No Walk in the Park

ANSWER

This ECG demonstrates sinus rhythm with second-degree type II block, right-axis deviation, and ST-T wave changes in the inferior leads, suggestive of ischemia. A P-P interval of 100 beats/min meets the criteria for sinus rhythm.

Second-degree type II block is evidenced by two P waves for each QRS complex with a consistent PR interval. In this example, the PR interval is significantly prolonged at 415 ms. Normally, this would be a rather impressive first-degree AV block. However, a second P wave (integrated in the ST interval, best seen in the rhythm strip at the bottom) makes this second-degree type II block.

Right-axis deviation is defined by an R-wave axis of 90° to 180°; thus this patient qualifies at 131°. Finally, ST-T wave depressions are evident in leads II, III, and aVF, suggestive but not indicative of inferior ischemia. The patient was found to have a recurrent perivalvular abscess of his artificial aortic valve, as well as right lower lobe pneumonia.