Electrocardiogram

(ECG-iii)
Arrhythmias

Dr sanamajeed
MPhil physiology
Iimc
 Learning objectives

• By the end of this Lecture, all First year MBBS students

would be able to:

• Enumerate abnormal sinus rhythm.

 Case Scenario

A 57-year-old man presents to Pakistan Railway Hospital's

emergency department with complaints of shortness of
breath and chest pain radiating to the left arm and jaw for
the past 2 hours. On physical examination, he appears to be
in mild distress and tachycardia with a heart rate of 170bpm
and a blood pressure of 105/70mmHg. An electrocardiogram
(ECG) shows a  sinus tachycardia  with an elevation of the ST
segment, and T waves represent ventricular polarization. and
diagnosed as an acute myocardial infarction.
 Questions

• Why would this patient have tachycardia?

• What is approximate normal heart rate in Ventricular
arrhythmias?
• What are the most common ECG changes in Sinus
arrhythmias ?
• What would the ST segment of this ECG look like?
• What does the T wave represent?
 Arrhythmias

Arrhythmia refers to irregular heartbeat or disturbance in the

rhythm of heart.

Arrhythmias are any deviations from the normal sinus rhythm

 Classification:
• In arrhythmia, SA node may or may not be the pacemaker.

• If SA node is not the pacemaker, any other part of the heart such
as atrial muscle, AV node and ventricular muscle becomes the
pacemaker.

• Because of this, arrhythmia is classified into two types:

A. Normotopic arrhythmia

B. Ectopic arrhythmia.
 SA
NODE
 Normotopic arrhythmia:

• Normotopic arrhythmia is the irregular heartbeat, in which

SA node is the pacemaker.
• Normotopic arrhythmia is of three types:

1. Sinus 2. Sinus 3. Sinus

arrhythmia tachycardia bradycardia.
 Sinus arrhythmia:

Sinus arrhythmia is a
normal rhythmical It is also called
increase and decrease respiratory sinus
in heart rate, in relation arrhythmia (RSA).
to respiration.

Normal sinus rhythm means

the normal heartbeat in
which SA node is a
pacemaker.
Normal heart rate is 72 per
minute.

However, under physiological

conditions, in a normal healthy
person, Heart rate increases
during inspiration and decreases
during expiration.
 ECG Changes:
• ECG is normal during sinus arrhythmia.

• Only the duration of R-R interval varies rhythmically according to

phases of respiration.

It is shortened during inspiration and prolonged during expiration.

 Normotopic arrhythmia:

• Normotopic arrhythmia is the irregular heartbeat, in which

SA node is the pacemaker.
• Normotopic arrhythmia is of three types:

1. Sinus 2. Sinus 3. Sinus

arrhythmia tachycardia bradycardia.
 Sinus tachycardia:

• Sinus tachycardia is the increase in discharge of impulses

from SA node, resulting in increase in heart rate.

• The heart rate increases up to 100-150/minute.

 ECG Changes:

• ECG is normal in sinus tachycardia, except for short R-R

intervals because of increased heart rate.
 Normotopic arrhythmia:

• Normotopic arrhythmia is the irregular heartbeat, in which

SA node is the pacemaker.
• Normotopic arrhythmia is of three types:

1. Sinus 2. Sinus 3. Sinus

arrhythmia tachycardia bradycardia.
 Sinus bradycardia:

• Sinus bradycardia is the reduction in discharge of impulses

from SA node resulting in decrease in heart rate.

• Heart rate is less than 60/minute.

 ECG Changes:

• ECG shows prolonged waves and prolonged R-R interval.

 Vagal Stimulation as a Cause of Bradycardia

• Any circulatory reflex that stimulates the vagus nerves causes

release of Acetylcholine at the vagal endings in the heart, thus
giving a parasympathetic effect.

• The most striking example of this occurs in patients with carotid

sinus syndrome.
 Ectopic arrhythmias:

• Ectopic arrhythmia is the abnormal heartbeat, in which one

of the structures of heart other than SA node becomes the
pacemaker.

• Impulses produced by these structures are called ectopic foci.

 Heart block

• Heart block is the blockage of impulses generated by SA

node in the conductive system.

• Based on the area affected, the heart block is classified into

two types.

1. Sinoatrial block

2. Atrioventricular block
 Sinoatrial Block – AV Nodal Rhythm

• Blockage of impulse from the SA node before it enters into

the atrial muscle.

• It is also known as sinus block.

• Occur due to defect in internodal fibers.

 Sinoatrial Block – AV Nodal Rhythm

• Standstill of atria (no P wave) → AV node start generating

the impulses(become pacemaker)→Ventricles pick up a
new rhythm and heart start beating with the decrease rate
of 40 to 60/minute.(rate of ventricular QRS complex is slow,
otherwise not altered).
 ECG Changes

• No P wave.
• Slow rate of ventricular QRS complex.
 Atrioventricular Block:

In this condition, impulses cannot pass from atria into the

ventricles through AV bundles (bundle of His).
Causes:
Condition in which there is decrease rate of conduction or blockage
of conduction occur is as follows;
1. Ischemia of AV-node/AV bundles
2. Compression of AV bundles by the scar or calcified tissues
3. Inflammation of AV node( diphtheria, rheumatic fever)
4. Extreme Stimulation of heart by 10th nerve
 Types of AV block

• Atrioventricular block is of two categories:

1. Incomplete heart block

2. Complete heart block.

 Incomplete Heart Block

• In this condition, transmission of impulses from atria to

ventricles is slowed down but not blocked completely.

• Incomplete heart block is of two types:

i. First degree heart block

ii. Second degree heart block

 First degree heart block

• First degree heart block is the heart block in which the

conduction of impulses through AV node is very slow, i.e.
the AV nodal delay is longer.

• It is also called delayed conduction.

 ECG changes

• In ECG, the P-R interval is very much prolonged and is more

than 0.20 second(normal is 0.16 seconds).
 2nd degree heart block
• Second degree heart block is the type of heart block in which
some of the impulses pass through the ventricles and some
are not.

• At this time, P wave is present but there is no QRS-T wave

(dropped beats).

• If every other beat drops, rhythm is 2:1.

• 3:1 or 3:2 rhythm can be observed.

 ECG Changes
• In ECG, the ventricular complex (QRST) is missing
accordingly.
 Complete Heart Block-(Third degree heart block):
• Complete heart block is the condition in which the impulses produced
by SA node cannot reach the ventricles because of poor conduction in
AV node.

• It is also known as complete atrioventricular block or third degree

heart block.

• Because of this, the ventricles beat in their own rhythm by

establishing their own signals originated in AV node or AV bundle.

• This rhythm is independent of atrial beat.`

 Stokes-Adams Syndrome—Ventricular Escape.

• In some patients with A-V block, the total block comes and goes;
that is, impulses are conducted from the atria into the ventricles
for a period of time and then suddenly impulses are not conducted.

• At this time,Purkinje system beyond the block, usually in the distal

part of the A-V node begins discharging rhythmically at a rate of 15
to 40 times per minute and acting as the pacemaker of the
ventricles.
 ECG changes

• On ECG ,there is no relation between the rhythm of P wave

and rhythm of QRS complex.
 Extra-systole
• Extrasystole is the premature contraction of the heart before its
normal contraction.

• It is caused by an ectopic focus (discharge of an impulse from any part

of the heart other than the SA node).

• Parts of the heart which give origin for ectopic foci are AV node, atrial
musculature and ventricular musculature.
• The ectopic focus produces an extra beat of the heart that is always
followed by
a compensatory pause.
Atrial Extra-systole Nodal Extra-systole Ventricular
Ventricular Extra-systole
Extra-systole
• In this condition, a P • P wave is merged •• In
In this
this condition,
condition, anan
wave appears with QRS complex extra
extra QRS
QRS complex
complex
immediately after and all the follows
follows
This QRS the
the
complex
regular
regularalso
TT
the regular T wave. chambers of the wave.
wave.
has a
• P wave is small and heart contract •• This
This
high
QRS
QRSvoltage.
complex
complex is is
shapeless. together. • prolonged
prolonged
T wave of this
as
as the
the
beat is
• The P-R interval of impulse
impulse
inverted.is
is conducted
conducted
this beat is short. through
through ventricular
ventricular
muscle
muscle andand not
not
through
through thethe
conductive
conductive system.
system.
 Paroxysmal Tachycardia

• Paroxysmal tachycardia is the sudden attack of increased heart

rate due to ectopic foci arising from atria, AV node or ventricles.

• Paroxysmal tachycardia is of three types:

1. Atrial paroxysmal tachycardia

2. AV nodal paroxysmal tachycardia

3. Ventricular paroxysmal tachycardia

 Atrial Flutter

• Atrial flutter is an arrhythmia characterized by rapid

ineffective atrial contractions, caused by ectopic foci
originating from atrial musculature.

• Both the atria beats rapidly like the wings of a bird, hence
the name atrial flutter originate.
 Atrial Flutter

• Atrial rate is about 250 to 350/minute.

• Atrial flutter is common in patients suffering from

cardiovascular diseases.

• Initially, it is marked by palpitations that are unnoticed.

• However, prolonged atrial flutter may lead to atrial

fibrillation or heart failure.
ECG changes
 Atrial fibrillation

• Atrial fibrillation is the type of arrhythmia characterized by

rapid and irregular atrial contractions at the rate of 300 to
400 beats/minute.

• Atrial fibrillation is common in old people and patients with

heart diseases.
 ECG changes

• P wave is absent in ECG.

• QRS complex normal
 Ventricular Fibrillation

• Ventricular fibrillation is the most dangerous cardiac

arrhythmia, characterized by rapid and irregular twitching
of ventricles.

• Ventricles beat very rapidly and irregularly.

• The rate reaches to 400 to 500/minute.

 Mechanism
• Cardiac impulses within the ventricular muscle mass first
stimulate one portion of the ventricular muscle, then another
portion, then another, and eventually feeding back onto itself to
re-excite the same ventricular muscle over and over—never
stopping.

• When this happens, many small portions of the ventricular

muscle will be contracting at the same time, while other portions
will be relaxing.
• The ventricular chambers neither enlarge nor contract but remain in
an indeterminate stage of partial contraction, pumping either no
blood or negligible amounts-

• Unconsciousness occurs within 4 to 5 seconds for lack of blood flow

to the brain, and irretrievable death of tissues begins to occur
throughout the body within a few minutes.