A young man presented to the ED for cough and runny nose and was bradycardic, so an ECG was recorded:

There is sinus rhythm with complete AV dissociation due to complete (third degree) AV block.  The escape has a slurred upstroke.  Is this a delta wave?

The patient stated that he knows he has this and that whenever he feels weak he just takes some methamphetamine and he feels fine!  He refused any treatment or evaluation.

The rhythm is interesting, though, and we have some disagreement about whether it is an nodal escape with a fasciculo-ventricular accessory pathway, or a ventricular escape with “Pseudo” Delta waves.  In any case, there must be some pre-excitation.

If it is fasculo-ventricular, as our EP expert says (and I defer to him), then this is a potential ladder diagram, as drawn by Christopher Watford:

K. Wang has graciously offered to let me insert pages 212 and 213 on Pseudo Delta waves from his great Atlas of Electrocardiography:

It seems to me that Pseudo Delta waves are only “Pseudo” in that the do not necessarily represent an accessory pathway, the way we normally associate delta waves with WPW.

However, it also seems that any delta wave implies some pre-excitation.  Ventricular beats often take some time to reach the conducting fibers and will thus often have pre-excitation of some sort.