A stroke patient with an unusual electrocardiogram

Abstract

We present a case of a 70 year old man with a history of paroxysmal atrial flutter who was admitted to the hospital with symptoms and imaging consistent with an acute stroke. Physical exam was notable for a pulse rate of 50 beats per minute and right sided facial droop with mild dysarthria. Admission ECG shows a junctional bradycardia with evidence of dual AV node physiology, rarely manifested in a retrograde fashion on a standard ECG. The patient likely experienced parasympathetic sinus node slowing in the setting of acute stroke. During post-stroke monitoring, the patient demonstrated return of sinus rhythm with chronotropic competence and he had no additional arrhythmia during admission.

Keywords: AV node; Bradycardia; ECG.

Figure 1:

Twelve-lead ECG on admission.

Figure 2:

Ladder diagram. A. Leads V1 and II on admission ECG. Red arrows represent retrograde conduction through the fast pathway, the blue arrows represent retrograde conduction through the slow pathway. B. Ladder diagram demonstrates each junctional impulse followed by conduction to the ventricles as well as to the atria utilizing dual AV nodal pathways in an alternating pattern, resulting in the alternating R-P intervals.