Report:

Atrial fibrillation with controlled response (top & bottom)

Mean BP 85 & 83 mmHg

Pacemaker rhythm (middle)

Mean BP 68 mmHg

Comment:

The slight asynchrony in contraction secondary to LBBB-type conduction becomes significant in a critically impaired ventricle165. Non-ischaemic chest pain may also result166.

This is not due to abolition of atrial transport by ventricular pacing: the patient is already in AF.

More of the same is illustrated below (Figs 236a, 236b). Ideally, the patient should have developed LBBB of his own; then the ventricular pacing should make no difference! A bad taste joke one says on the rounds.

Tall T Waves: Myocardial Rupture

Report:

Sinus rhythm

Third degree AV block

Junctional escape rhythm 43/min

Prominent T waves

Comment:

A rare cause of tall T waves, not unlikely in this case, is free wall rupture167. Other causes (infarction, reciprocal change to remote infarction, hyperkalæmia) cannot be excluded; however, sudden EMD remains, to use D. H. Spodick’s tongue-in-cheek term, ‘suggestoid’ of rupture. He actually refers to tall T waves in hæmopericardium of any ætiology, ascribing it to hæmolysis and local hyperkalæmia168.

The relatively short QT interval may reflect iatrogenous hypercalcæmia provoked by the EMD169.