Sinoatrial (SA) Node Arrhythmias

Page 32

■ Upright P waves all look similar. Note: All ECG strips in Tab 2 were recorded in Lead II.
■ PR intervals and QRS complexes are of normal duration.
3:00 PM

Normal Sinus Rhythm (NSR)

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Rate: Normal (60–100 bpm)

Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)
ECGS

Clinical Tip: A normal ECG does not exclude heart disease.

Clinical Tip: This rhythm is generated by the sinus node and its rate is within normal limits (60–80 bpm).
 Sinus Bradycardia
Page 33

■ The SA node discharges more slowly than in NSR.

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33

Rate: Slow (<60 bpm)

2142_Tab02_032-079.qxd

Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)
Clinical Tip: Sinus bradycardia is normal in athletes and during sleep. In acute MI, it may be protec-

ECGS
tive and beneficial or the slow rate may compromise cardiac output. Certain medications, such as beta
blockers, may also cause sinus bradycardia.
 Sinus Tachycardia
Page 34

■ The SA node discharges more frequently than in NSR.

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34
Rate: Fast (>100 bpm)
2142_Tab02_032-079.qxd

Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)

Clinical Tip: Sinus tachycardia may be caused by exercise, anxiety, fever, hypoxemia, hypovolemia,
ECGS

or cardiac failure.
 Sinus Arrhythmia
Page 35

■ The SA node discharges irregularly.

■ The R-R interval is irregular.
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2142_Tab02_032-079.qxd

Rate: Usually normal (60–100 bpm); frequently increases with inspiration and decreases with expira-
tion; may be <60 bpm
Rhythm: Irregular; varies with respiration; difference between shortest RR and longest RR intervals is
>0.12 sec
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12–0.20 sec)

ECGS
QRS: Normal (0.06–0.10 sec)

Clinical Tip: The pacing rate of the SA node varies with respiration, especially in children and eld-
erly people.
 Sinus Pause (Sinus Arrest)
Page 36

■ The SA node fails to discharge and then resumes.

■ Electrical activity resumes either when the SA node resets itself or when a slower latent pacemaker
begins to discharge.
■ The pause (arrest) time interval is not a multiple of the normal PP interval.
3:00 PM

3.96 - sec pause/arrest

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2142_Tab02_032-079.qxd

Rate: Normal to slow; determined by duration and frequency of sinus pause (arrest)
Rhythm: Irregular whenever a pause (arrest) occurs
P Waves: Normal (upright and uniform) except in areas of pause (arrest)
PR Interval: Normal (0.12–0.20 sec)
ECGS

QRS: Normal (0.06–0.10 sec)

Clinical Tip: Cardiac output may decrease, causing syncope or dizziness.

 Sinoatrial (SA) Block
Page 37

■ The block occurs in some multiple of the PP interval.

■ After the dropped beat, cycles continue on time.
3:00 PM

Dropped beat
X
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2142_Tab02_032-079.qxd

Rate: Normal to slow; determined by duration and frequency of SA block

Rhythm: Irregular whenever an SA block occurs
P Waves: Normal (upright and uniform) except in areas of dropped beats
PR Interval: Normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)

ECGS
Clinical Tip: Cardiac output may decrease, causing syncope or dizziness.
 Atrial Arrhythmias
Page 38

■ P waves differ in appearance from sinus P waves.

■ QRS complexes are of normal duration if no ventricular conduction disturbances are present.
3:00 PM

Wandering Atrial Pacemaker (WAP)

■ Pacemaker site transfers from the SA node to other latent pacemaker sites in the atria and the AV
junction and then moves back to the SA node.
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38
2142_Tab02_032-079.qxd

Rate: Normal (60–100 bpm)

ECGS

Rhythm: Irregular
P Waves: At least three different forms, determined by the focus in the atria
PR Interval: Variable; determined by focus
QRS: Normal (0.06–0.10 sec)
Clinical Tip: WAP may occur in normal hearts as a result of fluctuations in vagal tone.
 Multifocal Atrial Tachycardia (MAT)
Page 39

■ This form of WAP is associated with a ventricular response >100 bpm.

■ MAT may be confused with atrial fibrillation (A-fib); however, MAT has a visible P wave.
3:00 PM
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2142_Tab02_032-079.qxd

Rate: Fast (>100 bpm)

Rhythm: Irregular
P Wave: At least three different forms, determined by the focus in the atria
PR Interval: Variable; determined by focus
QRS: Normal (0.06–0.10 sec)

ECGS
Clinical Tip: MAT is commonly seen in patients with chronic obstructive pulmonary disease (COPD)
but may also occur in an acute MI.
 Premature Atrial Contraction (PAC)
Page 40

■ A single contraction occurs earlier than the next expected sinus contraction.
■ After the PAC, sinus rhythm usually resumes.
3:00 PM

PAC PAC
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Rate: Depends on rate of underlying rhythm

Rhythm: Irregular whenever a PAC occurs
P Waves: Present; in the PAC, may have a different shape
PR Interval: Varies in the PAC; otherwise normal (0.12–0.20 sec)
QRS: Normal (0.06–0.10 sec)
ECGS

Clinical Tip: In patients with heart disease, frequent PACs may precede paroxysmal supraventricular
tachycardia (PSVT), atrial fibrillation (A-fib), or atrial flutter (A-flutter).
 Atrial Tachycardia
Page 41

■ A rapid atrial rate overrides the SA node and becomes the dominant pacemaker.
■ Some ST segment and T wave abnormalities may be present.
3:00 PM
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2142_Tab02_032-079.qxd

Rate: 150–250 bpm

Rhythm: Regular
P Waves: Normal (upright and uniform) but differ in shape from sinus P waves
PR Interval: May be short (<0.12 sec) in rapid rates
QRS: Normal (0.06–0.10 sec) but can be aberrant at times

ECGS
 Supraventricular Tachycardia (SVT)
Page 42

■ This arrhythmia has such a fast rate that the P waves may not be seen.
3:00 PM

P wave buried in T wave

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42
Rate: 150–250 bpm
2142_Tab02_032-079.qxd

Rhythm: Regular
P Waves: Frequently buried in preceding T waves and difficult to see
PR Interval: Usually not possible to measure
QRS: Normal (0.06–0.10 sec) but may be wide if abnormally conducted through ventricles

Clinical Tip: SVT may be related to caffeine intake, nicotine, stress, or anxiety in healthy adults.
ECGS

Clinical Tip: Some patients may experience angina, hypotension, light-headedness, palpitations,
and intense anxiety.
 Paroxysmal Supraventricular Tachycardia (PSVT)
Page 43

■ PSVT is a rapid rhythm that starts and stops suddenly.

■ For accurate interpretation, the beginning or end of the PSVT must be seen.
■ PSVT is sometimes called paroxysmal atrial tachycardia (PAT).
3:00 PM

Sudden onset of SVT

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43
2142_Tab02_032-079.qxd

Rate: 150–250 bpm

Rhythm: Irregular
P Waves: Frequently buried in preceding T waves and difficult to see
PR Interval: Usually not possible to measure
QRS: Normal (0.06–0.10 sec) but may be wide if abnormally conducted through ventricles

ECGS
Clinical Tip: The patient may feel palpitations, dizziness, lightheadedness, or anxiety.
 Atrial Flutter (A-flutter)
Page 44

■ AV node conducts impulses to the ventricles at a ratio of 2:1, 3:1, 4:1, or greater (rarely 1:1).
■ The degree of AV block may be consistent or variable.
3:00 PM

Flutter waves
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Rate: Atrial: 250–350 bpm; ventricular: variable

Rhythm: Atrial: regular; ventricular: variable
P Waves: Flutter waves have a saw-toothed appearance; some may be buried in the QRS and not visible
PR Interval: Variable
QRS: Usually normal (0.06–0.10 sec), but may appear widened if flutter waves are buried in QRS
ECGS

Clinical Tip: A-flutter may be the first indication of cardiac disease.

Clinical Tip: Signs and symptoms depend on ventricular response rate.
 Atrial Fibrillation (A-fib)
Page 45

■ Rapid, erratic electrical discharge comes from multiple atrial ectopic foci.
■ No organized atrial depolarization is detectable.
3:00 PM

Irregular R-R intervals

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2142_Tab02_032-079.qxd

Rate: Atrial: ≥350 bpm; ventricular: variable

Rhythm: Irregular
P Waves: No true P waves; chaotic atrial activity
PR Interval: None
QRS: Normal (0.06–0.10 sec)

ECGS
Clinical Tip: A-fib is usually a chronic arrhythmia associated with underlying heart disease.
Clinical Tip: Signs and symptoms depend on ventricular response rate.
 Wolff-Parkinson-White (WPW) Syndrome
Page 46

■ In WPW, an accessory conduction pathway is present between the atria and the ventricles.
Electrical impulses are rapidly conducted to the ventricles.
■ These rapid impulses slur the initial portion of the QRS; the slurred effect is called a delta wave.
3:00 PM

Delta
wave
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2142_Tab02_032-079.qxd

Rate: Depends on rate of underlying rhythm

Rhythm: Regular unless associated with A-fib
P Waves: Normal (upright and uniform) unless A-fib is present
PR Interval: Short (<0.12 sec) if P wave is present
QRS: Wide (>0.10 sec); delta wave present
ECGS

Clinical Tip: WPW is associated with narrow-complex tachycardias, including A-flutter and A-fib.
 Junctional Arrhythmias
Page 47

■ The atria and SA node do not perform their normal pacemaking functions.
■ A junctional escape rhythm begins.

Junctional Rhythm
3:00 PM

Inverted P wave Absent P wave

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2142_Tab02_032-079.qxd

Rate: 40–60 bpm

Rhythm: Regular
P Waves: Absent, inverted, buried, or retrograde

ECGS
PR Interval: None, short, or retrograde
QRS: Normal (0.06–0.10 sec)

Clinical Tip: Sinus node disease that causes inappropriate slowing of the sinus node may exacer-
bate this rhythm. Young, healthy adults, especially those with increased vagal tone during sleep, often
have periods of junctional rhythm that is completely benign, not requiring intervention.
 Accelerated Junctional Rhythm
Page 48

Absent P wave
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48
Rate: 61–100 bpm
Rhythm: Regular
2142_Tab02_032-079.qxd

P Waves: Absent, inverted, buried, or retrograde

PR Interval: None, short, or retrograde
QRS: Normal (0.06–0.10 sec)

Clinical Tip: Monitor the patient, not just the ECG, for clinical improvement.
ECGS
 Junctional Tachycardia
Page 49

Retrograde P wave
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49

Rate: 101–180 bpm

Rhythm: Regular
2142_Tab02_032-079.qxd

P Waves: Absent, inverted, buried, or retrograde

PR Interval: None, short, or retrograde
QRS: Normal (0.06–0.10 sec)

Clinical Tip: Signs and symptoms of decreased cardiac output may be seen in response
to the rapid rate.

ECGS
 Junctional Escape Beat
Page 50

■ An escape complex comes later than the next expected sinus complex.

Junctional escape beats

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50
Rate: Depends on rate of underlying rhythm
2142_Tab02_032-079.qxd

Rhythm: Irregular whenever an escape beat occurs

P Waves: None, inverted, buried, or retrograde in the escape beat
PR Interval: None, short, or retrograde
QRS: Normal (0.06–0.10 sec)
ECGS
 Premature Junctional Contraction (PJC)
Page 51

■ Enhanced automaticity in the AV junction produces PJCs.

3:00 PM

PJC PJC
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51

Rate: Depends on rate of underlying rhythm

2142_Tab02_032-079.qxd

Rhythm: Irregular whenever a PJC occurs

P Waves: Absent, inverted, buried, or retrograde in the PJC
PR Interval: None, short, or retrograde
QRS: Normal (0.06–0.10 sec)

Clinical Tip: Before deciding whether isolated PJCs are insignificant, consider the cause.

ECGS
 Ventricular Arrhythmias
Page 52

■ In all ventricular rhythms, the QRS complex is >0.10 sec. P Waves are absent or, if visible, have no
consistent relationship to the QRS complex.
3:00 PM

Idioventricular Rhythm
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Rate: 20–40 bpm

Rhythm: Regular
P Waves: None
ECGS

PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance
Clinical Tip: Diminished cardiac output is expected because of the slow heart rate. An idioventricu-
lar rhythm may be called an agonal rhythm when the heart rate drops below 20 bpm. An agonal rhythm
is generally terminal and is usually the last rhythm before asystole.
 Accelerated Idioventricular Rhythm
Page 53
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53

Rate: 41–100 bpm

Rhythm: Regular
2142_Tab02_032-079.qxd

P Waves: None
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance

Clinical Tip: Idioventricular rhythms appear when supraventricular pacing sites are depressed or
absent. Diminished cardiac output is expected if the heart rate is slow.

ECGS
 Premature Ventricular Contraction (PVC)
Page 54

■ PVCs result from an irritable ventricular focus.

■ PVCs may be uniform (same form) or multiform (different forms).
■ Usually a PVC is followed by a full compensatory pause because the sinus node timing is not inter-
rupted. In contrast, a PVC may be followed by a noncompensatory pause if the PVC enters the sinus
3:00 PM

node and resets its timing, enabling the following sinus P wave to appear earlier than expected.

PVC
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Rate: Depends on rate of underlying rhythm

Rhythm: Irregular whenever a PVC occurs
P Waves: None associated with the PVC
ECGS

PR Interval: None associated with the PVC

QRS: Wide (>0.10 sec), bizarre appearance

Clinical Tip: Patients may sense PVCs as skipped beats. Because the ventricles are only partially
filled, the PVC frequently does not generate a pulse.
 Premature Ventricular Contraction: Uniform (same form)
Page 55
3:00 PM
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55

Premature Ventricular Contraction: Multiform (different forms)

2142_Tab02_032-079.qxd

ECGS
 Premature Ventricular Contraction: Ventricular Bigeminy (PVC every 2nd
Page 56

beat)
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56
Premature Ventricular Contraction: Ventricular Trigeminy (PVC every 3rd
beat)
2142_Tab02_032-079.qxd

ECGS
 Premature Ventricular Contraction: Ventricular Quadrigeminy (PVC every
Page 57

4th beat)
3:00 PM
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Premature Ventricular Contraction: Couplets (paired PVCs)

2142_Tab02_032-079.qxd

Couplets

ECGS
 Premature Ventricular Contraction: R-on-T Phenomenon
Page 58

■ The PVCs occur so early that they fall on the T wave of the preceding beat.
■ These PVCs occur during the refractory period of the ventricles, a vulnerable period because the
cardiac cells have not fully repolarized.
3:00 PM
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Rate: Depends on rate of underlying rhythm

Rhythm: Irregular whenever a PVC occurs
P Waves: None associated with the PVC
PR Interval: None associated with the PVC
QRS: Wide (>0.10 sec), bizarre appearance
ECGS

Clinical Tip: In acute ischemia, R-on-T phenomenon may be especially dangerous because the ven-
tricles may be more vulnerable to ventricular tachycardia (VT) or ventricular fibrillation (VF).
 Premature Contraction: Interpolated PVC
Page 59

■ The PVC occurs between two regular complexes; it may appear sandwiched between two normal
beats.
■ An interpolated PVC does not interfere with the normal cardiac cycle.
3:00 PM

Interpolated PVC
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Rate: Depends on rate of underlying rhythm

Rhythm: Irregular whenever a PVC occurs
P Waves: None associated with the PVC
PR Interval: None associated with the PVC
QRS: Wide (>0.10 sec), bizarre appearance

ECGS
 Ventricular Tachycardia (VT): Monomorphic
Page 60

■ In monomorphic VT, QRS complexes have the same shape and amplitude.
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60
Rate: 100–250 bpm
2142_Tab02_032-079.qxd

Rhythm: Regular
P Waves: None or not associated with the QRS
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance

Clinical Tip: It is important to confirm the presence or absence of pulses because monomorphic VT
ECGS

may be perfusing or nonperfusing.

Clinical Tip: Monomorphic VT will probably deteriorate into VF or unstable VT if sustained and not
treated.
 Ventricular Tachycardia (VT): Polymorphic
Page 61

■ In polymorphic VT, QRS complexes vary in shape and amplitude.

■ The QT interval is normal or long.
3:00 PM
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Rate: 100–250 bpm

Rhythm: Regular or irregular
P Waves: None or not associated with the QRS
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance

ECGS
Clinical Tip: It is important to determine whether pulses are present because polymorphic VT may
be perfusing or nonperfusing.
Clinical Tip: Consider electrolyte abnormalities as a possible cause.
 Torsade de Pointes
Page 62

■ The QRS reverses polarity and the strip shows a spindle effect.
■ This rhythm is an unusual variant of polymorphic VT with long QT intervals.
■ In French the term means “twisting of points.”
3:00 PM
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Rate: 200–250 bpm

Rhythm: Irregular
P Waves: None
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance
ECGS

Clinical Tip: Torsade de pointes may deteriorate to VF or asystole.

Clinical Tip: Frequent causes are drugs that prolong the QT interval, and electrolyte abnormalities
such as hypomagnesemia.
 Ventricular Fibrillation (VF)
Page 63

■ Chaotic electrical activity occurs with no ventricular depolarization or contraction.

■ The amplitude and frequency of the fibrillatory activity can define the type of fibrillation as coarse,
medium, or fine. Small baseline undulations are considered fine; large ones are coarse.
3:00 PM
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Rate: Indeterminate
Rhythm: Chaotic
P Waves: None
PR Interval: None
QRS: None

ECGS
Clinical Tip: There is no pulse or cardiac output. Rapid intervention is critical. The longer the delay,
the less the chance of conversion.
 Pulseless Electrical Activity (PEA)
Page 64

■ The monitor shows an identifiable electrical rhythm, but no pulse is detected.

■ The rhythm may be sinus, atrial, junctional, or ventricular.
■ PEA is also called electromechanical dissociation (EMD).
3:00 PM
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Rate: Reflects underlying rhythm

Rhythm: Reflects underlying rhythm
P Waves: Reflects underlying rhythm
PR Interval: Reflects underlying rhythm
QRS: Reflects underlying rhythm
ECGS

Clinical Tip: Potential causes of PEA are trauma, tension pneumothorax, thrombosis (pulmonary or
coronary), cardiac tamponade, toxins, hypo- or hyperkalemia, hypovolemia, hypoxia, hypoglycemia,
hypothermia, and hydrogen ion (acidosis).
 Asystole
Page 65

■ Electrical activity in the ventricles is completely absent.

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65

Rate: None
2142_Tab02_032-079.qxd

Rhythm: None
P Waves: None
PR Interval: None
QRS: None

Clinical Tip: Rule out other causes such as loose leads, no power, or insufficient signal gain.

ECGS
Clinical Tip: Seek to identify the underlying cause as in PEA. Also, search to identify VF.
 Atrioventricular (AV) Blocks
Page 66

■ AV blocks are divided into three categories: first, second, and third degree.

First-Degree AV Block
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Rate: Depends on rate of underlying rhythm

Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Prolonged (>0.20 sec)
ECGS

QRS: Normal (0.06–0.10 sec)

Clinical Tip: Usually a first-degree AV block is benign, but if associated with an acute MI it may lead
to further AV defects.
Clinical Tip: Often AV block is caused by medications that prolong AV conduction; these include
digoxin, calcium channel blockers, and beta blockers.
 Second-Degree AV Block—Type I
Page 67

(Mobitz I or Wenckebach)
■ PR intervals become progressively longer until one P wave is totally blocked and produces no QRS
complex. After a pause, during which the AV node recovers, this cycle is repeated.
3:00 PM

Blocked beat
X
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2142_Tab02_032-079.qxd

Rate: Depends on rate of underlying rhythm

Rhythm: Atrial: regular; ventricular: irregular
P Waves: Normal (upright and uniform), more P waves than QRS complexes
PR Interval: Progressively longer until one P wave is blocked and a QRS is dropped
QRS: Normal (0.06–0.10 sec)

ECGS
Clinical Tip: This rhythm may be caused by medication such as beta blockers, digoxin, and calcium
channel blockers. Ischemia involving the right coronary artery is another cause.
 Second-Degree AV Block—Type II
Page 68

(Mobitz II)
■ Conduction ratio (P waves to QRS complexes) is commonly 2:1, 3:1, or 4:1, or variable.
■ QRS complexes are usually wide because this block usually involves both bundle branches.
3:00 PM
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Rate: Atrial: usually 60–100 bpm; ventricular: slower than atrial rate
Rhythm: Atrial: regular; ventricular: regular or irregular
P Waves: Normal (upright and uniform); more P waves than QRS complexes
PR Interval: Normal or prolonged but constant
ECGS

QRS: May be normal, but usually wide (>0.10 sec) if the bundle branches are involved

Clinical Tip: Resulting bradycardia can compromise cardiac output and lead to complete AV block.
This rhythm often occurs with cardiac ischemia or an MI.
 Third-Degree AV Block
Page 69

■ Conduction between atria and ventricles is totally absent because of complete electrical block at or
below the AV node. This is known as AV dissociation.
■ “Complete heart block” is another name for this rhythm.
3:00 PM
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Rate: Atrial: 60–100 bpm; ventricular: 40–60 bpm if escape focus is junctional, <40 bpm if escape focus
is ventricular
Rhythm: Usually regular, but atria and ventricles act independently
P Waves: Normal (upright and uniform); may be superimposed on QRS complexes or T waves
PR Interval: Varies greatly

ECGS
QRS: Normal if ventricles are activated by junctional escape focus; wide if escape focus is ventricular

Clinical Tip: Third-degree AV block may be associated with ischemia involving the left coronary
arteries.
 Bundle Branch Block (BBB)
Page 70

■ Either the left or the right ventricle may depolarize late, creating a “wide” or “notched” QRS
complex.
3:00 PM

Notched QRS
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Rate: Depends on rate of underlying rhythm

Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12–0.20 sec)
QRS: Wide (>0.10 sec) with a notched appearance
ECGS

Clinical Tip: Bundle branch block commonly occurs in coronary artery disease.