Principles of ECG Diagnosis

3
Supraventricular Arrhythmias
Dr Ghazi Radaideh, MD, FRCP
Rashid Hospital
Dubai - UAE
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Things to Consider When Analyzing

Arrhythmias
Arrhythmias may be seen on 12-lead ECGs
or on strips of one or more leads.
Some arrhythmias are obvious at first
glance and don't require intense analysis.
Others, they require detective work and
logical thinking based on a knowledge of
cardiac electrophysiology.

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Reading 12-Lead ECG step-by-step

(RAWIHI)
1. Rate, Rhythm and Regularity
2. Determine the QRS Axis
3. Evaluate the Waves (P,QRS,T ) and
Intervals (PR,ST,QT)

4. Evaluate for chamber Hypertrophy

5. Look for myocardial Infarction and Ischemia
6. Interpret the ECG
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Supraventricular Arrhythmias
They are called
supraventricular
arrhythmias because they
originate in and involve
structures above the
ventricles.

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Arrhythmias
Supraventricular

Ventricular

Supraventricular Arrhythmias
Objectives:
1.Sinus Rhythm
2.Escapes& Premature atrial complexes
3. Atrial tachycardia & Multifocal atrial tachycardia
4.Atrial fibrillation
5.Atrial flutter
6.SVT (AVNRT, AVRT)
7.Junctional rhythms and tachycardias
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Normal Sinus Rhythm (NSR)

The electrical impulse is formed in the SA
node and conducted normally.

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Normal Sinus Rhythm Parameters

Rate
Regularity
P waves
PR interval
QRS duration

68 (Normal60 - 100 bpm)

regular
normal
0.16 (0.12 - 0.20 s)
0.08 (0.04 - 0.12 s)

Any deviation from above is sinus tachycardia,

sinus bradycardia or sinus arrhythmia
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Bradycardia
the normal sinus
rhythm slows.

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What is the ECG diagnosis?

Rate?
Regularity?
P waves?

30 bpm

PR interval?

0.12 s
0.10 s

regular
normal

QRS duration?
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Sinus bradycardia
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Tachycardia
the normal
sinus rhythm
fasts.

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What is the ECG diagnosis?

Rate?
Regularity?
P waves?

130 bpm

PR interval?

0.16 s
0.08 s

regular
normal

QRS duration?

Sinus tachycardia

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Sinus Arrhythmia
Variations in heart rate from beat
to beat that are greater than
would be expected from normal
respiratory variation.

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Escapes
When the dominant pacemaker( SAN) fails
to discharge, an escape beat arises from
special sites(Subsidiary pacemakers) within
the conduction system.
Slow and protective rhythms
sites and rate of escapes
sinoatrial node region = 70 per minute.
junctional region= 50 per minute.
ventricular focus= 30 per minute.
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Atrial Escape Complex

P wave that occurs later than would be
expected from the sinus rate( SLOWER
THAN THE BASELINE RATE)

If the focus is away from the sinoatrial node the P wave will be abnormal,
but followed with a normal QRS complex and T wave.
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Premature Atrial Contractions

Deviation from NSR
These ectopic beats originate in the
atria (but not in the SA node),
the contour of the P wave, the PR
interval, and the timing are different
than a normally generated pulse
from the SA node.

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Premature Atrial Contractions

Single

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Double

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Premature Atrial Contractions

Bigeminy

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Wandering pacemaker.
The origin of the atrial contraction may also vary or wander.

Consequently, the P-waves will vary in polarity, and the PR

interval will also vary.

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Atrial tachycardia
Typically arises from an ectopic source in the atrial
muscle:
Atrial rate of 150-250 beats/min.
The P waves may be abnormally shaped depending
on the site of the ectopic pacemaker
The ventricular rate depends on the degree of
atrioventricular block.
Increasing the degree of block with carotid sinus massage
or adenosine may aid the diagnosis.
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Atrial tachycardia Parameters

Rate of R?
Regularity?
P waves?
P to R ratio?
QRS duration?
Interpretation?
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190
Regular

regular

Abnormal
1:1
0.08 s
AT with 1:1 conduction
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Atrial tachycardia with AV block

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Multifocal Atrial Tachycardia (MAT)

and rhythm
Multifocal atrial
tachycardia occurs
when multiple sites
in the atria are
discharging

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Multifocal Atrial Tachycardia (MAT)

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Atrial Fibrillation

Atrial Fibrillation

Atrial activity is poorly defined; may see course

or fine undulations or no atrial activity at all.
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Atrial fibrillation Parameters

Rate?
Regularity?
P waves?

140 bpm

PR interval?

none
0.06 s

irregularly irregular
none

QRS duration?
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AF with rapid ventricular response :

(note : irregularly irregular rhythm)

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 Atrial Flutter
Sustained by a
macro-reentrant
circuit in the lower
Rt. atrium.

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Atrial flutter Parameters

Rate?
Regularity?
P waves?

70 bpm

PR interval?

none
0.06 s

regular
flutter waves

QRS duration?
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Atrial flutter with 2:1 ratio

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PSVT Parameters

Rate?
Regularity?
P waves?

74 148 bpm
Regular
regular

PR interval?

0.16 s
0.08 s

Normal

QRS duration?
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none
none

AV Nodal Reentrant Tachycardia

(AVNRT):
The retrograde P wave is often
simultaneous with the QRS and, therefore,
not seen on the ECG.

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1. Orthodromic AVRT
Orthodromic AVRT

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2.Antidromic Tachycardia

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Antidromic AVRT

Antidromic AVRT

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AV Junctional Dysrhythmias
Junctional
dysrhythmias originate
in the AV junction

The impulse
is conducted
differently
than SA and
retrograde
conduction
may be seen.

if the SA node does not fire or is blocked, escape

mechanisms of the AV junction and ventricle are part
of the system.
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Junctional Escape Beats

(nodal escape Beats)
Junctional dysrhythmias
originate in the AV
junction

The beat after the delay will show no P wave (either due to an absence of
atrial contraction or because it is partially lost within the QRS complex) .
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AV Junctional Rhythm
This is a sequence of 3 or more junctional
escapes.
With the junctional rhythm, the AV junction
is the pacemaker controlling the heart rate

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Parameters of AV Junctional Rhythm

40 - 60beats
Regular
Inverted. Appears either before,
after, or during the QRS.
PR interval: < 0.12 sec if seen before the QRS.
QRS :
Normal

Rate:
Rhythm:
P wave:

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Accelerated AV Junctional Rhythm

If the rate of junctional rhythm is 60-100 b/m is
called accelerated junctional rhythm

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Accelerated junctional rhythm

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Tachyarhythmias
Narrow complex
Regular

ST
AT
SVT
AFL
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Wide complex

Irregular

Regular

AF

VT

MAT
AFL /AT with
variable AV
conduction
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SVT
With abberant
conduction

Irregular

AF with
accessory
pathway

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