in lead aVL are consistent with the left atrial origin of atrial ectopic beats [7].
Delayed occurrence of the sinus P wave after the ectopic atrial beat (P'P equal to PP) suggests that the sinus node was depolarized by the premature atrial beat. Since the P' duration was short, there obviously was no substantial lag in right atrial depolarization, as would occur if the left atrial impulse reached the right atrium after the long way first down near the atrioventricular junction and then upward across the right atrium. The shortest to imagine course of depolarization from the left atrium to the right atrium is through the Bachmann's bundle, left-to-right, a possibility demonstrated under epicardial mapping [3]. This would mean that the inter-atrial block in this patient was unidirectional from right-to-left, while left-to-right conduction through the Bachmann bundle of ectopic atrial stimuli was not affect
Inter-atrial block is an independent predictor of supraventricular tachyarrhythmias, and it has been associated with left atrial thrombi and systemic embolization. This justified continuing in the proposito anticoagulation with apixaban, though past atrial fibrillation and long time ago pulmonary embolism.
There was no funding to this work and there are no conflicts of interest to declare
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
