ST segment depression: causes and treatment methods. ECG pictures in coronary heart disease (CHD) What does st segment elevation mean

When problems with the cardiovascular system begin, the most reasonable solution is to contact a cardiologist. In a hospital setting, doctors can provide qualified assistance and carry out the appropriate diagnostics. What happens to the heart if the electrocardiogram shows depression of the st segment on the ECG? What are the reasons for the deviation from the norm? Do you need any therapy? Is there a risk to human life and health?

Why do an ECG

Analysis of the CT segment state in the electrocardiogram picture remains a very relevant method of modern diagnostics. With the help of an ECG, cardiological pathologies can be detected at an early stage and their therapy can be started. Therapeutic practice shows that the treatment and prognosis of many of these diseases depend on the stage of the pathology at which they are diagnosed.

Timely diagnosis of cardiac pathologies will save you from serious complications

It is possible to assess how much the ST segment has been displaced only in combination with other parameters of the cardiogarmma. Depression or elevation alone does not necessarily indicate pathology; it may be part of the norm.

Considering the results of electrocardiography, one cannot but pay attention to the symptoms that appear. The displacement of the CT segment may be associated with non-coronary changes in the myocardium.

Important! In rare cases, segment displacement can be a sign of acute coronary syndrome. This requires an emergency ambulance.

General information about segment offset

When a person is healthy, his ECG is normal. Elevation of the st segment (rise) or decrease may indicate pathologies within the body. Normally, the st segment is located on the isoline, although there is also a certain range of acceptable indicators.

Depression st is acceptable in the limb leads up to 0.5 mm. Indicators greater than or equal to 0.5 in leads V1-V2, 0.5 are considered a deviation.

Elevation of the st segment at the limb leads should be less than 1 mm. For leads V1-V2, the norm is considered to be up to 3 mm, and for V5-V6 - up to 2 mm.

Only a doctor analyzes the cardiogram

Where this information applies

Knowing the rate of elevation of the st segment on the ECG helps in diagnosing some serious cardiac pathologies: myocardial infarction, coronary heart disease, myocardial hypertrophy, LV aneurysm, pericarditis, myocarditis, PE, etc.

So, with heart attacks, there is no decrease in the st segment. This indicator can increase up to 2-3 mm at a rate of up to 1. In addition to the growth of the CT segment, a pathological Q wave may appear in the electrocardiogram picture.

It is effective to use the troponin test if a heart attack is suspected. When there is a significant displacement of the CT segment, the latter analysis allows to clarify the diagnosis. If the test is negative, the patient has not had a heart attack, and acute coronary artery disease requires treatment.

To correctly diagnose and prescribe effective treatment, it is important for a cardiologist to carefully read the electrocardiogram. There are some rules, taking into account which, you can qualitatively help the patient.

The experience of the cardiologist determines how he reads the ECG and what treatment he chooses

First of all, the ability of the heart to conduct electrical impulses is analyzed. The frequency and rhythm of the pulse is calculated, the regularity of the heart contractions is assessed. Then the cardiologist pays attention to the work of the pacemaker and determines how well the impulses travel along the pathways of the heart.

After these studies, the cardiologist assesses the position of the electrical axis, examines the rotations of the heart around the longitudinal, transverse and anteroposterior axis. At the same stage, the P wave is evaluated.

The next step in decoding the electrocardiogram is to examine the state of the QRS-T complex. When assessing the ST segment, the J point is important (the moment the S wave transitions to the ST segment).

The shape of the arc, which forms the J point to the end of the ST segment, determines the presence of pathology. If it is concave, then the deviation is benign. Convex is a sign of myocardial ischemia.

Causes of cardiac changes

Myocardial infarction and other serious cardiovascular pathologies do not develop overnight. Perhaps the person neglected the alarming symptoms for some time, or did not follow the recommendations of the attending physician. Some did not take such a diagnosis as ischemic disease seriously, underestimating the risks of pathology.

On the results of the electrocardiogram, deviations from the norm may appear for various reasons. Most often, this study gives a reliable idea of \u200b\u200bthe work of the heart muscle. Although mistakes do occur, they are very rare.

Important! ST segment depression symptoms sometimes appear even in healthy people. If, in addition to changes in the ECG, there are no negative symptoms, we can talk about a physiological norm. Although periodic visits to a cardiologist and monitoring of the state of the heart should not be neglected.

Deviations from the norm in the picture of the electrocardiogram may appear if the procedure is performed incorrectly. This situation is possible if the electrodes are incorrectly applied. In this case, there is not enough contact, and the device takes inaccurate data.

Other non-cardiac causes of ECG abnormalities:

electrolyte disturbances;
hyperventilation of the lungs;
drug abuse, including drug abuse;
frequent alcohol consumption;
drinking cold water.

The development of any pathology can be suspended subject to timely diagnosis and competent treatment. To do this, when the slightest unpleasant symptoms appear in the heart area, it is recommended to visit a therapist to get a referral for examination. This can prevent the development of serious and dangerous pathologies.

How to decipher the ECG analysis, the norm and deviations, pathologies and the principle of diagnosis

Observed in chronic ischemic heart disease. A - horizontal; B - oblique descending; B - with an arc facing upward convexity; G - oblique ascending; D - trough-shaped; E - rise of the ST segment.

Horizontal displacement of the ST segment. It is characterized by a decrease in the ST segment below the isoline with its horizontal location. The ST segment goes into a positive biphasic (- +) smoothed or negative T wave.
Oblique downward displacement of the ST segment (from R to T). As you move away from the QRS complex, the degree of ST segment displacement downward from the isoline gradually increases. The ST segment goes into negative, two-phase (+) smoothed, or positive T.
Displacement of the ST segment from top to bottom from the isoline with the arc facing upward. Depression of the ST segment is not uniformly expressed throughout its entire length, but has the shape of an arc, the convexity of which is directed upward. The ST segment goes into a positive, biphasic (+), smoothed or negative T wave.
Oblique upward displacement of the ST segment (from S to T). The greatest depression of the ST segment is observed immediately after the end of the QRS complex. Following this, the ST segment gradually rises to the isoline and usually turns into a positive or smoothed T wave.
Trough displacement of the ST segment. This type of displacement of the ST segment has the shape of an arc, the convexity of which is directed downward. It is also observed during treatment with cardiac glycosides. The ST segment goes into a smoothed biphasic (- +) or positive T wave.

The first two types of ST segment displacement are most specific for chronic ischemic heart disease, i.e. horizontal and oblique descending.

"Guide to electrocardiography", V.N. Orlov

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In the event that the myocardium experiences a significant or critical oxygen deficiency, a cascade of biochemical changes occurs as a result of which certain changes appear on the ECG - depression of the ST segment.

Such changes in most cases should be regarded as acute until proven otherwise. But sometimes depression persists on the ECG for years, even in people without coronary artery problems. Only a clinical picture will allow you to resolve the issue of patient management tactics, but we will not talk about the clinic.

And so, first of all, let's see where this ST segment is located on the ECG.

On the left you see a schematic representation of an individual complex and ST segment. If you draw an imaginary line (ISOLINE) from the beginning to the end of the complex, then it will just pass through the ST segment. That is, there is no elevation, no depression, this is the norm. If the segment were below the isoline it would be called "depression", if, on the contrary, above the isoline, it would be called "elevation".

It should be noted that levitation or depression are not always pathological, it depends on their severity

Normal at rest

in the chest leads depression should be less than 0.5 mm.

in limb leads depression should be less than 0.5-1 mm.

Let's take a look at the ECG fragment

First you need to draw an isoline, the accuracy of the measurement depends on the correctness of this stage. Usually, with the help of a ruler, a more or less flat section of the isoline between two complexes is found and a line is drawn through them. This will be the isoline. Somehow like this.

Now you can clearly see that the ST segment is under the isoline. But what to do now, where to measure this very depression? It is clear that you need to attach the ruler vertically and measure from the isoline to the line of the segment itself, but where to do it?

Here you can see that if the place is chosen arbitrarily, then you can get completely different values \u200b\u200bof depression. How to proceed? The answer is simple, the measurement should be carried out as follows. You need to find the point (j) where the S wave ends, or if there is no S wave, then the point of intersection of the descending R knee with the isoline. Then, from this point, set aside 0.08 s (4 mm) and measure the depression (this will be point i) in it. Some foreign authors recommend postponing 0.04 s. (2 mm). But if there is derpess, then it is by 0.04 and by 0.08.

In our case, the situation will look like this

Thus, we can say that in lead V5 there is a depression of up to 0.5 mm (this is the norm), and in V6 about 0.8 mm, which is beyond the norm, but does not always indicate true ischemia. In such cases, one should describe such depression in custody. And the clinician will already puzzle over what to do with this, detailed clinical interpretation is beyond the scope of this course.

The next topic is the most important in the entire section "ISHEMIA"

LBBB, electrocardiographic and postmortem studies show that ~ 80% of LBBB patients have an increase in LV mass.

Remember: It is noted when:

Hypertrophy of the ninth ventricle

Myocardial infarction

Congenital heart defects

Degenerative disorders of the conducting system

Occasionally - a variant of the norm

48. Incomplete left bundle branch block

LBBB morphology with QRS width\u003e 0.09 sec and< 0,12 сек.

49. Nonspecific intraventricular conduction disorders

QRS complex\u003e 0.11 sec wide, but its morphology does not have the criteria for RBBB or LBBB, or

Pathological form of the QRS complex without its widening

Remember: Nonspecific intraventricular conduction disorders can occur when:

Antiarrhythmic overdose(especially class IA and IC)

Hyperkalemia

Left ventricular hypertrophy

WPW syndrome

Hypothermia

Severe metabolic disorders

50. Functional (heart rate-related) aberrant intraventricular conduction

Wide QRS complex rhythm (\u003e 0.12 sec) due to supraventricular arrhythmias such as atrial fibrillation, atrial flutter, and other supraventricular tachycardias. Remember: Since the right bundle branch has a longer refractory period than the left bundle, aberrant (accessory) conduction usually takes place first along the left pedicle, ending with RBBB morphology.

Remember: May remind ventricular tachycardia.

Remember: Returning to normal intraventricular conduction may be accompanied by changes in the T wave.

Q wave myocardial infarction

MYOCARDIAL ISCHEMIA, DAMAGE, INFARCTION

Ischemia: depression of the ST segment; the T wave is usually negative; Q wave is missing

Damage: ST segment elevation; Q wave is missing

Heart attack: pathological Q wave; elevation or depression of the ST segment; T wave negative, normal or positive "coronary"

SIGNS OF ELEVATION

Re-emerging segment elevationST from the J point (the transition point of the QRS complex to the ST segment) in\u003e 2 adjacent leads

ST elevation\u003e 2 mm in leads V1, V2, or V3

ST elevation\u003e 1 mm in other leads

Usually with oblique (convex) configuration

May persist from 48 hours to 4 weeks from the onset of AMI

Remember: Persistence of ST segment elevation beyond 4 weeks suggests ventricular aneurysm

T-BEAM INVERSION usually occurs with persistent ST-segment elevation (as opposed to pericarditis) and may persist for a long period

Remember: AMI can occur without significant ST-segment elevation or depression: 40% of patients with left circumflex artery occlusion and 10-15% of patients with right coronary or left descending artery occlusion may not have significant ECG changes.

PATHOLOGICAL TOOTH Q

Any Q wave in leads V1 - V3

Q wave\u003e 0.03 sec in leads I, II, aVL, aVF, V4, V5, or V6

Q wave changes must be present in at least 2 adjacent leads, Q wave depth must be greater than 1 mm

Remember: The presence of a Q wave cannot be used to reliably differentiate between transmural and subendocardial MI.

Remember: Abnormal Q waves will regress or disappear after a few months or years in 20% of patients with Q-MI.

THE RANGE OF AMI CAN BE DETERMINED BY ECG:

Recent or acute:Repolarization disorders in AMI tend to develop in a relatively predictable manner. Usually the earliest sign is a T wave change (- coronary T wave‖) In the area of \u200b\u200bheart attack; these changes are often overlooked as they are registered very early (< 15 мин) при ангинозном приступе и быстро регрессируют. Если трансмуральная ишемия сохраняется в течение больше, чем несколько минут, коронарные зубцы Т эволюционируют в sT segment elevationwhich must be\u003e 1 mm high. ST segment elevation in AMI usually has an upward bulge (as opposed to acute pericarditis or early repolarization syndrome, in which ST segment elevation is concave). As AMI develops further, ST segment elevation decreases and the T wave becomes negative.The T wave usually deepens progressively with decreasing ST segment elevation. Pathological Q waveappears within the first hours or days from the onset of AMI.

Acute MI: Abnormal Q wave, ST segment elevation (combined with ST depression in reciprocal leads). Early coronary (tall, pointed) T wave (transient)

Recent MI: Abnormal Q wave, contour ST segment, ischemic (usually negative) T wave

Unknown or old:Abnormal Q wave, isoelectric ST segment, nonspecific changes or T wave norm

Remember: Previous MI may have missing Q waves: (1) Anterior MI: may

only there is a decrease in the progression of the R wave in leads V2 -V5; and (2) Posterior MI: R-wave dominance in leads V1 and / or V2, usually associated with inferior MI. Often there is ST segment depression in leads V1-V3

DIAGNOSTICS OF Q-IM IN LOCATIONS OF THE LEGS

RBBB: Does not complicate the diagnosis of Q-MI

LBBB: Any diagnosis with LBBB is difficult. However, signs of acute injury are sometimes evident.

51. Anterolateral MI (recent or acute)

Pathological Q wave with ST segment elevation in leads V4 - V6

52. Anterolateral MI (unknown or old)

Pathological Q wave in leads V4 - V6 without ST segment elevation

53. Anterior septal MI (recent or acute)

Pathological Q wave with ST segment elevation in at least 2 adjacent leads

between V1 - V4

Remember: Most ECGs show a decrease in the progression of R-wave voltage in leads V2-V5 with previous MI, even in the absence of pathological Q waves.

54. Anterior or anterior septal MI (unknown or old)

Pathological Q wave in at least 2 adjacent leads between V1 - V4 without ST segment elevation

55. Lateral MI (recent or acute)

Pathological Q wave with ST segment elevation in leads I and aVL

Remember: An isolated Q wave in lead aVL does not qualify as a lateral MI.

56. Lateral MI (unknown or old)

Abnormal Q wave in leads I and aVL without ST-segment elevation

57. Inferior MI (recent or acute)

Pathological Q wave with ST segment elevation in at least two leads from II, III, aVF

Remember: Combines with ST segment depression in leads I, aVL, V1 -V3.

58. Lower MI (of unknown age or old)

Pathological Q wave in at least two leads from II, III, aVF without ST segment elevation

59. Posterior MI (recent or acute)

Initial R wave\u003e 0.04 sec in V1 or V2 with amplitude greater than S wave amplitude (R / S\u003e 1) and ST segment depression (typically\u003e 2 mm)

Tall T waves are usually recorded in the same leads where the R wave is dominant. Remember: The posterior wall of the left ventricle differs from the anterior, inferior, and lateral walls in that it does not have electrodes directly above it. Instead of a Q wave and ST-segment elevation, acute posterior MI is represented by mirrored anterior precordial leads (V1-V3), including a high R wave (mirrored abnormal Q wave), and horizontal ST segment depression (mirroring ST elevation). Acute posterior MI is often associated with inferior or nidnolateral MI, but may be isolated.

Remember: RH, WPW syndrome, and RBBB can interfere with the diagnosis of posterior MI.

60. Posterior MI (unknown or old)

High R wave (R / S\u003e 1) in leads V1 or V2 without ST segment depression

Remember: There are other possible causes of tall R waves in leads V1 or V2, including RVH, WPW syndrome, RBBB, and incorrect chest electrode placement.

Remember: Signs of ischemia or infarction of the lower wall are often present.

Repolarization disorders

61. Variant of the norm, early repolarization

Elevation of the initial part of the ST segment at the point between the QRS complex and the ST segment (point J)

Concave ST-segment elevation ends in a symmetrical positive T wave (often of increased amplitude)

Remember: ST segment elevation should be less than 25% of the T wave height in lead V6

Notch or notch on the descending R-wave

The most common changes inV2 -V5; sometimes in II, III, aVF

No reciprocal ST segment depression

Remember: Some ST segment elevation is present in most young healthy people, especially in the chest leads.

62. Normal variant, juvenile T wave

Permanent negative T wave (usually asymmetrical and shallow) in the leadsV1-V3 in adolescence

The T wave is still positive in leads I, II, V5, V6

Remember: The juvenile T wave is a variant of a normal ECG in children, rarely seen as a normal variant in adult women, and very rarely in adult men.

63. Nonspecific ST and / or T changes

Small (< 1 мм) депрессия или элевация сегмента ST, и/или

Smooth or slightly negative T waveRemember: A normal T wave is usually\u003e 10% of the height of an R wave Remember: May occur when:

Organic myocardial damage

Taking medication (such as quinidine)

Electrolyte disturbances (hyperkalemia, hypokalemia)

Hyperventilation

Myxedema

A recent heavy meal

Stress

Pancreatitis

Pericarditis

CNS damage

LVH

Gpw

His bundle branch block

Standard variant

Persistent juvenile changes: wave inversionT in leads V 1 -V 3 in young people

64. ST and / or T T changes suggesting myocardial ischemia

Ischemic ST segment changes:

Horizontal or oblique segment depressionST with (or without) negative T waves

Remember: Flutter waves or atrial repolarization waves (which can be seen in atrial dilatation, pericarditis, atrial infarction) can deform the ST segment and create the effect of "pseudodepression"

Ischemic T wave changes:

Biphasic T wave with (or without) ST segment depression

Symmetrical or deep negative waveT; often prolonged QT intervalRemember: Reciprocal T-wave changes (eg, high positive T waves in the inferior leads with deep negative T waves in the anterior leads) may be noticeable.Remember: T-waves may become less negative or positive during acute ischemia (“pseudonormalization”).

Remember: U-wave (positive or negative) is often recorded. Remember: A high positive T wave can also be detected when:

Variant of the norm in adults

Hyperkalemia

Start of AMI

LVH

CNS damage

Anemia

65. ST and / or T changes suggesting ischemic injury

Acute oblique ST-segment elevation\u003e 1 mm (initially may be concave) in leads representing the site of myocardial injury / infarction

Dynamics of changes in the ST segment and T wave: the T wave becomes negative before the ST segment returns to the isoline

Reciprocal ST segment depression in leads opposite to the infarction area

Acute posterior wall injury is often accompanied by horizontal or oblique ST-segment depression with positive T waves in leads V1 and / or V2 with a high R wave in the same leads

Remember: It is important to consider the clinical data, as ST segment elevation can also be recorded with:

Acute pericarditis

Ventricular aneurysm

Early repolarization syndrome

LVH

Hyperkalemia

His bundle branch block

Myocarditis

Hypertrophic cardiomyopathy

CNS damage

Normal variant (ST elevation up to 3 mm may be visible in leads V1-V3)

66. ST and / or T waveform changes suggesting electrolyte abnormalities

Some changes suggest hyperkalemia, hypokalemia, hypercalcemia, hypocalcemia Remember: Hypomagnesemia - common reason imitation of hypocalcemia (prolongation of the QT interval)

Remember: Renal failure is often accompanied by multiple electrolyte disturbances with ECG changes.

67. Secondary changes in ST and / or T in hypertrophy of the heart chambers

LVH: displacement of the ST segment and T wave in the direction discordant to the main deviation of the QRS complex:

segment depressionST (oblique) and negative T wave, when the QRS complex is mostly positive (leads I, V5, V6)

insignificant (< 1 мм) элевация сегмента ST и положительный зубец T, когда ком-

the QRS plex is mostly negative (leads V1, V2); sometimes there may be more significant ST elevation up to 2-3 mm in leads V1 -V2

RH: ST segment depression and negative T wave in leads V1-V3 and sometimes in the response

denii II, III, aVF

68. Prolongation of the QT interval

Corrected QT interval (QTc)\u003e 0.44 sec, where QTc \u003d QT at heart rate 60 / min \u003d interval

QT divided by the square root of the previous RR interval

Remember: It is imperative to measure the QT interval in the lead with the largest T wave and its clear ending. Also look for the lead with the longest QT.

The simplest way to determine the QT interval is:

0.40 sec - the norm of the QT interval at a heart rate of 70 / min. For every 10 bpm above (or below) 70, subtract (or add) 0.02 sec to the QT length. (The measured value should be within ± 0.04 sec of the calculated normal).Example: For a heart rate of 100 / min, the calculated normal QT interval \u003d 0.40 sec - (3 x 0.02 sec) \u003d 0.34 ± 0.04 sec. For heart rate - 50 / min, the calculated normal QT \u003d 0.40 sec + (2 x 0.02 sec) \u003d 0.44 ± 0.04 sec.

In general, the normal intervalQT should be less than 50% of the RR interval. Remember: The QT interval represents the period of electrical systole (i.e., the time it takes to depolarize and repolarize the ventricles), it varies inversely with heart rate, lengthens during sleep (presumably due to increased vagal tone). Remember: Conditions associated with prolongation of the QT interval:

Medication (quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, phenothiazine, lithium, tricyclic antidepressants)

Hypomagnesemia

Hypocalcemia

Severe bradycardia

Intracranial hemorrhage

Myocarditis

Mitral valve prolapse

Myxedema

Hypothermia

High protein diet

Romano-Ward Syndrome

Jervell and Lange-Nielson syndrome (congenital deafness)

69. Significant U wave

Amplitude\u003e 1.5 mm

Remember: The U wave is normally 5-25% of the T wave height, and is greatest in leads V2 and V3

Remember: Main reasons:

Hypokalemia

Bradyarrhythmias

Hypothermia

LVH

Ischemic heart disease

Medications (cardiac glycosides, quinidine, amiodarone, isoproterenol).

Various clinical conditions

70. The effect of digoxin

ST segment depression (concave)

T wave flattened, negative or biphasic

Shortening the QT interval

Increasing the amplitude of the U wave

Prolongation of the PR interval

Remember: ST changes are difficult to interpret in LVH, RH, bundle branch block. However, if there is typical ST-segment sagging and a shortened QT interval, the effect of digoxin is highly likely.

71. Digitalis intoxication

Digitalis intoxication can cause almost any type of rhythm and conduction disturbance other than interventricular block. Typical disorders include:

Paroxysmal atrial tachycardia with conduction block

Atrial fibrillation with completeAV block (regular RR intervals)

AV block II and III degree

Complete AV block with accelerated junctional or idioventricular rhythm

Supraventricular tachycardia with aberration

Remember: Digitalis intoxication can be exacerbated by hypokalemia, hypomagnesemia, hypercalcemia.

Remember: Electrical cardioversion for atrial fibrillation is contraindicated for signs of digitalis intoxication due to the risk of asystole and ventricular fibrillation.

72. Effect of antiarrhythmic drugs

The following effects are possible:

Moderate prolongation of the QT interval

U-wave enlargement (one of the early signs)

Nonspecific ST and / or T changes

Decreased frequency with atrial flutter

73. Intoxication with antiarrhythmic drugs

The following effects are possible:

Significant lengthening of the QT interval

Ventricular arrhythmias, including Torsade de Pointes

Broadening of QRS complexes

Various degreesAV block

Significant sinus bradycardia, sinus node arrest, sinoatrial block.

74. Hyperkalemia

ECG changes depend on the level of K + ions in the blood and the rate of its increase:

K + \u003d 5.5 - 6.5 mEq / L

High, pointed, narrow at the base teethT

Remember: Typically these T waves are\u003e 10 mm in the chest leads and\u003e 6 mm in the limb leads. May also occur in AMI, LVH, LBBB

Shortening the intervalQT

Reversible front or rear hemiblock

K + \u003d 6.5 - 7.5 mEq / L

1st degree AV block

Smoothed and widened teethP

Wide complexesQRS

K +\u003e 7.5 mEq / L

Disappearance of teethP, which can be caused by:

Stopping the sinus node, or

―Synoventricular conduction‖ (sinus impulses are conducted to the ventricles through specialized atrial fibers without atrial depolarization)

LBBB, RBBB, or significant diffuse intraventricular conduction disorder

Segment elevationST

Arrhythmias and conduction disturbances, including ventricular tachycardia, ventricular fibrillation, idioventricular rhythm, asystole

75. Hypokalemia

The following changes are possible:

U wave magnification

ST segment depression and T wave flattening

Remember: Changes in the ST-T segment and U wave during hypokalemia are observed in 80% of patients with potassium ion levels< 2,7 mEq/L, по сравнению с 35% пациентов с уровнем калия 2,7-3,0 mEq/L, и у 10% пациентов с уровнем калия > 3.0 mEq / L.

Increase in amplitude and width of the P wave

Sometimes a marked increase in QT

Remember: If hypokalemia therapy does not normalize the QT interval, rule out hypomagnesemia.

Arrhythmias and conduction disturbances, including paroxysmal atrial tachycardia with conduction block, grade I-II AV block, AV dissociation, PVC, ventricular tachycardia and ventricular fibrillation.