CONCEPTS OF ATRIAL AND

VENTRICULAR ARRHYTMIAS
Ketut Erna Bagiari, MD
ECTOPIC IMPULSE
Any impulse that does
not originate from the
sinus node is an ectopic
impulse
➢Ventricular origin
➢Supraventricular
origin
SUPRAVENTRICULAR COMPLEX
❑ Premature supraventricular complex:
Premature atrial complex
Premature junctional complex

❑ Late or escape supraventricular complex

PREMATURE AND LATE ATRIAL COMPLEXES
BLOCKED PAC
PAC WITH PROLONGED PR INTERVAL
PAC WITH ABERRANCY
• A pause is fully compensatory if the distance between two sinus complexes straddling a PAC is
the same as the distance between two sinus complexes straddling a normal sinus impulse.
ECG FINDINGS OF PREMATURE ATRIAL COMPLEXES

P wave and PR interval

• The P wave is premature and is inscribed before the QRS complex.
• The P wave may be difficult to recognize if it is hidden in the T wave of the previous complex or is isoelectric in the lead used for
monitoring.
• The P wave is ectopic and therefore has a different contour when compared with the sinus impulse.
• The PR interval may be normal (≥0.12 seconds) or it may be prolonged (0.20 seconds).
• The P wave may be blocked and not followed by a QRS complex; thus, only a pause may be present.

QRS complex
• QRS is narrow
• The QRS complex may be wide when the impulse is conducted to the ventricles aberrantly or there is preexistent bundle branch
block
• A QRS complex may not be present if the PAC is blocked.

Compensatory pause
The pause after the PAC is usually not fully compensatory
ATRIAL ARRHYTMIA
•Atrial flutter
•Atrial fibrillation
•Atrial Tachycardia
ECG FINDING OF ATRIAL FLUTTER
• Atrial rate of 300 50 bpm with a minimum atrial rate of 240 to 250
bpm.
• Very regular and uniform flutter waves with a saw tooth or picket
fence appearance.
• Flutter waves are typically inverted in leads II, III, and aVF and upright
in V1 in 90% of cases, although this may be reversed in 10% of cases,
`becoming upright in leads II, III, and aVF and inverted in V1.
ATRIAL FLUTTER
CLASSIFICATION ATRIAL FLUTTER BASED ON ECG PRESENTATION
ATRIAL FIBRILLATION
ECG FINDING IN AF
o Fibrillatory waves are present in baseline ECG representing
disorganized atrial activity
o The R-R intervals are irregularly irregular
o The ventricular rate is variable and depends on the number of atrial
impulses conducted through the AV node
o The QRS complexes are narrow unless there is preexistent bundle
branch block, ventricular aberration, or preexcitation
MECHANISM OF AF
CAROTID SINUS STIMULATION IN DIFFERENTIATING AF FROM OTHER
NARROW COMPLEX SUPRAVENTRICULAR ARRHYTHMIAS
AF WITH WPW
Atrial Tachycardia

• Focal Atrial Tachycardia

• Multifocal Atrial Tachycardia

ECG FINDING IN FOCAL ATRIAL TACHYCARDIA
• Presence of a regular narrow complex tachycardia >100 bpm
• Ectopic P waves, which are different from sinus P waves, precede the QRS complexes
usually with a PR interval ≥0.12 seconds
• The P waves are uniform and the atrial rate varies to as high as 250 bpm
• The baseline between the P waves is usually flat or isoelectric and not wavy or
undulating as in atrial flutter.
• Second-degree or higher grades of AV block may occur because the tachycardia is not
dependent on the AV node.
• The tachycardia terminates with a QRS complex in contrast to reentrant SVT
(atrioventricular nodal reentrant tachycardia [AVNRT] and atrioventricular reentrant
tachycardia [AVRT]), which usually terminates with a retrograde P wave
LOCALIZING TACHYCARDIA

• If the ectopic focus is in the

right atrium(A),the P waves
are inverted in V1 or if
biphasic are initially upright
and terminally negative. In
lead aVL, the P waves are
upright or biphasic
• If the ectopic focus is in the
left atrium(B),the P waves
are positive in V1.If biphasic,
the P waves are initially
inverted and terminally
upright. In lead aVL, the P
waves are isoelectric (flat)or
inverted
LOCALIZING TACHYCARDIA

If the P waves are

upright in II,III and aVF,
the origin of the
tachycardia is in the
superior right or left
atria

If the P waves are

inverted in II, III, and
aVF, the origin of the
tachycardia is in the
inferior right or left atria
MULTIFOCAL ATRIAL TACHYCARDIA

ECG Findings of MAT

• At least three consecutive P waves with different morphologies with a
rate >100 bpm
• The PR as well as the R-R interval is variable with isoelectric baseline
between P waves.
VENTRICULAR ARRHYTMIA

Nonsustained ventricular tachycardia (VT)

• Monomorphic
• Polymorphic
Sustained VT
• Monomorphic
• Polymorphic
Torsades de pointes

Ventricular flutter

Ventricular fibrillation
PVC
Focus Unifocal

Multifocal

Pattern Bigeminy
Trigemini
Quadrigeminy
Paired
Unifocal

Multifocal
 BIGEMINI

TRIGEMINI

QUADRIGEMINI
INTERPOLATED PVC
LOCALIZING THE ORIGIN OF THE PREMATURE VENTRICULAR COMPLEX (PVC)
WHERE IS THE ORIGIN ?
POLIMORFIK VT
NON SUSTAINED VT
TORSADE DE POINTES
VENTRICULAR FLUTTER
TERIMA KASIH