It's 7 am. You are the cardiologist with the resonsibility of reading yesterdays EKG's done in the hospital. There is a pile of EKG's. You breeze through most of them until you come to the one below. You have no clinical data, just the EKG, what is your interpretation and what would you expect to see when yuo look at this patients neck veins?

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With out calipers this one is tough. There is obvious atrial flutter present with the flutter waves consistently the same morphology in all the leads and in a regular fashion which can be marked out. At the same time the ventricular rate is rock solid regular, independant of the atrial rate. A clue that this is going on is the various "PR" intervals before the QRS complexes. These arent true PR intervals cause their is no conduction but if you look carefully there is no consistent relationship between the flutter waves and the QRS. Also another clue is the ventricular rate. If the rate where above 60, lets say in the 90's than the rate would be a little too fast for a junctional or ventricular pacemaker which typically takes over when the rate drops below 60. But here the ventricular rate (coming from one of the bundles creating a Left Posterior Fascicular Block Pattern) is regular and at a slow enough rate (38) to be considered coming from below the atrium. With all these clues together we get the final read of Atrial flutter with complete heart block.

As far as the neck vein examination, you would see "Cannon A waves" every time a flutter wave was burried with in the QRS, meaning atrial contraction against a closed tricuspid and mitral valve. This would produce a bigger than normal pulsation which would be easy to see.