A 48-year-old man with a history of hypertension, diabetes mellitus (type 2), hypothyroidism, and left ventricular dysfunction presents with fatigue, dyspnea, and palpitations. The admission ECG is depicted below (Figure 1):
The ECG shows which of the following?
The correct answer is: F. A, C, and D
Atrial Fibrillation (A), Left anterior fascicular block aberration (C), and Right bundle branch block aberration (D).
The atrial rhythm is atrial fibrillation. The patient has left ventricular hypertrophy (R wave in AVL > 11 mm) with secondary asymmetric T wave changes rather than ischemic T wave abnormality. The wider complex beats represent right bundle branch block (RBBB) plus left anterior fascicular block (LAFB) aberration. The last beat in lead I, II and III shows LAFB aberration without RBBB. Aberrant conduction with a RBBB morphology is common in rhythms such as atrial fibrillation with frequent long-short cycles (Ashman's phenomenon).
Gulamhusein S, Yee R, Ko PT, Klein GJ. Electrocardiographic criteria for differentiating aberrancy and ventricular extrasystole in chronic atrial fibrillation: Validation by intracardiac recordings. J Electrocardiol 1985;18:41-50.