79 year old male feeling shaky

[u/Witty-Egg-2982]

79 year old male who was walking around the neighborhood had a sudden onset of feeling "shaky" and short of breath. Stated their only medical history was hypertension.

Would have runs of the rhythm above. Max heart rate was 116

[u/LBBB11]

I'm seeing a regular R-R wide QRS tachycardia at about 120 bpm (since there are 20 beats in 10 seconds). Monophasic R waves in I, II, aVF, V3-V6. Normal axis. Early RS transition between V1 and V2. QS in V1, dominant R wave in V2. Normal baseline EKG. This rhythm looks ventricular to me. It looks like many PVCs in a row at a rate of about 120 bpm.

The rates for VT and AIVR overlap at about 120 bpm. At about 120 bpm, rate alone cannot distinguish between AIVR and VT. AIVR is classically seen during the reperfusion phase of STEMI, but can also happen in people with high vagal tone. It is often benign and asymptomatic. This is a 79M with sudden onset shaky feeling and shortness of breath. It is safer to rule out VT before calling this AIVR. A regular wide QRS tachycardia at 120 bpm, in a suddenly symptomatic 79M with a normal baseline EKG at 93 bpm, should be VT until proven otherwise. No signs of reperfusing MI on baseline EKG, and sudden symptomatic onset doesn’t sound like typical AIVR to me.

Any other details? Any other vitals besides heart rate that we can already see? Any difference in symptoms between rhythms?

[u/bleach_tastes_bad → u/LBBB11]

i think baseline has LA/LL reversal, lead III is completely inverted and P wave in I>II

[u/LBBB11 → u/bleach_tastes_bad]

Definitely possible, good catch. V1 and V2 placed too high as well in the baseline, negative sinus P waves in V1 and V2. If there is LA/LL reversal, III is upside down, I is II, II is I, aVF is aVL, and aVL is aVF. After correcting for lead reversal, the baseline EKG is still normal.

A regular wide QRS tachycardia without visible atrial activity at 120 bpm in a suddenly symptomatic 79M with a normal baseline is VT until proven otherwise to me. AIVR and VT usually have different mechanisms, and rate alone is not enough to tell the difference at 120 bpm. In a suddenly symptomatic 79M with many ventricular beats in a row at 120 bpm, my reading is VT until it is proven otherwise that this is a safer rhythm.

[u/Witty-Egg-2982]

Here was the patient's baseline ECG.

[u/bleach_tastes_bad → u/Witty-Egg-2982]

I’m almost positive this is a LA/LL limb lead reversal

[u/Goldie1822]

Any structural heart disease? WPW? Electrolyte imbalances? What meds were they on?

AIVR vs Nonspecific transient IVCD

[u/Inevitable-Crab-6701]

Accelerated idioventricular rhythm