Aberrantly Conducted APC: “The Alien QRS Complex”

Revan Satrio, Rolando Agustian Halim, M. Adhitya Nagara, Muhammad Rusydi1

Emergency Department, Bukit Asam Medika Hospital, Muara Enim

1
Cardiologist at RS Bukit Asam Medika

Introduction
An Atrial Premature Contraction (APC) occurs when a focus in the atrium generates an action potential
before the next scheduled SA node action potential. A typical APC findings on electrocardiogram is a
premature p wave that is usually looks different from the sinus p wave (inverted or else) and then
followed by normal formed QRS complex. However, APC can be manifested in a different way, such as
blocked or aberrantly conducted APC.
Case Description
A 90-year-old woman came to the emergency room with complain of shortness of breath and cough.
History was remarkable for chronic obstructive pulmonary disease and hypertension. Vital signs are
remarkable for increased respiratory rates and temperature. Physical examination shows wheezing in both
lung fields, and irregularity of heart beats. Electrocardiogram shows multiple APC with some of them are
aberrantly conducted. The patient then was diagnosed by the internist with acute exacerbation of chronic
obstructive pulmonary disease. She was then admitted to receive treatment in high-care unit.

1st 2nd 3rd

1st 2nd 3rd

Electrocardiogram findings. It’s interesting that the 3rd beat QRS complex is different
from the other. The 1st one is QRS from sinus beat, the 2nd is from APC.
Discussion
The word “Alien” in this case is used to refer to a QRS complex that is different than the others, which is
caused by an aberrantly conducted APC complex. An aberrantly conducted APC complex occurs when
the premature atrial impulse conducted normally across the AV node and bundle of His find one of the
bundle branches still refractory from the previous impulse, resulting in a slightly wide or different formed
QRS complex. In this case we can see that the APC occurs twice in a row, resulting in a couplets APC or
even can result in a burst APC, a condition that’s often a prelude to atrial fibrillation.
Conclusion
Aberrantly conducted APC occurs when an impulse of an APC finds the His-Purkinje system is still
partly in its refractory period. It will result in slightly different QRS complex than that’s usually found in
normal APC.