Graded Phenomenon (Yasser’s Phenomenon); A Novel Electrocardiographic Phenomenon Change the Arrhythmia Directory; Retrospective-Observational Study

A heart arrhythmia is clearly
described as a variation in the normal heart rate (HR) and/or
rhythm regularity that is not physiologically justified...


Introduction
Arrhythmias Scoping of arrhythmias: A heart arrhythmia is clearly described as a variation in the normal heart rate (HR) and/or rhythm regularity that is not physiologically justified [1]. Cardiac arrhythmias are happening if the electrical impulses that parallel your heartbeats don't release precisely, causing tachycardia,

Sinus Arrhythmia
Normal sinus rhythm: Normal sinus rhythm (NSR) is the rhythm that origins from the sinus node (SAN) and identify the known rhythm of the healthy heart [32]. The rate in NSR is commonly regular. But it varies depending on autonomic inputs into the SAN.

Sinus arrhythmia scoping:
The term sinus arrhythmia refers to a normal phenomenon of alternating mild acceleration and slowing of the heart rate that occurs with breathing in and out respectively [33]. When there is an irregularity in the sinus rate, it is termed sinus arrhythmia (SA) [1]. Sinus arrhythmia is a common change in the NSR [34,35]. Sinus rhythm with a beat-to-beat variation in the P-P interval (the time between successive P waves), producing an irregular ventricular rate [36]. It is usually quite pronounced in children and steadily decreases with age. This can also be present during meditation breathing exercises that involve deep inhaling and breath holding patterns [37].
Sinus arrhythmia characteristics: Sinus arrhythmia characteristically presents with an irregular rate in which the variation in the R-R interval greater than 0.12 seconds34 or the P-P-interval of more than 120 ms (3 small boxes) [35][36][37][38]. There should be a 10% difference between the maximum and minimum cardiac cycle length [8]. The P-P interval gradually lengthens and shortens cyclically, usually corresponding to the phases of the respiratory cycle7 with normal sinus P-waves with both constant morphology [35,36] and P-R interval [35,36] Sinus arrhythmia is a physiological condition that most commonly occurs in the young healthy adults [34,36] and children [34]. Sinus arrhythmia is a common incidental sign seen on routine Electrocardiogram (ECG) [34]. Often an asymptomatic and normal finding, the evaluation of sinus arrhythmia is limited. Generally, SA is at most mildly symptomatic (e.g., palpitations) [39].
Sinus arrhythmia prognostic value: Typically, its presence is a prognostic indicator for good cardiovascular health [34,35].
Loss of SA may indicate underlying heart failure or structural heart disease [33].

Junctional arrhythmias pathophysiology:
If there is a blockage for the sinoatrial node (SAN) electrical activity is blocked or is less than the automaticity of the atrioventricular node (AVN)/ 222 reserpine, inhalation anesthetics, cimetidine, isoproterenol infusion, narcotics, beta-blockers, and ivabradine implicated in causing junctional tachycardia [41].

Paroxysmal Supraventricular Tachycardia
Paroxysmal supraventricular tachycardia scoping: Paroxysmal supraventricular tachycardia (PSVT) accounts for intermittent episodes of supraventricular tachycardia with sudden onset and termination. PSVT is part of the narrow QRS-complex tachycardias with a regular ventricular response in contrast to multifocal atrial tachycardia (MAT), atrial fibrillation (AF), and atrial flutter [45].   Table 3. For more details on general, clinical, and laboratory data for the cases see Tables 4-6. Table 3 showing remarks of the study method and data. taken which showed an interesting progressive bigeminy PVCs was described as: "Graded phenomenon right to left extension, upgrading" (Figure 1). Bigeminy PVCs initially started in V1-6 leads (all chest leads) ( Figure 1A), then extended to aVR, aVL, and aVF leads ( Figure 1B), then I, II, and III leads to becoming total ECG bigeminy PVCs ( Figure 1C). ( Figure 1D), then into irregular PVCs ( Figure 1E) lastly extended to runs of VT ( Figure 1F). There is a mild renal impairment (serum creatinine: 2.86 and blood urea:95). The operator advised adding nitroglycerin IVI and diltiazem oral tablet.

Methods of Study and Patients
Despite there was a response but the recurrence was founded. The patient advised for further electrophysiological study (EPS). For more details see Tables 4-6.

Case no. 2: (Progressive Polymorphic Ventricular Tachycardia (Pvt))
A 58-year-old married Egyptian housewife female patient presented to the POC with dizziness, dyspnea, and palpitations. The patient gave a history of psycho-familial troubles. Clinically, she had appeared myxedematos. There was sub-clinical hypothyroidism and congestive heart failure (CHF). Serial ECG tracings were taken which showed an interesting progressive polymorphic ventricular tachycardia (PVT) was described as: "Graded phenomenon left to the right extension, upgrading" (Figure 2). PVT initially started in part of I, II, and III leads (Figure 2A), then extended to the remaining part of I, II, and III leads ( Figure 2B), then I, II, and III leads to then extended to part of aVR, aVL, and aVF leads ( Figure   2C), lastly extend to V1,2, 3, and part of V4-6 ( Figure 2D), then into irregular PVCs ( Figure 2E) extended to runs of VT ( Figure 2F). The patient advised for further electrophysiological study (EPS). For more details see Tables 4-6.

Case No. 3: (Progressive Bidirectional Sectors Of Tachycardia (BSOT))
A 75-year-old married Egyptian housewife female patient presented to the POC with chest pain, dyspnea, and palpitations.
The patient initially diagnosed as hypertensive crises with junctional tachycardia. Serial ECG tracings were taken which showed interesting progressive bidirectional sectors of tachycardia (PSOT) with a normal rhythm in between until becoming total tachycardia in all ECG tracing (Figure 3). PSOT initially started in first part of I, II, and III, aVR, aVL, and aVF leads ( Figure 3A), then extended to last part of I, II, III, and aVR, aVL, and aVF and first part of, aVR, aVL, aVF, and V1-3 leads ( Figure 3B), then first part of I, II, III, middle part of aVR, aVL, aVF and V1-3, and last part of I, II, III, and V4-6 leads ( Figure 3C), then extend to last part of aVR, aVL, and aVF, and all V1-6 leads ( Figure 3D), lastly it includes all ECG leads ( Figure 3E). The patient advised for further electrophysiological study (EPS). For more details see Tables 4-6.

Figure 3:
A-E ECG tracings showing "Graded phenomenon with an interested progressive bidirectional sectors of tachycardia (BSOT) with normal rhythm in between until become total tachycardia in the all ECG tracing" SOT initially started in first part of I, II, and III, aVR, aVL, and aVF leads (3 A tracing; blue color), then extended to last part of I, II, III, and aVR, aVL, and aVF and first part of, aVR, aVL, aVF, and V1-3 leads (3 B tracing; green color), then first part of I, II, III, middle part of aVR, aVL, aVF and V1-3, and last part of I, II, III, and V4-6 leads (3 C tracing; gold color), then extend to last part of aVR, aVL, and aVF, and all V1-6 leads (3 D tracing; green color), lastly it includes all ECG leads (3 E tracing; turquoise color).

Case No. 4: (Intermittent Wandering Pacing Rhythm (Wpr) With Progressive Extension From Left To Right)
An 11-year-old Egyptian boy student patient presented to the POC with pleuritic chest pain. There was no history of heart disease. Serial ECG tracings were taken which showed an interesting intermittent Wandering pacing rhythm (WPR) with progressive extension from left to right. It progresses until becoming total junctional rhythm in all ECG tracing except lead I and aVL, then spontaneously normalized (Figure 4). WPR initially started in I, II, and first part of III, aVR, aVL, and aVF leads, then sinus bradycardia in the remaining part of aVR, aVL, and aVF leads, then junctional rhythm (JR) in part of V1-3, lastly sinus bradycardia in the remaining part of V-3, and all V4-6 leads ( Figure 4A), then JR including all ECG tracing except lead I and aVL ( Figure 4B), then spontaneously normalized ( Figure 4C). The patient advised for further electrophysiological study (EPS). For more details see Tables 4-6.

Figure 4:
A-C Serial ECG tracings were taken which showed an interesting intermittent Wandering pacing rhythm (WPR) with progressive extension from left to right. It progresses until becoming total junctional rhythm in all ECG tracing except lead I and aVL, then spontaneously normalized. WPR initially started in I, II, and first part of III, aVR, aVL,and aVF leads (green arrows and color), then sinus bradycardia in the remaining part of aVR, aVL, and aVF leads (black and blue arrows, and color), then junctional rhythm (JR) in part of V1-3 (green arrows and color), lastly sinus bradycardia in the remaining part of V-3, and all V4-6 leads (black and blue arrows, and color) (4 A. ECG tracing), then JR including all ECG tracing except lead I and aVL (4 B. ECG tracing), then spontaneously normalized (4 C. ECG tracing).

Case No. 5: (Progressive Accelerated Junctional Rhythm (Ajr) With The Right To The Left Extension)
A 37-year-old married Egyptian housewife female patient presented to the POC with irritable bowel syndrome with chest tightness, and palpitations. She gave a history of anxiety due to delayed infertility. The patient initially diagnosed as anxiety with a junctional rhythm. Serial ECG tracings were taken which showed progressive accelerated junctional rhythm (AJR) with the right to the left extension. with a normal rhythm in between until becoming total junctional rhythm in the all ECG tracing, then spontaneously normalized ( Figure 5). JR initially started in V1-6 leads ( Figure   5A), then extended to all ECG leads except aVL ( Figure 5B), then spontaneously normalized in all ECG leads ( Figure 5C). The patient advised for further electrophysiological study (EPS). For more details see Table 4, 5, and 6.  234 Figure 13: ECG tracing was taken which showed insignificant isolated PVCs (red arrows).

Case No. 14: (Insignificant isolated PVCs but important)
A 60-year-old married Egyptian female housewife presented to the ER with dizziness. There was a history of compensated chronic renal failure (CRF) on regular hemodialysis. She was admitted to ICU as symptomatic bradycardia. ECG tracing was taken which showed sinus bradycardia with few PVCs (Insignificant isolated PVCs but important) ( Figure 14A). The above abnormalities reversed after atropine iv injection (1 mg). ( Figure 14B). The patient advised for further electrophysiological study (EPS). For more details see

Case No. 15: (Down-grading with less frequency of PVCs in CHF)
A 66-year-old married Egyptian male electrician presented to the orthopnea. The patient had a recent history of CHF. He was admitted to the ICU as a CHF. Serial ECG tracings were taken which   Figure 15: ECG tracings were taken which showed "down-grading PVCs" with ECG strip (red arrows). There is wavy triple an electrocardiographic sign (Yasser sign) for hypocalcemia in the anterior leads esp. V4-6 (green arrows).

Case No. 16: (Sinus arrhythmia spontaneously graded to normal)
A 66-year-old married housewife Egyptian female patient presented to the ER for follow up. The ECG recordings were showing sinus arrhythmia ( Figure 16A). ECG recordings were taken one minute later and were completely normal without any medications (Passing phenomenon) ( Figure 16B). The patient was only managed with reassurance. No recurrence for above ECG abnormalities on later serial ECG tracings follows up. For more details see Tables 4-6.

Case No1 29 (Sinus arrhythmia spontaneously graded to normal)
A 34-year-old married worker Egyptian male patient presented to the ER for blood pressure follow up. The ECG recordings were showing sinus arrhythmia. ECG recordings were taken four minutes later and were completely normal without any medications (Pass phenomenon). The patient was only managed with reassurance. No recurrence for above ECG abnormalities on later serial ECG tracings follows up. For more details see Tables 4-6..

Case No 30 (Sinus arrhythmia spontaneously graded to normal with anxiety)
An 85-year-old married housewife Egyptian female patient presented to the emergency room with palpitation. The patient had a recent history of anxiety. ECG recordings were showing sinus arrhythmia. ECG recordings were taken three minutes later and were completely normal without any medications (Pass phenomenon). The patient was only managed with reassurance. No recurrence for above ECG abnormalities on later serial ECG tracings follows up. For more details see Tables 4-6..

Figure 20:
showing the graphical presentation for developmental changes in the "Graded phenomenon".

2.
The Course in "Graded Phenomenon" is Classified into: 1.

3.
The risk in "Graded phenomenon" is classified into: 1.

Figure 22:
showing the graphical presentation for risk outcomes in "Graded phenomenon".

8.
The risk in the "Graded phenomenon" is either high

18.
f. Therapeutic reversal: It is meaning that there is a new arrhythmic change after using the traditional antiarrhythmic e.g. case No. 14.
g. The extension for arrhythmia in "Graded phenomenon" are : The up-grading phenomenon with the right to left extension: It is meaning that the arrhythmic change starting from the right side of ECG tracing directed toward its left side e.g. case No. 1. 12. The risk in arrhythmia with "Graded phenomenon" are: a. High: This is meaning that there will be possible serious outcomes like; sudden cardiac deaths congestive heart failure, Torsades de pointes, and VT ventricular tachycardia e.g. case No. 1, 2, and 7.
b. Non-risk: This is meaning that there will not be possible serious outcomes e.g. case No. 1, 2, and 7. c. Still-risk: This is meaning that there are no current possible serious outcomes but maybe with passing the time e.g. case No. 18, 24, and 26.

Conclusion and Recommendation
Graded phenomenon (Yasser's phenomenon) is a novel electrocardiographic phenomenon change the arrhythmia directory. It is a crucial step for understanding arrhythmia. The phenomenon is a new strong guide for monitoring and follows up arrhythmic patients in cardiovascular patients. There are interlacing correlations between the "passing phenomenon" [49] and the current "Graded phenomenon" especially in cases of arrhythmia that is spontaneously changed to normal sinus rhythm with no uses of medications or therapeutic maneuvers like DCC and Valsalva's e.g. case No. 16 and17. Electrophysiology studies (EPS) is recommended for more future study and understanding the "Graded phenomenon". Physiological study for the cellular electrolytes may be advised future options for the "Graded phenomenon".

Conflicts of Interest
There are no conflicts of interest.