Agonal Rhythm
Report:
Sinus bradycardia
?Shifting pacemaker
SVEBs
RBBB
3rd degree AV block.
Ventricular standstill
Comment:
Normally, the right atrium is the last part of human heart to stop beating. This is not possible to diagnose from surface electrocardiogram.
The changing P wave morphology may reflect either a new atrial pacemaker or a progressive conduction defect in the atria.
Note the shallow but surprisingly prolonged atrial repolarisation (PT) waves. The PT segment is slightly but definitely elevated in the lower strips. This would be normally ascribed to atrial infarction but in this case is merely a manifestation of agonal rhythm, analogous to agonal ST segment elevation.
Agonal rhythm is usually manifest as progressive bradycardia, often from subsidiary pacemakers, and progressive conduction deficits. Eventual ventricular asystole may be preceded by third degree AV block, as here, or by the extinction of the remaining subsidiary pacemaker; sometimes by VT or VF.
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