There is no obvious distortion of the T wave preceding the first wide complex beat to suggest that the arrhythmia was initiated by an ectopic P wave. In addition, AV dissociation is suggested by the distortion of the T wave that follows the first wide complex beat. It is seen best in lead V1. Note also the T wave abnormality shown with the arrow. These changes, which are suggestive of dissociated sinus P waves, are less obvious in lead II, indicating the importance of studying multiple leads in order to identify the P waves.