What Do You Think 1

32 year-old one legged ballerina with acute gout in the amputated leg.

Overnight tracings from Holter monitor recording. There is a pause (red highlight).

What do you think?

The top tracing is Wenckebach second degree AV block.

There is an increasing PR interval (red horizontal arrows) and 2:1 AV block. Such findings are common in the young overnight and are the result of vagal hypertonia.

What is the significance of the two non-conducted P waves?

The first non-conducted P wave (red highlight) times out as a sinus P wave. The second is a non-conducted atrial ectopic, structurally different from the sinus P waves

The timing of the non-conducted atrial ectopic (yellow highlight) can be before or after the non-conducted sinus P wave (red highlight), even in the same patient.

It’s all in the timing.