Skip to content

 MENU
 BLOG
 ECG
 CCC
 TOP 100
 PODCASTS
 EPONYM
 MEDMASTERY
 PART ONE
 INTENSIVE

AV Block: 2nd degree, Mobitz I

(Wenckebach Phenomenon)
 Ed Burns and Robert Buttner

 Feb 8, 2021
HOMEECG LIBRARY

ECG Library Homepage

Definition of Mobitz I block (Wenckebach phenomenon)

Progressive prolongation of the PR interval culminating in a non-conducted P
wave:

 PR interval is longest immediately before dropped beat

 PR interval is shortest immediately after dropped beat

AV block: 2nd degree, Mobitz type I

Other Features:
 The P-P interval remains relatively constant
 The greatest increase in PR interval duration is typically between the first and second
beats of the cycle
 The RR interval progressively shortens with each beat of the cycle
 The Wenckebach pattern tends to repeat in P:QRS groups with ratios of 3:2, 4:3 or 5:4

Mechanism
 Mobitz I is usually due to reversible conduction block at the level of the AV node
 Malfunctioning AV nodal cells tend to progressively fatigue until they fail to conduct
an impulse. This is different to cells of the His-Purkinje system which tend to fail
suddenly and unexpectedly (i.e. producing a Mobitz II block)

Causes of Wenckebach Phenomenon

 Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
 Increased vagal tone (e.g. athletes)
 Inferior MI
 Myocarditis
 Following cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)

Clinical Significance
 Mobitz I is usually a benign rhythm, causing minimal haemodynamic disturbance and
with low risk of progression to third degree heart block
 Asymptomatic patients do not require treatment
 Symptomatic patients usually respond to atropine
 Permanent pacing is rarely required
ECG Examples
Example 1

Mobitz I AV block

 Progressive prolongation of PR interval, with a subsequent non-conducted P wave

 Repeating 5:4 conduction ratio of P waves to QRS complexes
 Relatively constant P-P interval despite irregularity of QRS complexes
The first clue to the presence of Mobitz I AV block on this ECG is the way the QRS
complexes cluster into groups, separated by short pauses. This phenomenon usually
represents 2nd-degree AV block or non-conducted PACs; occasionally SA exit block.

Thanks to Dr Harry Patterson, FACEM, for providing this ECG.

Example 2

Mobitz I AV block

 QRS complexes clustered in groups, separated by non-conducted P waves.

 The P:QRS conduction ratio varies from 5:4 to 6:5.
 Note the difference in PR interval between the first and last QRS complex of each
group.
Example 3

Mobitz I AV block associated with inferior STEMI and RV infarction

 The majority of the rhythm strip shows 2:1 AV conduction, which makes discerning
the type of block difficult (i.e. it could represent Mobitz I or Mobitz II)
 However, there is a single 3:2 Mobitz I cycle visible in the middle of the rhythm strip
(QRS complexes 5 + 6). If you look hard, you can see a non-conducted P wave
deforming the downslope of the T wave in complex 6
 Continuous rhythm strip recording revealed that this patient was indeed in Mobitz I
AV block
AV block may occur in the context of an inferior STEMI due to ischaemia of the AV
node, or due to increased vagal tone (Bezold-Jarisch reflex)
An Interesting Case of Wenckebach

Mobitz I in a patient with atrial pacing following mitral valve surgery

 Small atrial pacing spikes precede the QRS complexes.

 The interval between the pacing spikes increases progressively until there is a non-
conducted pacing spike.
 To find out the story behind this ECG, check out this chapter from the ECG Exigency
series:”Post-op Pacing Puzzler“

Diagnosis Wenckebach?
This ECG rhythm strip was originally featured on this page as an example of
Wenckebach AV block. Can you spot the “deliberate” mistake?
  Q1. What features of Wenckebach AV block are present on this ECG?
 Q2. What features of Wenckebach are notably ABSENT?
 Q3. What possible explanations could exist to explain this tracing?
Now read ECG exigency 18.2 for answers and explanations to these questions.

Related Topics

 AV block: 1st degree

 AV block: 2nd degree, Mobitz II
 AV block: 2nd degree, “fixed ratio blocks” (2:1, 3:1)
 AV block: 2nd degree, “high grade AV block”
 AV block: 3rd degree (complete heart block)
History

 Eponymythology History of Second-degree AV block. LITFL 2018

 Eponym Karel Frederik Wenckebach (1864 -1940). LITFL 2018
 Eponym. Woldemar Mobitz (1889 – 1951). LITFL 2018
 Eponym. John Hay (1873 – 1959). LITFL 2018

Advanced Reading
Online

 Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics.
Medmastery
 Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert.
Medmastery
 Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG
interpretation. Medmastery
 Rawshani A. Clinical ECG Interpretation ECG Waves
 Smith SW. Dr Smith’s ECG blog.
Textbooks
  Zimmerman FH. ECG Core Curriculum. 2023
 Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and
Interpretations, 2022
 Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
 Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
 Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical
Care. 2e, 2019
 Hampton J, Adlam D. The ECG Made Practical 7e, 2019
 Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG. 2015
 Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
 Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and
Pediatric 6e, 2008
 Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

 ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
 ECG A to Z by diagnosis – ECG interpretation in clinical context
 ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
 100 ECG Quiz – Self-assessment tool for examination practice
 ECG Reference SITES and BOOKS – the best of the rest

ECG LIBRARY
more EKG…

Ed Burns
Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a
passion for ECG interpretation and medical education | ECG Library |

Robert Buttner
MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency
Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and
procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the
LITFL ECG Library. Twitter: @rob_buttner
One comment

1.
Tom Spanne
NOVEMBER 20, 2023 / 22:28REPLY
Well done!
Leave a Reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.

Unlock exclusive content and resources. Sign up for our newsletter

today!

First Name *
Email Address *
Agree to our Privacy Policy

 Educational videos
 Handy PDF downloads
 Inspirational quotes
 Clinical pearls
 And so much more!

 Facebook
 Twitter
 Instagram
 Vimeo
 RSS Feed
 MENU