The document summarizes a presentation on electrocardiographic passing phenomena given at a cardiology conference. It includes 10 case studies demonstrating different types of passing phenomena, such as accelerated junctional rhythm, bigeminy, and sinus arrhythmia. It discusses the historical discovery of these phenomena, how they are analyzed and classified, common target diseases they may indicate but not necessarily be related to, and how reassuring patients can be an effective therapy. Statistics on the study subjects are provided, such as average age and percentages of occupations and main complaints. Serial electrocardiograms are presented for each case study and management primarily involved reassurance without medical intervention.

1. 25th International Conference on Cardiology and Vascular Imaging”
Webinar
October 29-30, 2021
Zurich, Switzerland

2. Elsayed
MB Bch, PGDip Cardiology (Middlesex
University, RILA)
Researcher and author
Critical Care Unit
Work: Egyptian Ministry of Health (MOH)
Damietta, Damietta Health Affairs

3. My greetings

4. Electrocardiographic Passing
Phenomenon
(Flying Phenomenon)
or
(Yasser’s Phenomenon)

5. Electrocardiographic Passing
Phenomenon
(Flying Phenomenon or Yasser’s Phenomenon)
Conveys the Traditional Cardiovascular Management
Interpretations and Reassurance
Retrospective Observational Study

6. Figure 1; true case model for the passing phenomenon (technical form)

7. Learning objectives
• The study
• Discovery and historical bit
• Understanding and analysis for the phenomenon
• Types of the phenomenon
• Target diseases
• Examples
• The study data and statistics
• Functional outcomes and significance
• Mechanisms
• How to deal with it? (Management)
• Summary
• Conclusion and Recommendations

8. Table 1- showing remarks of the study method and data.
Issue Definition
Title Electrocardiographic passing phenomenon (Flying
phenomenon or Yasser’s phenomenon) conveys the
traditional cardiovascular management; interpretations and
reassurance
Estimated Enrollment 18
participants
Study Type Observational
Observational Model Case-only
Time Retrospective
Study Start Date February 1, 2016
Estimated Study Completion Date ended on July 16, 2019
Analytic method Comparative using percentage %

9. Discovery

10. 1. History
• Discovery was an accidental
• Precise clinical and electrocardiographic observation.
• I had been observing for important ECG changes then disappear
within a few seconds to a few minutes.

11. 2. Bases of
Electrocardiographic passing
phenomenon
(Flying phenomenon)
(Yasser’s sign)

12. • The analysis for this phenomenon in
the author interpretations are based on
the following;

13. 1.The ECG changes are transient.

14. 2.The ECG changes
spontaneously will be reversed
within a few seconds to a few
minutes.

15. 3. There are no used medications
to help this reversal.

16. 4.The ECG changes are either
technical or pathophysiological.

17. 5.The ECG changes are either
technical, physiological, or
pathophysiological.

18. 6. The serial ECG tracings are
essential in understanding.

19. 7. All these ECG changes may not
be related to the diagnosis of
relevant diseases.

20. 8.Reassurance is immediate therapy.

21. 9.The sum of previous points is the
“Electrocardiographic passing phenomenon (Flying
phenomenon or Yasser’s phenomenon)”.

22. Types for phenomenon

23. • Morphologically, there three types for the
phenomenon were reported:

24. 1.Technical

25. • Technical: There are ECG
technical errors and may be
misdiagnosed as an organic
disease.

26. 2.Physiological

27. • Physiological: Presence of physiological
risk factor e.g. (fear and anxiety) and may
be misdiagnosed as an organic disease. But
there is no local organic or structural
change.

28. 1.Pthophysiological (organic)

29. • Pthophysiological (organic): Presence of
local organic or structural change.
Investigations are parallel with the
diagnosis

30. Target diseases

31. • Accelerated junctional rhythm
• Mimic ST-segment elevation myocardial infarction with
accelerated junctional rhythm
• Sinus arhythmia
• Bigeminy
• Trigeminy
• Quaderigeminy
• Pentageminy

32. Let me to introducing examples for understanding

33. Case No. 1

34. Mimic acute STEMI with Accelerated junctional rhythm in
pleurisy and cold
A 17-year-old single Egyptian male student presented to a physician
outpatient clinic with pleuritic chest pain. The patient had a recent history of an
attack of a common cold. The ECG recordings were showing ST-segment
elevation in all inferior ECG leads (II, III, aVF) with P-wave inversion through lead
I, all inferior ECG leads (II, III, aVF), and V3-6, upright P-wave in aVR with VR;78
bpm. (Figure 2A). ECG recordings were taken one minute later and were
completely normal without any medications. (Figure 2B). The troponin test was
below the normal level. CXR film was showing increased bronchovascular
marking. Echocardiography was normal. Pleurisy was managed only with
ibuprofen (tab., 400 mg/8 hours for 5 days). No recurrence for above ECG
abnormalities on later serial ECG on follow up

35. • Figure 2: A. the initial ECG tracing showing ST-segment elevation in all inferior ECG leads (II, III, aVF) (blue
arrows) with P-wave inversion (orange arrows) through lead I, all inferior ECG leads (II, III, aVF), and V3-6, upright
P-wave in aVR (green arrows) with VR;78 bpm. B. ECG tracing one minute later showing normalization of all above
changes.

36. Case No. 2

37. Calculous cholecystitis-induced non-specific ST-segment
elevation like-myocardial infarction and bradycardia
A 28-year-old married Egyptian female officer, an obese patient presented to the ER with vomiting and severe
epigastric pain which referred to both chest and back. The patient had a history of calculous cholecystitis. There was
a positive Murphy’s sign. The patient was admitted to ICU as chest pain for further assessment. The ECG recordings
were showing ST-segment elevation in leads aVL, aVF with reciprocal ST-segment elevation in leads aVR and T-
wave inversion in lead II, III, and aVF with VR;52 bpm (Figure 3A). ECG recording was taken 33 seconds later showing
spontaneous disappearance of above ST-segment elevations with reciprocal ST-segment elevations. This had
happened without any medications There was still the presence of T-wave inversions in II, III, and aVF leads. (Figure
3B). The abdominal US showed calculous cholecystitis. The electrolytes, thyroid function tests, troponin test,
Echocardiography, were normal. was normal. No recurrence for above ECG abnormalities on later serial ECG tracings
follows-up. Abdominal ultrasound showed multiple variable-sized gallbladder stones with inflammation in the
bladder wall. The patient was referred to the surgeon for acalculous cholecystitis management.

38. Figure 3: Serial ECG tracings A. tracing showing ST-segment elevations in aVL, aVF leads (blue arrows) with reciprocal ST-segment depressions
in aVR lead (red arrows), T-wave inversion in II, III, and aVF leads (purple arrows) with sinus bradycardia (VR;52 bpm), and AC artifacts in V6 lead
(black arrows) B. tracing was taken with 33 seconds of A. tracing showing spontaneous disappearance of above ST-segment deviations. There
was still the presence of a T-wave inversion in II, III, and aVF leads (purple arrows) with sinus bradycardia (VR;52 bpm), and AC artifacts in V6
lead (black arrows)

39. Case No. 3

40. Sinus arrhythmia
A 66-year-old married housewife Egyptian female patient
presented to the ER for follow-up. The ECG recordings were
showing sinus arrhythmia (Figure 4A). ECG recording was taken
one minute later and was completely normal without any
medications (Figure 4B). Echocardiography was normal. The
patient was only managed with reassurance. No recurrence for
above ECG abnormalities on later serial ECG tracings follows up.
(Figure 4).

41. Figure 4: Figure 15: A. the initial ECG tracing showing sinus arrhythmia (green arrows) and with VR; 92 bpm. B. ECG tracing one minute later
showing normalization of all above changes.

42. Case No. 4

43. Bigeminy with AF, RBBB, and suspected acute pulmonary
embolism
A 67-year-old married Egyptian female housewife presented to the ER with
dyspnea, tachypnea, and palpitations. The patient gave a history of IHD. The ECG
recordings were showing AF, RBBB, ST-depressions in V4-6 leads, and bigeminy
through all ECG leads (Figure 5A). ECG recordings were taken three minutes later
and were completely disappearance only for bigeminy (Figure 5B). Bigeminy
disappears without any medical interventions. The patient was admitted to ICU as
suspected of acute pulmonary embolism. No recurrence of bigeminy on later
serial ECG tracings. The patient was managed with standard therapy of pulmonary
embolism. D-dimer, CXR, CTPA, and echocardiography were done. The patient left
the hospital within one day of recovery. (Figure 5).

44. Figure 5: A. The initial ECG tracing shows AF, RBBB, ST-depressions in V4-6 leads (blue arrows), and bigeminy
through most ECG leads (green arrows). B. The second ECG tracing (three minutes after the first ECG) showed
complete disappearance only for bigeminy.

45. Case No. 5

46. Sinus arrhythmia
A 57-year-old married housewife Egyptian female patient
presented to the ER for inguinal hernia preoperative
preparation. The ECG recording was showing sinus arrhythmia
(Figure 6A). ECG recording was taken one minute later and was
completely normal without any medications (Figure 6B).
Echocardiography was normal. The patient was only managed
with reassurance. No recurrence for above ECG abnormalities
on later serial ECG tracings follows up. (Figure 6).

47. Figure 6: A. the initial ECG tracing showing sinus arrhythmia (green arrows) with VR; 76 bpm. B.
ECG tracing one minute later showing normalization of all above changes.

48. Case No. 6

49. Angina and bronchial asthmia with intermittent
pathological Q-wave in lead III
A 65-year-old married, housewife, Egyptian female patient
presented to the ER with acute tachypnea and anginal chest
pain. The patient was managed in ICU as an unstable anginal
with intravenous nitroglycerin infusion, oral aspirin, clopidogrel,
oral diltiazem, and S.C. enoxaparin sodium was given. Later
echocardiography showed diastolic dysfunction with a normal
EF of 64%. Serial ECG tracings showed intermittent pathological
Q-wave in lead III (Figure 7).

50. Figure 7: Serial ECG tracings; A. tracing showing NSR of VR; 92 with no pathological Q-wave in
lead III. B. tracing showing NSR of VR; 88 with the appearance of pathological Q-wave in lead III.
C. tracing showing NSR of VR; 90 with the disappearance of pathological Q-wave in lead III.

51. Case No. 7

52. Pentageminy with cerebrovascular accident
A 70-year-old single Egyptian housewife female patient
presented to the ED with a severe headache. The patient had
been admitted to ICU as a CVA. Brain CT showed SAH. The ECG
recordings were showing pentageminy through all ECG leads, ST-
segment depressions in all anterior leads with sinus tachycardia
(VR;100 bpm) (Figure 8A). ECG recordings were taken one and
half a minute later and were the disappearance of pentageminy
without any medications. (Figure 8B). CXR film was showing
cardiomegaly. Echocardiography showed LV systolic dysfunction.

53. Figure 8: Serial ECG tracings; A. tracing showing pentageminy through all ECG leads (black arrows)., ST-segment depressions in
the all anterior leads (green arrows) with sinus tachycardia (VR;100 bpm). B. tracing was taken one and half a minute later and
showed the disappearance of pentageminy with very few and still ST-segment depressions (green arrows).

54. Case No. 8

55. Trigeminy with anxiety and old IMI
A 49-year-old married Egyptian teacher male patient
presented to the POC with palpitations. The patient appeared
anxious. Recent history of socio-familial stress. The ECG
recording shows trigeminy through all ECG leads with VR;66 bpm
(Figure 9A). ECG recording was taken one minute later with the
disappearance of trigeminy without any medications. (Figure
9B). Echocardiography was normal. No recurrence for above ECG
trigeminy on later serial ECG tracings follows up. (Figure 9)

56. Figure 9; Serial ECG tracings; A. tracing showing trigeminy beats (green arrows) with evidence of
inferior MI (orange arrows). B. tracing was taken one minute after the first ECG showing nearly
normalization of all above changes.

57. Case No. 9

58. Accelerated junctional rhythm with myositis
A 43-year-old married housewife Egyptian female patient presented
to POC with MSK chest pain. Local tenderness was elicited. The ECG
recording was showing accelerated junctional rhythm in the inferior
leads ( II, III, aVF) and all anterior leads (V1-6) (Figure 10A). ECG
recording was taken two minutes later and was completely normal
without any medications (Figure 10B). Otherwise of leukocytosis
(14400) and increased CPK (473 IU/L). Troponin test and
echocardiography were normal. The patient was managed only with
diclofenac potassium (tab., 25 mg/8 hours for 5 days). No recurrence for
above ECG abnormalities on later serial ECG on follow-up.

59. Figure 10; Serial ECG tracings; A. tracing showing P-wave inversion through all inferior ECG leads (II, III, aVF) (gold arrows) and all
anterior chest leads (V1-6) (gold arrows) but there are upright P-wave in aVR (green arrows), with VR; 90 bpm. B. tracing was
taken two minutes later showing normalization of all the above changes.

60. Case No. 10

61. An electrocardiographic anxiety- induced quadrigeminy
A 28-year-old married Egyptian male worker presented to the hospital
outpatient clinic for a regular check-up. The patient had a recent history of
anxiety. The ECG recording was showing quadrigeminy through all ECG leads
(Figure 11A). ECG recording was taken one minute later and was completely
normal (Figure 11B). Patient pulse during the first ECG showed irregular
regularity while pulse examination was completely regular during the second
ECG. Quadrigeminy disappears without any medical interventions. No recurrence
of quadrigeminy on later serial ECG tracings. Echocardiography was normal. The
patient left the hospital after reassurance.

62. Figure 11; Serial ECG tracings; A. tracing showing quadrigeminy during patient’s anxiety from electrocardiographic electricity
through all ECG leads (black arrows indicate quadrigeminal PVCs followed by three normal sinus beats (blue arrows). B. tracing
was taken one minute after the first ECG ) showing complete showing normalization of all above changes. The red arrow
indicates the time and date of the ECG.

63. The study data and statistics

64. Table 2: Summary of the history, clinical, and management data for all the study cases.

65. Age

66. Figure 12 showes age averages.
• Averages (Range;17-85, minimum;17, maximum; 85, mean; 54.83, median; 56,
and mode; 56) (Figure 12)

67. Sex and percentages
(%)

68. • 50% of the study cases are male (9 cases) and 50%
are female (9 cases) (Figure 13).
Figure 13 shows sex and percentages (%).

69. Occupation and percentages (%)

70. • Student; 5.56% (1 case)
• Teacher; 11.11% (2 cases)
• Housewife; 50% (9 cases)
• Farmer; 5.56% (1 cases)
• Worker; 16.67% (3 cases)
• Driver; 5.56% (1 case)
• Carpenter; 5.56% (1 case) (Figure 14)

71. Figure 14 shows various occupation percentages in the
study.

72. The main complaint

73. • Chest pain; 22.22% (4 cases)
• Palpitations; 16.67% (3 cases)
• Dyspnea; 5.56% (1 case)
• Headache; 5.56% (1 case)
• Abdominal pain; 16.67% (3 cases)
• On preoperative preparation; 5.56% (1 case)
• On follow up; 27.78% (5 cases) (Figure 15).
Figure 15 shows percentages of the main complaint in
the study.

74. The average time elapsed between both ECG
tracings
(minutes)

75. • Averages (Range;1-4, minimum;1, maximum;
4, mean; 1.638, median; 1.25, and mode; 1)

76. Basic diagnosis

77. • Cold ; 11.11% (2 cases)
• Cervical disc prolapse; 5.56% % (1 case)
• Myositis; 5.56% % (1 case)
• Anxiety; 16.67% (3 cases)
• CVA with HTN; 5.56% % (1 case)
• Old MI; 5.56% % (1 case)
• Renal pain; 5.56% % (1 case)
• Ischemic colitis; 5.56% % (1 case)
• HTN; 5.56% % (1 case)
• AF with suspected APE; 5.56% % (1 case)
• SF; 5.56% % (1 case)
• On follow-up; 16.67% % (3 cases)
• On preoperative preparation; 5.56% % (1 case) (Figure 16)

78. Figure 16 shows percentages of basic diagnosis in the study.

79. Cardiac diagnosis

80. • Accelerated junctional rhythm; 22.22% (4 cases)
• Mimic ST-segment elevation myocardial infarction with
accelerated junctional rhythm; 5.56% % (1 case)
• Sinus arhythmia; 22.22% (4 cases)
• Bigeminy; 11.11% (2 cases)
• Trigeminy; 11.11% (2 cases)
• Quaderigeminy; 16.67% % (3 cases)
• Pentageminy; 11.11% (2 cases) (Figure 17)

81. Figure 17 shows different cardiac diagnoses.

82. Reassurance but consider the organic
cause

83. • There is reassurance for all cases of the study (100%).
• But the reassurance with the presence of organic
cardiac cause was only in seven cases of this study
(38.89%).

84. Functional outcomes and significance

85. • Functionally, the outcomes for the phenomenon that
are based on the underlying structural disease

86. Mechanisms
of
“Passing phenomenon”
(Yasser’s phenomenon)

87. • Indeed, the Mechanisms of “Passing phenomenon” (Yasser’s phenomenon) is unknown.
• But, myocardial hyperexcitability and electrolytes change inside the maybe suggested
theory for understanding this phenomenon.

88. Management
of
“Passing phenomenon”
(Yasser’s phenomenon)

89. • Essential points are considered in the management of the “Passing phenomenon” (Yasser’s
phenomenon)
• Serial ECG tracings
• The significance
• The course
• The underline cardiac diagnosis
• The time between the ECG tracings
• The types.

90. Summary

91. • Definition of “Passing phenomenon”. It is a transient electrocardiographic change
that spontaneously reversed within a few seconds to a few minutes without any
medical interventions and apparent hemodynamic impact.
• Not all cases have an organic cause.
• The common denominator among the cases was the appearance of transient significant
electrocardiographic changes with prompt and spontaneous disappearance of these changes within
a few seconds to a few minutes without any medical interventions.
• Otherwise, the medications for the basic pathology, all patients were lucky when no any given
medications or interference had happened.
• All these ECG changes may not be related to the diagnosis of relevant diseases.
• These changes were transient.
• The reversibility had happened within a few seconds to a few minutes.

92. • Myocardial hyperexcitability and electrolyte changes inside the maybe suggested
theory for this phenomenon.
• Don’t neglect the significance of the serial ECG tracing copies.
• Depending on the new phenomenon, some arrhythmias and anti-arrhythmic should
be reviewed again.
• Don’t hurry to manage the ECG arrhythmic abnormalities unless be sustained.
• Regards to ST-segment elevation, the physician should not urge to manage as ST-
segment elevation or coronary artery vasospasm until established and confirmed the abnormalities.
• Reassurance is immediate therapy.
• The electrophysiological study is the future advised investigation.

93. Conclusion and Recommendations

94. • “Passing phenomenon” is a transient electrocardiographic change
that spontaneously reversed within a few seconds to a few minutes
without any medical interventions and apparent hemodynamic
impact.
• Reassurance is immediate therapy.
• The electrophysiological study is the future advised investigation.

95. Acknowledgment

96. I wish to thank Ahmed Alghobary, B.sc. for his technical support.

97. References

98. 1. Elsayed YMH. Electrocardiographic Passing Phenomenon (Flying
Phenomenon or Yasser’s Phenomenon) Conveys the Traditional
Cardiovascular Management; Interpretations and Reassurance. Retrospective
Observational Study Anaest & Sur Open Access J. 2020;1(3):1-19. DOI:
10.33552/ASOAJ.2020.01.000515
2. Elsayed YMH. STsegment elevation myocardial infarction mimic and
Passing phenomenon or Yasser’s phenomenon with squaring sign; don’t hurry
for an emergency management; A case report . Clinical Medicine and
Medical Research. 2020;1(2):35−38. URL:
http://clinicalmedicine.in/index.php/cmmr/article/view/18
3. Elsayed YMH. Calculous Cholecystitis -Induced Non-Specific ST-Segment
Elevation LikeMyocardial Infarction and Bradycardia: A Case Report. Biomed
J Sci & Tech Res. 2019;22(1):16386-88. BJSTR. MS.ID.003698. DOI:
10.26717/BJSTR.2019.22.003698

99. Thank you