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By Francis Morris; William Brady; A John Camm

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Atrial conduction proceeds in a retrograde fashion producing inverted P waves in leads II, III, and aVF. However, since atrial and ventricular depolarisation often occurs simultaneously, the P waves are frequently buried in the QRS complex and may be totally obscured. A P wave may be seen distorting the last part of the QRS complex giving rise to a “pseudo” S wave in the inferior leads and a “pseudo” R wave in V1. Atrioventricular re-entrant tachycardias occur as a result of an anatomically distinct atrioventricular connection.

This type of “slow-fast” re-entry circuit is found in 90% of patients with atrioventricular nodal re-entrant tachycardia. 1 Mechanism of atrioventricular nodal re-entrant tachycardia showing the slow and fast conduction routes and the final common pathway through the lower part of the atrioventricular node and bundle of His. 2 A premature atrial impulse finds the fast pathway refractory, allowing conduction only down the slow pathway (left). By the time the impulse reaches the His bundle, the fast pathway may have recovered, allowing retrograde conduction back up to the atria—the resultant “circus movement” gives rise to slow-fast atrioventricular nodal re-entrant tachycardia (right).

Clinical evidence of atrioventricular dissociation—that is, “cannon” waves in the jugular venous pulse or variable intensity of the first heart sound—indicates a diagnosis of a ventricular tachycardia. The absence of these findings, however, does not exclude the diagnosis. 9 Left axis deviation and right bundle branch block in man with previous inferior myocardial infarction. 10 Monomorphic ventricular tachycardia in same patient, showing a shift of axis to right of > 40° (note positive concordance).

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