Scenario: A 72-year-old man is admitted to the coronary care unit with palpitations, shortness of breath, and weakness. In the emergency department, the patient was in normal sinus rhythm. He had undergone coronary artery bypass graft surgery 3 weeks earlier after an acute myocardial infarction. According to the ECG software, the rhythm is atrial flutter with 2:1 atrioventricular block, right bundle branch block (RBBB), and left posterior fascicular block (LPFB). The patient is alert and oriented and states, “I feel fine.”

Ventricular tachycardia; heart rate 150/min

Although computer algorithms have improved greatly, clinician oversight is essential. In this example, the computer algorithm was not sophisticated and used simple criteria for 2:1 atrioventricular block (heart rate, 150/min) and RBBB (wide QRS and Rsr morphology in V1), thus triggering those diagnoses.

However, in the setting of ischemic heart disease,...

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