What does this ecg look like to you?

I know there are some highly knowledgeable members here. I'm just curious what the thoughts are on what this ecg looks like? The heart rate was 115bpm it cut off on the screenshot.



Edited 1 time(s). Last edit at 07/02/2023 12:32AM by cornerbax.

What device is used here for this EGC?

Carey would be more qualified, but I would say that is atrial Flutter at a 3:1 or possible a 2:1 ratio. A regular 10 or 12 lead EKG would show the little P-waves making the diagnosis certain. Looks to regular a rhythm to be AFIB. I am assuming it's not Tachycardia, but I am not familiar with your device, I only have worked with regular EKG machines.



Edited 1 time(s). Last edit at 07/02/2023 02:05AM by The Anti-Fib.

Thanks for the response. I used my fitbit ecg on my fitbit Charge 5. I can run an ecg with my Kardia as well and it looks very similar. I noticed the regular rhythm in the R waves or at least from what I researched it looks regular. I was thinking Aflutter as well but don't know enough to say which is why I thought id ask here.

There's no way to be sure what that is from a recording like that, but flutter seems likely. It's at a rate of about 120, which would be a common rate for flutter. It might be identifiable if you had a Kardia 6L or maybe even if you used the lead II method with a regular Kardia (right fingers and left knee on the sensors).

Looks very much like flutter with 2:1 or 3:1 conduction. That said, you would need more than lead one to eliminate other arrythmia's such as atach.

What is interesting is that my heart rate is usually around 100 and between 115 at rest, but for some reason today it's lower on average. I just did an ECG with Kardia and it shows 67BPM but it shows as "UNCLASSIFIED" which i'm guessing is because Kardia will only detect certain rhythm's.

I don't have the 6L, just the standard Kardia.

Quote
cornerbax
What is interesting is that my heart rate is usually around 100 and between 115 at rest, but for some reason today it's lower on average. I just did an ECG with Kardia and it shows 67BPM but it shows as "UNCLASSIFIED" which i'm guessing is because Kardia will only detect certain rhythm's.

I don't have the 6L, just the standard Kardia.

Unclassified often means a mixture of an NSR and PACs, which confuses it. It does detect six arrhythmias but not flutter, which it usually tags as tachycardia.

Interesting. Very often I get the tachycardia reading and it's always at a heart rate of 110-120 so I'm sure that's likely flutter. Any thoughts on the ecg I attached reflects?

Quote
cornerbax
What is interesting is that my heart rate is usually around 100 and between 115 at rest, but for some reason today it's lower on average. I just did an ECG with Kardia and it shows 67 BPM but it shows as "UNCLASSIFIED" which i'm guessing is because Kardia will only detect certain rhythm's.

I don't have the 6L, just the standard Kardia.

Do you happen to subscribe to their KardiaCare subscription plan? If so, their PDF report has a heart rate vs time graph. It is a little screwy as the primary Y axis is based on RR time in ms, which makes the heart rate side inverted and also has kind of a logarithmic look to it. The reason I ask is that sometimes it is easier to see patterns on a HR vs. time graph. NSR with PACs is pretty obvious in this format, as is afib. Whereas looking at the ECG, it just looks variable. If you don't have the subscription, I can describe how to do it manually, just takes a little effort.

Quote
cornerbax
Interesting. Very often I get the tachycardia reading and it's always at a heart rate of 110-120 so I'm sure that's likely flutter. Any thoughts on the ecg I attached reflects?

This 2nd EGC you submitted looks to me like NSR with PAC's every other beat (Atrial Bigeminy).

I think I'm seeing "p" waves on the second ECG (the small waveform just before the QRS waveform). If you hold your Kardia with your right thumb on the contact, then place the left contact either around your left knee (or somewhere on your left leg) or to the left of and a bit below your navel on your belly. This will give you a Lead II presentation which gives a better representation of the p wave. Absence of a p wave is an indicator of afib.

I agree with Anti-Fib: NSR with bigeminal PACs.

Quote
GeorgeN
I think I'm seeing "p" waves on the second ECG (the small waveform just before the QRS waveform). If you hold your Kardia with your right thumb on the contact, then place the left contact either around your left knee (or somewhere on your left leg) or to the left of and a bit below your navel on your belly. This will give you a Lead II presentation which gives a better representation of the p wave. Absence of a p wave is an indicator of afib.

Did you try with the left contact on the V4 location ?
That's the way I usually do. P waves are clear too.

Thanks again for all of the responses, again very much appreciated. I learn something new every day I've never heard of this. Is NSR with bigeminal PACs any relation to AFIB/AFLUTTER? Is it better or worse that I would have NSR with bigeminal PACs, VS. AFIB or AFLUTTER?

@George, thank you. I can pay for a subscription but I don't want to get obsessive with ECG's. I was just curious after 4 months or so on Sotalol and Diltiazem what the ECG reflected. I don't have the 6L KARDIA, that is just the 1 lead Kardia and I put the first two fingers on each of the contacts to get the ECG.

Anyone have any thoughts on NSR with bigeminal PACs vs. Afib/Aflutter?

Quote
cornerbax
Is NSR with bigeminal PACs any relation to AFIB/AFLUTTER?

No

Quote

Is it better or worse that I would have NSR with bigeminal PACs, VS. AFIB or AFLUTTER?

Better! It is NSR!! Note your heart rate. If you are in NSR then lots of things are better.

Quote

@George, thank you. I can pay for a subscription but I don't want to get obsessive with ECG's. I was just curious after 4 months or so on Sotalol and Diltiazem what the ECG reflected. I don't have the 6L KARDIA, that is just the 1 lead Kardia and I put the first two fingers on each of the contacts to get the ECG.

Single lead is fine for looking at P waves


Per Pompom's comment

Quote
Pompom
Did you try with the left contact on the V4 location ?

.

I decided to do a search on contact locations to maximize the P wave amplitude. Came up with this paper. One comment is that most ECG contact locations are set to maximize visualization of the ventricular data.

Figure 9 shows the V4 location (on p6 of the PDF).



So what you can try is holding the Kardia with your right thumb on the contact, then place the contact on the V4 location (doesn't have to be perfect!) as shown in the image and see what you get. I've not played with this yet.

George, are you saying take the 1 lead Kardia I have and put my left thumb on one contact and use my right hand to place the other contact at the V4 location? It sounds that was just want to make sure you aren't talking about the 6L as I don't have a 6L.

Also, is it normal to alternate between NSR with Pacs and either Aflutter and Afib? If I am regularly in NSR with PACS would different medication be better and would am ablation still be beneficial assuming I never go into complete Normal sinus rhythm without any PACS?

I don't know what I was thinking. I just used my right hand and right thumb on one contact and placed the other contact in the V4 location as shown on the diagram. I've attached a screenshot of the ecg. Any better idea now of what the ecg shows?

Quote
cornerbax
I don't know what I was thinking. I just used my right hand and right thumb on one contact and placed the other contact in the V4 location as shown on the diagram. I've attached a screenshot of the ecg. Any better idea now of what the ecg shows?

Still hard to tell. I think I'm seeing a P wave on some of the beats in the first line. & yes, your device works fine for this.

I think it still looks like NSR with bigeminal PACs. I'm guessing the easy thing is if the rate is low, you are likely in NSR (of course with PACs at the moment).

Thanks George. Any thoughts on if it's common or unusual to fluctuate between NSR with Pacs and say Aflutter or Afib? When my resting heart rate is much lower these tend to be the ecgs. If I see my resting heart rate is high higher the flutter ecg tend to appear.

With that said, does that change anything I should discuss with my EP on medication or potential ablation?

Quote
cornerbax
With that said, does that change anything I should discuss with my EP on medication or potential ablation?

No, not really. All that's relevant here is you're experiencing a lot of PACs. It will be kind of a "duly noted" thing for your EP and it doesn't change decisions. The conversation needs to be continue drug therapy or go for an ablation, and currently the guidelines say choose ablation. Drug therapy will not work forever and ablations get harder the longer you wait. But, on the other hand, it might be worth waiting for PFA to become widely available if you can.

The only thing I would caution against is letting your EP do an ablation unless they're very highly experienced with thousands of afib ablations under their belt. Don't feel compelled to stay with them out of loyalty or whatever. It's way too important a choice to base on a misplaced sense of loyalty.

Hey Carey thank you again. I have read many of your posts and even before I found this forum I had no intention of being loyal to any of these doctors. The contrary exactly. One cardiologist gave me propafenone AFTER two days in the hospital with the worst rapid heart rate I've ever had and with extensive tests where he deemed it to be the Flecanide. They can't find anything with any tests so he prescribes propafenone. After even worse reactions a different cardiologist got me off the 1C medicines and onto sotalol and diltiazem. The propafenone should of never been prescribed per the second cardiologist as it was in the same 1C class and they deemed my significant adverse reactions to the Flecanide.

All the while ALL of them were MASSIVELY pushing ablation. I read people pretty well and I can genuinely say these "doctors" were more salesmen than doctor. I do understand the importance of ablation but these doctors were not wanting to even see if I ever got back in sinus rhythm on my own or with medication. I'm sure ablations pay much more than writing prescriptions but it's very unfortunate there are people who may of gotten ablations and who with time WOULD of gotten into sinus rhythm on their own if they were given the opportunity.

Regardless, I am working with Dr. Natalie's office as of last week and he will review all of my medical records when he is back next week. I did want to say to you that it may be no coincidence after many months on sotalol and diltiazem where I seemed to be in aflutter most of the time and where my resting heart rate was almost always over 100-115.

If you remember my post regarding those medications I did lots of research and didn't even consult my EP. I just increased Diltiazem 120mg on my own. I didn't do this blindly but I figured if 240mg of sotalol and 240mg of diltiazem wasn't slowing my heart and where I read up to 540mg diltiazem can be taken daily I couldn't see how another 120mg of diltiazem to 360mg a day would do any harm in my case. It seems Bradycardia is the biggest concern with sotalol and diltiazem and I was closer to tachycardia even with 480mg combined between the two.

Within a week of continuing 240mg of sotalol at 120mg twice a day and going to 360mg of diltiazem extended release once a day my resting heart rate has dropped at least 25-30bpm on average. I will consult my EP or even Dr Natale when he gets back next week via Norma who has been exceptional. I will inform them of the change and see their thoughts.

I'm the meantime, do you think there's a chance I'll get into normal sinus rhythm without Pacs?



Edited 1 time(s). Last edit at 07/04/2023 11:46PM by cornerbax.

Carey, I forgot to mention that you stole my exact thoughts on PFA. Ive read your stuff and mother members who just had a year anniversary and have been perfect with it etc. Because it has many less potential negative affects that is the route I would prefer to go if I do end up getting an ablation. Speaking to Norma last week I may be a candidate for it and I'd likely be all in on it if so. I will await to hear back when Dr. Natale reviews my medical records.

In the meantime I'll continue to monitor my resting and daily heart rates on the increased Diltiazem. As of a week in I've had zero side effects and a much lower overall heart rate, in addition to potentially being in NSR with PACS. If there's a better chance to revert to NSR from where I am not vs Aflutter or AFIB hopefully I will.

Quote
cornerbax
I'm the meantime, do you think there's a chance I'll get into normal sinus rhythm without Pacs?

Without doing something more than what you're doing now? No, probably not.

I've been where you are now with the NSR + bigeminal PACs. It would last for weeks, and then just as my brain was adjusting and beginning to filter out the PACs and not notice them, they would stop. But then a few days later they would start again but my brain had reset and I was noticing every single one of them again.

Sounds to me like you're on the right track with your thinking and planning, so keep doing what you're doing.

@Cornerbax :

I agree with the comments saying those are bigeminal PACs. I'm used to this kind of disorder: those PACs are often annoying, but mostly harmless. And they usually don't lead to AFib. Depending on the way you feel them, you may think your heart is beating half as slowly as it is really beating. I mean you may feel "heavy" normal beats and barely feel the discrete PACs (except if you take your pulses with your fingers).
I've lots of ECG tracings like this.

The device I make use of is not a Kardia, but a HealForce Prince; but it can be used the same way (between hands - between right hand and left leg - between right hand and torso). I guess the built in hardware and software may give better or worse printings, the processing (filtering) being different.
I can't see clear "P" waves on the tracing you got from V4 position; but I've pretty good results that way. As my ectopics are PACs as well as PVCs (don't ask why they come and go, I'm searching for years and still don't know), the V4 location allows the PACs to be displayed "positive" (QRS pointing upwards - no P wave) and the PVCs mostly "negative" (wider QRS pointing downwards - no P wave). There may be ectopics somewhere "in between", often hard to say of what kind they are, but sure they're ectopics (no P waves).
Normal beats have clear P waves displayed.

Here are some Kardia images - jpgs made from a PDF.

NSR this morning- right hand thumb to left V4. Good p wave:


This is the tachogram of the above, provided by Kardia. It is an unusual presentation. The heart rate y axis is on the right side. Increasing going down. The scaling is unusual as it is based on the RR time in seconds, a linear scale on the left side, increasing going up.


This is afib. No p waves.


This is the tachogram. The variability is very apparent, especially when you look at the right y scale. Note as the rate goes higher, the scale is compressed.




Edited 1 time(s). Last edit at 07/05/2023 11:03AM by GeorgeN.

Thanks, George. Interesting, as always.

Thank you all again.

Quote
Without doing something more than what you're doing now? No, probably not.

I've been where you are now with the NSR + bigeminal PACs. It would last for weeks, and then just as my brain was adjusting and beginning to filter out the PACs and not notice them, they would stop. But then a few days later they would start again but my brain had reset and I was noticing every single one of them again.

Sounds to me like you're on the right track with your thinking and planning, so keep doing what you're doing

I figured there wasn't a great chance to get into NSR but at least my heart rate is down much better than it was. I feel absolutely no fluttering/skipped beats in this NSR with PACS so I definitely prefer this over AFIB/AFLUTTER. Either way, I need to get into NSR sooner vs. later so I'll await Dr. Natale's review of my medical records and the MVP.

One question Carey, do you think the Texas location over the Thousand Oaks location is better for a PFA ABLATION? I'm actually very close to Thousand Oaks but i've read that the Imaging equipment may be better in Texas? I've worked 6 days a week for the last 10 years, sometimes 7, so it may actually be nice to get away for a few days anyway. Just curious your thoughts on Thousand Oaks vs. Texas for a PFA ablation with Dr. Natale?

Quote
cornerbax
One question Carey, do you think the Texas location over the Thousand Oaks location is better for a PFA ABLATION? I'm actually very close to Thousand Oaks but i've read that the Imaging equipment may be better in Texas? I've worked 6 days a week for the last 10 years, sometimes 7, so it may actually be nice to get away for a few days anyway. Just curious your thoughts on Thousand Oaks vs. Texas for a PFA ablation with Dr. Natale?

I would go to Austin. Not only is the imaging better, pretty much everything is better. They built an entirely new EP lab in 2019 and got all the latest whiz bang toys and gadgets. Everything is new. The place looks like the bridge of the Starship Enterprise. I got a tour when they were almost finished with construction, which you can view here.

I don't know if Thousand Oaks is a teaching hospital, but St. David's isn't, so you're guaranteed there won't be any fellows doing any of the procedure because there aren't any fellows. Also, all rooms are private, the food is the best hospital food I've ever had (and I've had a lot since getting food from hospital cafeterias is common practice for EMS personnel). And I must say the staff is the nicest, most competent I've ever encountered.

That said, if you can get PFA in one location but not the other, I would choose the PFA.

Those pictures look incredible and I'm sold. I'm going with PFA and in Austin only. I don't care about convenience, it isn't like i'm buying a pair of shoes. From everything i've read I have to go with PFA. You did RF, right? Or did you do PFA, Carey?

I did RF. In 2017 when I had my (hopefully) final ablation, PFA wasn't even in clinical trials yet. I'd heard of it, but it was "future tech" at that time.

Quote
cornerbax
Those pictures look incredible and I'm sold. I'm going with PFA and in Austin only. I don't care about convenience, it isn't like i'm buying a pair of shoes. From everything i've read I have to go with PFA.

They have 6 of those incredible labs! And, everything is on one floor so Dr. Natale just has to walk a few hundred steps to visit patients in their rooms—which he does do. I never waited for more than a few seconds when I pressed the call button for a nurse—really excellent care.

Quote
They have 6 of those incredible labs! And, everything is on one floor so Dr. Natale just has to walk a few hundred steps to visit patients in their rooms—which he does do. I never waited for more than a few seconds when I pressed the call button for a nurse—really excellent care.

Between this and the Starship Enterprise state of art facility/technology, I almost want to go even if I didn't have Heart Arrythmias...lol

Quote
cornerbax
Between this and the Starship Enterprise state of art facility/technology, I almost want to go even if I didn't have Heart Arrythmias...lol

On my second visit (for a Watchman) I had the presence of mind to ask about different pieces of equipment and what role each of the many who were busily prepping me played in the procedure. Too bad we don’t get to stay awake and watch! I you are interested, there are videos of Natale performing ablations on YouTube and also a tour when the new labs opened.

P.S. I send you a PM—link is in the line with your username at the top.

Quote
P.S. I send you a PM—link is in the line with your username at the top.

I just saw it and responded. Thanks, Daisy.