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Read the ecg

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"first degree atrioventricular block"

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first degree atrioventricular block ECG interpretation clinical significance guideline

Quick answer

ECG interpretation from this photograph:
  • Rhythm: Sinus rhythm with mild sinus arrhythmia
  • Rate: About 60 bpm
  • PR interval: About 199 ms, borderline prolonged. This is at the threshold for first-degree AV block, though some criteria require PR >200 ms.
  • QRS: Narrow, about 82 ms
  • QTc: About 386 ms, normal
  • Axis: Appears normal
  • ST-T changes: There is apparent concave ST elevation with prominent T waves in V2-V5, which may represent benign early repolarization, particularly in a younger male. The photo and baseline artifact make this difficult to confirm safely.
The machine report reads: sinus arrhythmia, first-degree AV conduction delay, borderline ECG.
Important: If this ECG was done because of chest pain, pressure, shortness of breath, sweating, fainting, nausea, or pain radiating to the arm/jaw/back, treat the anterior ST elevation as potentially serious and seek emergency assessment now. A clinician should compare it with previous ECGs and, if symptomatic, repeat the ECG and check troponin.ECG interpretation from the photo:
  • Rhythm: Sinus rhythm with mild sinus arrhythmia
  • Rate: About 60 bpm
  • Axis: Appears normal
  • Intervals: PR about 199 ms, which is borderline prolonged. It does not clearly meet the usual definition of first-degree AV block, which requires PR >200 ms, although the machine flags possible AV-conduction delay. Definition of first-degree AV block
  • QRS: Narrow, about 70 ms
  • QTc: About 386 ms, normal
  • ST-T: Prominent upright T waves in the anterior chest leads, especially V2-V5. I do not see definite diagnostic ST-segment elevation, reciprocal ST depression, or a clear acute infarction pattern from this photograph.
  • Technical limitation: Considerable baseline/muscle artifact in limb leads reduces confidence in fine ST-T assessment.
Impression: Sinus rhythm with mild sinus arrhythmia and a borderline PR interval. No definite acute ischemic ECG changes visible on this image. The automated statement of “first-degree AV conduction delay” is borderline and should be confirmed by a clinician reviewing the original tracing and clinical context.
If this ECG was obtained because of chest pain, breathlessness, sweating, fainting, new palpitations, or severe dizziness, seek urgent in-person assessment now, including repeat ECG and troponin testing as appropriate.

Patient wants to start pde5 inhibitors for ED

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"erectile dysfunction" AND "phosphodiesterase 5 inhibitors"

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Princeton IV consensus erectile dysfunction cardiovascular risk PDE5 inhibitors nitrates recommendations

The ECG finding alone does not contraindicate a PDE5 inhibitor. The tracing appears to show sinus rhythm with a borderline PR interval, but no definite acute ischemic change or dangerous conduction abnormality. A possible mild first-degree AV delay, if confirmed, is not itself a reason to withhold sildenafil, tadalafil, vardenafil, or avanafil.
Before prescribing, confirm:
  1. No nitrates in any form: GTN/nitroglycerin tablets, spray, patches, isosorbide mono/dinitrate, nicorandil, or recreational “poppers.” This is an absolute contraindication because of potentially profound hypotension. Do not use nitrates for at least 24 hours after sildenafil, vardenafil, or avanafil, and at least 48 hours after tadalafil. ACC Princeton IV summary
  2. No riociguat, and assess for significant baseline hypotension or unstable cardiovascular disease.
  3. Cardiac fitness for sexual activity: no active chest pain/unstable angina, decompensated heart failure, uncontrolled hypertension, symptomatic arrhythmia, recent MI/stroke, or poor exercise tolerance. Patients who can perform moderate exercise without cardiac symptoms are generally low risk for sexual activity and PDE5 therapy. Princeton IV guidance
  4. Medication review: use caution with alpha-blockers, multiple antihypertensives, and substantial alcohol intake because of additive hypotension. If on an alpha-blocker, ensure stable dosing and begin PDE5 treatment conservatively.
  5. ED cardiovascular assessment: ED can be a marker of occult cardiovascular risk. Check BP, diabetes status/HbA1c, lipids, smoking, obesity, renal function as appropriate, and consider broader ASCVD risk assessment. ACC review
Practical conclusion: If he is asymptomatic, has reasonable exercise tolerance, and uses neither nitrates/nicorandil nor riociguat, the ECG does not prevent starting a PDE5 inhibitor. It should still be prescribed after the above medication and cardiovascular screen.
Tell him: if chest pain occurs after taking a PDE5 inhibitor, do not self-administer GTN. Call emergency services and state which medication and when it was taken.
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