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Chapter 4

Atrial Arrhythmias

OVERVIEW

Atrial rhythms originate in the atria. Their common electrocardiogram (ECG) features are P waves that dif- fer in appearance from sinus P waves and normal- duration QRS complexes if no ventricular conduction disturbances are present. Atrial rhythms described in this chapter include:

Wandering atrial pacemaker

Multifocal atrial tachycardia

Premature atrial contraction

Atrial tachycardia

Supraventricular tachycardia

Paroxysmal supraventricular tachycardia

Atrial flutter

Atrial fibrillation

Wolff-Parkinson-White

flutter • Atrial fibrillation • Wolff-Parkinson-White Clinical Tip: All ECG strips in this chapter were recorded

Clinical Tip:

All ECG strips in this chapter were recorded in lead II.

WANDERING ATRIAL PACEMAKER

The pacemaker site transfers from the sinoatrial (SA) node to other latent pacemaker sites in the atria and the atrioventricular (AV) junction and then moves back to the SA node.

(AV) junction and then moves back to the SA node. Rate: Normal (60–100 beats/minute [bpm]) P

Rate: Normal (60–100 beats/minute [bpm])

P Waves: At least three different forms, determined by focus in atria

Rhythm: Irregular

PR Interval: Variable; determined by focus

QRS: Normal (0.06–0.10 seconds [sec])

by focus QRS: Normal (0.06–0.10 seconds [sec]) Clinical Tip: Wandering atrial pacemaker may occur in

Clinical Tip:

Wandering atrial pacemaker may occur in normal hearts as a result of fluctuations in vagal tone. It may also be seen in patients with heart disease or chronic obstructive pulmonary disease (COPD).

39

40 ECG Mastery

MULTIFOCAL ATRIAL TACHYCARDIA

This form of wandering atrial pacemaker is associated with a ventricular response of greater than 100 bpm.

Multifocal atrial tachycardia may be confused with atrial fibrillation; however, multifocal atrial tachycardia has a visible P wave.

however, multifocal atrial tachycardia has a visible P wave. Rate: Fast (greater than 100 bpm) P

Rate: Fast (greater than 100 bpm)

P Wave: At least three different

forms, determined by focus in atria

Rhythm: Irregular

PR Interval: Variable; determined by focus

QRS: Normal (0.06–0.10 sec)

Variable; determined by focus QRS: Normal (0.06–0.10 sec) Clinical Tip: Multifocal atrial tachycardia is commonly

Clinical Tip:

Multifocal atrial tachycardia is commonly seen in patients with chronic obstructive pulmonary disease but may also occur in acute myocardial infarction.

PREMATURE ATRIAL CONTRACTION

A single contraction occurs earlier than the next expected sinus contraction.

After the premature atrial contraction (PAC), sinus rhythm usually resumes.

atrial contraction (PAC), sinus rhythm usually resumes. Rate: Depends on rate of underlying rhythm P Waves:

Rate: Depends on rate of underlying rhythm

P Waves: Present; in the PAC, may

have a different shape

Rhythm: Irregular whenever a PAC occurs

PR Interval: Varies in the PAC; otherwise normal (0.12–0.20 sec)

QRS: Normal (0.06–0.10 sec)

normal (0.12–0.20 sec) QRS: Normal (0.06–0.10 sec) Clinical Tip: In patients with heart disease, frequent

Clinical Tip:

In patients with heart disease, frequent PACs may precede paroxysmal supraventricular tachycardia, atrial fibrillation, or atrial flutter.

Chapter 4

Atrial Arrhythmias

41

ATRIAL TACHYCARDIA

A rapid atrial rate overrides the SA node and becomes the dominant pacemaker.

Some ST wave and T wave abnormalities may be present.

• Some ST wave and T wave abnormalities may be present. Rate: 150–250 bpm P Waves:

Rate: 150–250 bpm

P Waves: Normal (upright and

uniform) but differ in shape from sinus P waves

Rhythm: Regular

PR Interval: May be short (less than 0.12 sec) in rapid rates

QRS: Normal (0.06–0.10 sec) but can be aberrant at times

SUPRAVENTRICULAR TACHYCARDIA

Supraventricular tachycardia has such a fast rate that the P waves may not be seen. They are frequently buried in the T waves.

may not be seen. They are frequently buried in the T waves. Rate: 150–250 bpm P

Rate: 150–250 bpm

P Waves: Frequently buried in

preceding T waves and difficult

to see

Rhythm: Regular

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:but may be wide if abnormally conducted through ventricles Supraventricular tachycardia may be related to caffeine

Supraventricular tachycardia may be related to caffeine intake, nicotine, stress, or anxiety in healthy adults.

Clinical Tip:intake, nicotine, stress, or anxiety in healthy adults. Some patients may experience angina, hypotension,

Some patients may experience angina, hypotension, lightheadedness, palpitations, and intense anxiety.

42 ECG Mastery

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

Paroxysmal supraventricular tachycardia is a rapid rhythm that starts and stops suddenly.

For accurate interpretation, the beginning or end of the paroxysmal supraventricular tachycardia must be seen.

Paroxysmal supraventricular tachycardia is sometimes called paroxysmal atrial tachycardia.

is sometimes called paroxysmal atrial tachycardia. Rate: 150–250 bpm P Waves: Frequently buried in

Rate: 150–250 bpm

P Waves: Frequently buried in

preceding T waves and difficult to see

Rhythm: Irregular

PR Interval: Usually not possible to measure

QRS: Normal (0.06–0.10 sec) but may be wide if abnormally conducted through ventricles

but may be wide if abnormally conducted through ventricles Clinical Tip: The patient may feel palpitations,

Clinical Tip:

The patient may feel palpitations, dizziness, lightheadedness, or anxiety.

ATRIAL FLUTTER

The AV node conducts impulses to the ventricles at a 2:1, 3:1, 4:1, or greater ratio (rarely 1:1).

The degree of AV block may be consistent or variable.

• The degree of AV block may be consistent or variable. Rate: Atrial: 250–350 bpm; ventricular:

Rate: Atrial: 250–350 bpm; ventricular: variable.

P Waves: Flutter waves have a

saw-toothed appearance; some may not be visible, being buried in QRS

Rhythm: Atrial: regular; ventricular: variable

PR Interval: None, not measurable

QRS: Usually normal (0.06– 0.10 sec), but may appear widened if flutter waves are buried in the QRS

may appear widened if flutter waves are buried in the QRS Clinical Tip: The presence of

Clinical Tip:

The presence of atrial flutter may be the first indication of cardiac disease.

flutter may be the first indication of cardiac disease. Clinical Tip: Signs and symptoms depend on

Clinical Tip:

Signs and symptoms depend on the ventricular response rate.

Chapter 4

Atrial Arrhythmias

43

ATRIAL FIBRILLATION

Rapid, erratic electrical discharge comes from multiple atrial ectopic foci.

No organized atrial depolarization are detectable.

• No organized atrial depolarization are detectable. Rate: Atrial: equal to or greater than 350 bpm;

Rate: Atrial: equal to or greater than 350 bpm; ventricular: variable

P Waves: No true P waves; chaotic

atrial activity

PR Interval: None

Rhythm: Irregular

QRS: Normal (0.06–0.10 sec)

None Rhythm: Irregular QRS: Normal (0.06–0.10 sec) Clinical Tip: Atrial fibrillation is often a chronic

Clinical Tip:

Atrial fibrillation is often a chronic arrhythmia associated with underlying heart disease.

arrhythmia associated with underlying heart disease. Clinical Tip: Signs and symptoms depend on the ventricular

Clinical Tip:

Signs and symptoms depend on the ventricular response rate.

WOLFF-PARKINSON-WHITE SYNDROME

In Wolff-Parkinson-White Syndrome, an accessory conduction pathway is present between the atria and the ventricles. Electrical impulses may be rapidly conducted to the ventricles.

These rapid impulses create a slurring of the initial portion of the QRS; the slurred effect is called a delta wave.

of the QRS; the slurred effect is called a delta wave. Rate: Depends on rate of

Rate: Depends on rate of underlying rhythm

Rhythm: Regular unless associated with atrial fibrillation

P Waves: Normal (upright and

uniform) unless atrial fibrillation is present

PR Interval: Short (less than 0.12 sec)

QRS: Wide (greater than 0.10 sec); delta wave present

sec) QRS: Wide (greater than 0.10 sec); delta wave present Clinical Tip: Wolff-Parkinson-White Syndrome is associated

Clinical Tip:

Wolff-Parkinson-White Syndrome is associated with narrow-complex tachycardias, including atrial flutter and atrial fibrillation.

44 ECG Mastery

It is important to distinguish the variables with each arrhythmia to properly identify the ECG. The summary of identifying ECG features for atrial arrhythmias is presented in TABLE 4-1.

Table 4.1 ATRIAL ARRHYTHMIAS: IDENTIFYING FEATURES

Name

Rate

Rhythm

P Waves

PR Interval

QRS

Wandering atrial

Normal (60–

Irregular

At least three

Variable;

Normal (0.06–

pacemaker

100

bpm)

different forms, determined by focus in atria

determined

 

0.10

sec)

 

by focus

 

Multifocal atrial

Fast (greater

Irregular

At least three different forms,

Variable;

Normal (0.06–

tachycardia

than

determined

 

0.10

sec)

100

bpm)

determined by focus in atria

by focus

 

Premature atrial

Depends on

Irregular

Present; in the PAC, may have a differ- ent shape

Varies in

Normal (0.06–

contraction

rate of

whenever

the PAC;

 

0.10

sec)

underlying

a PAC

otherwise

 

rhythm

occurs

normal

 

(0.12–

0.20

sec)

Atrial tachycardia

150–250 bpm

Regular

Normal (upright and uniform) but differ in shape from sinus P waves

May be short (less than

Normal (0.06–

   

0.10

sec) but

0.12

sec) in

can be aberrant

rapid rates

 

at times

Supraventricular

150–250 bpm

Regular

Frequently buried

Usually not

Normal (0.06–

tachycardia

in preceding

possible to

 

0.10

sec) but

T

waves and

measure

may be wide if abnormally conducted through ventricles

difficult to see

 

Paroxysmal

150–250 bpm

Irregular

Frequently buried

Usually not

Normal (0.06–

supraventricular

in preceding

possible to

 

0.10

sec) but

tachycardia

T

waves and

measure

may be wide if abnormally conducted through ventricles

difficult to see

 

Atrial flutter

Atrial: 250–

Atrial:

Flutter waves

None, not

Usually normal (0.06–0.10 sec), but may appear widened if flutter waves are buried in the QRS

 

350

bpm;

regular;

have a

measurable

ventricular:

ventricular:

saw-toothed

variable

variable

appearance;

 

some may not

be visible,

being buried

in QRS

 

Atrial fibrillation

Atrial: equal

Irregular

No true P waves;

None

Normal (0.06–

 

to or

chaotic

 

0.10

sec)

greater than

 

atrial

 

350

bpm;

activity

ventricular:

 

variable

Wolff-Parkinson-

Depends on

Regular

Normal (upright

Short (less

Wide (greater than 0.10 sec);

White Syndrome

rate of

unless

and uniform)

than

underlying

associated

unless atrial

0.12

sec)

delta wave present

rhythm

with atrial

fibrillation is

 
 

fibrillation

present

 

Chapter 4

Atrial Arrhythmias

45

Chapter 4 Review

This review tests your understanding of the content introduced in this chapter. Follow the instructions for each exercise and check your answers at the end of the chapter.

MULTIPLE CHOICE: ATRIAL ARRHYTHMIAS

Select the best answer for each of the following ques- tions by circling the letter.

1. The 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.

A. Multifocal atrial tachycardia

B. Premature atrial contraction

C. Wandering atrial pacemaker

D. Wolff-Parkinson-White Syndrome

2. This form of wandering atrial pacemaker is asso- ciated with a ventricular response of greater than 100 bpm.

A. Premature atrial contraction

B. Wolff-Parkinson-White Syndrome

C. Atrial flutter

D. Multifocal atrial tachycardia

3. P waves have a saw-toothed appearance; some may not be visible, being buried in the QRS.

A. Atrial flutter

B. Wandering atrial pacemaker

C. Wolff-Parkinson-White Syndrome

D. Multifocal atrial tachycardia

4. Rapid, erratic electrical discharge comes from multiple atrial ectopic foci; no true P waves, chaotic atrial activity; no PR interval and irregular R-R intervals.

A.

Wolff-Parkinson-White Syndrome

B.

Atrial fibrillation

C.

Normal sinus rhythm

D.

Atrial tachycardia

5. rapid atrial rate overrides the SA node and

A

becomes the dominant pacemaker; the P waves are normal (upright and uniform) but differ in shape from sinus P waves.

A. Wolff-Parkinson-White Syndrome

B. Atrial tachycardia

C. Normal sinus rhythm

D. Premature atrial contraction

6. This arrhythmia has such a fast rate that the

P waves may not be seen; the rate is between 150–250 bpm.

A.

Normal sinus rhythm

B.

Premature atrial contraction

C.

Supraventricular tachycardia

D.

Wolff-Parkinson-White Syndrome

7. single contraction occurs earlier than the next

A

expected sinus contraction.

A. Premature atrial contraction

B. Wandering atrial pacemaker

C. Wolff-Parkinson-White Syndrome

D. Premature ventricular contraction

ECG PRACTICE STRIPS: ATRIAL ARRHYTHMIAS

For instructions on analyzing the ECG strips, please see the guidelines given at the end of Chapter 2.

ECG 4•1

see the guidelines given at the end of Chapter 2. ECG 4•1 Rate: Rhythm: P Waves:

Rate:

Rhythm:

P Waves:

 

PR Interval:

QRS:

Interpretation:

 

46 ECG Mastery

ECG 4•2

46 ECG Mastery ECG 4•2 Rate: P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•3 Rate:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•3

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•3 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•4

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•4 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

Chapter 4

Atrial Arrhythmias

47

ECG 4•5

Chapter 4 Atrial Arrhythmias 47 ECG 4•5 Rate: P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•6

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•6 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•7

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•7 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

48 ECG Mastery

ECG 4•8

48 ECG Mastery ECG 4•8 Rate: P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•9 Rate:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•9

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•9 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

Chapter 4

Atrial Arrhythmias

49

ECG CHALLENGE PRACTICE STRIPS

Take the ECG challenge! The following ECG strips build on what you learned from Chapter 3: Sinoatrial Node Arrhythmias and Chapter 4: Atrial Arrhythmias.

ECG 4•10

Arrhythmias and Chapter 4: Atrial Arrhythmias. ECG 4•10 Hint: Notice the P waves are normal but

Hint: Notice the P waves are normal but encroach on the preceding T waves. Notice the P waves are normal but encroach on the preceding T waves.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•11

Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•11 Hint: Look closely at the ST segment depression

Hint: Look closely at the ST segment depression and inverted T waves. Look closely at the ST segment depression and inverted T waves.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

50 ECG Mastery

ECG 4•12

50 ECG Mastery ECG 4•12 Hint: A peaked T wave usually indicates hyperkalemia. Rate: P Waves:
50 ECG Mastery ECG 4•12 Hint: A peaked T wave usually indicates hyperkalemia. Rate: P Waves:

Hint: A peaked T wave usually indicates hyperkalemia.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•13

Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•13 Rate: P Waves: Interpretation: Rhythm: PR Interval: QRS:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•14

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•14 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

Chapter 4

Atrial Arrhythmias

51

ECG 4•15

Chapter 4 Atrial Arrhythmias 51 ECG 4•15 Rate: P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•16

Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•16 Rate: P Waves: Interpretation: Rhythm: PR Interval: QRS:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•17

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•17 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

52 ECG Mastery

ECG 4•18

52 ECG Mastery ECG 4•18 Hint: Notice the pause after beats 3 and 5. Rate: P
52 ECG Mastery ECG 4•18 Hint: Notice the pause after beats 3 and 5. Rate: P

Hint: Notice the pause after beats 3 and 5.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•19

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•19 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

Chapter 4

Atrial Arrhythmias

53

ECG 4•20

Chapter 4 Atrial Arrhythmias 53 ECG 4•20 Hint: Look closely for the “U” waves. Rate: P

Hint: Look closely for the “U” waves. Look closely for the “U” waves.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•21

Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•21 Hint: Use the Precise Heart Rate Calculation: 1,500/39

Hint: Use the Precise Heart Rate Calculation: 1,500/39 = 38.46 rounded to 38. Or, 38 bpm. Use the Precise Heart Rate Calculation: 1,500/39 = 38.46 rounded to 38. Or, 38 bpm.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

54 ECG Mastery

ECG 4•22

54 ECG Mastery ECG 4•22 Hint: Notice the ST segment elevation. Rate: P Waves: Interpretation: Rhythm:
54 ECG Mastery ECG 4•22 Hint: Notice the ST segment elevation. Rate: P Waves: Interpretation: Rhythm:

Hint: Notice the ST segment elevation.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•23

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•23 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

Chapter 4

Atrial Arrhythmias

55

ECG 4•24

Chapter 4 Atrial Arrhythmias 55 ECG 4•24 Hint: Notice the change in rhythm at the 3-sec

Hint: Notice the change in rhythm at the 3-sec mark. Notice the change in rhythm at the 3-sec mark.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•25

Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•25 Hint: Notice the block between beats 6 and

Hint: Notice the block between beats 6 and 7. Notice the block between beats 6 and 7.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

56 ECG Mastery

ECG 4•26

56 ECG Mastery ECG 4•26 Hint: Notice the ST segment depression. Rate: P Waves: Interpretation: Rhythm:
56 ECG Mastery ECG 4•26 Hint: Notice the ST segment depression. Rate: P Waves: Interpretation: Rhythm:

Hint: Notice the ST segment depression.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•27

P Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•27 Rate: P Waves: Interpretation: Rhythm: PR Interval:

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

Chapter 4

Atrial Arrhythmias

57

ECG 4•28

Chapter 4 Atrial Arrhythmias 57 ECG 4•28 Hint: Notice the change in rhythm at the 3-sec

Hint: Notice the change in rhythm at the 3-sec mark. Notice the change in rhythm at the 3-sec mark.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

ECG 4•29

Waves: Interpretation: Rhythm: PR Interval: QRS: ECG 4•29 Hint: Remember sinus arrhythmia has an irregular rhythm

Hint: Remember sinus arrhythmia has an irregular rhythm that varies with respiration. Remember sinus arrhythmia has an irregular rhythm that varies with respiration.

Rate:

P Waves:

Interpretation:

Rhythm:

PR Interval:

QRS:

58 ECG Mastery

ECG 4•30

58 ECG Mastery ECG 4•30 Hint: Notice the long PR interval. Rate: Rhythm: P Waves:  
58 ECG Mastery ECG 4•30 Hint: Notice the long PR interval. Rate: Rhythm: P Waves:  

Hint: Notice the long PR interval.

Rate:

Rhythm:

P Waves:

 

PR Interval:

QRS:

Interpretation:

 

Answers to Chapter 4 Review

MULTIPLE CHOICE

1. C

2. D

3. A

4. B

5. B

6. C

7. A

ECG PRACTICE STRIPS AND ECG CHALLENGE

ECG 4•1

Rate: 214 bpm (1,500/7 = 214.28 rounded to 214) Rhythm: Regular P Waves: Buried in T waves PR Interval: None, not measurable QRS: 0.08 sec Interpretation: Supraventricular tachycardia

ECG 4•2

Rate: 94 bpm (1,500/16 = 93.75 rounded to 94) Rhythm: Regular

P Waves: Flutter waves

PR Interval: None QRS: 0.10 sec Interpretation: Atrial flutter with 3:1 AV block (every third flutter wave is buried in the QRS—this can be seen by marching out the flutter waves with calipers)

ECG 4•3

Rate: 214 bpm (1,500/7 = 214.28 rounded to 214) Rhythm: Regular

P Waves: Not clearly visible, buried in T waves

PR Interval: None, not measurable QRS: 0.08 sec Interpretation: Supraventricular tachycardia with ST segment depression

ECG 4•4

Rate: 140 bpm (counting all beats), 188 bpm in beats 1 through 10, 83 bpm in beats 11 through 14 Rhythm: Irregular (due to change in rhythm)

P Waves: Buried in T waves in beats 1 through 10,

normal in beats 11 through 14 PR Interval: None in beats 1 through 10, 0.16 sec in beats 11 through 14 QRS: 0.10 sec Interpretation: Paroxysmal supraventricular tachy- cardia (supraventricular tachycardia converting to normal sinus rhythm)

Chapter 4

Atrial Arrhythmias

59

ECG 4•5

Rate: 60 bpm

Rhythm: Irregular (due to R-R intervals)

P Waves: None

PR Interval: None QRS: 0.10 sec Interpretation: Atrial fibrillation (irregular with fibrillatory baseline)

ECG 4•6

Rate: 50 bpm (counting PACs)

Rhythm: Irregular (due to PACs)

P Waves: Normal

PR Interval: 0.20 sec QRS: 0.08 sec Interpretation: Sinus bradycardia with two bigeminal PACs at beats 2 and 4

ECG 4•7

Rate: 50 bpm Rhythm: Irregular (due to the variable AV block)

P Waves: Flutter waves

PR Interval: None QRS: 0.08 sec Interpretation: Atrial flutter with variable AV block

ECG 4•8

Rate: 180 bpm

Rhythm: Irregular (due to R-R intervals)

P Waves: None

PR Interval: None QRS: 0.08 sec Interpretation: Atrial fibrillation (irregular with fibrillatory baseline)

ECG 4•11

Rate: 88 bpm Rhythm: Regular

P Waves: Normal

PR Interval: 0.20 sec QRS: 0.10 sec Interpretation: Normal sinus rhythm with ST segment depression and inverted T waves

ECG 4•12

Rate: 79 bpm Rhythm: Regular

P Waves: Normal

PR Interval: 0.12 sec QRS: 0.08 sec Interpretation: Normal sinus rhythm with peaked T waves

ECG 4•13

Rate: 50 bpm Rhythm: Regular

P Waves: Normal

PR Interval: 0.20 sec QRS: 0.08 sec Interpretation: Sinus bradycardia

ECG 4•14

Rate: 40 bpm Rhythm: Regular

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.10 sec Interpretation: Sinus bradycardia

ECG 4•15

ECG 4•9

Rate: 125 bpm

Rate: 120 bpm

Rhythm: Regular

Rhythm: Irregular (due to change in rhythm)

P Waves: Normal

P

Waves: Normal in first three beats, buried in

PR Interval: 0.12 sec

ECG 4•16

T waves in remaining beats PR Interval: 0.16 sec in first three beats QRS: 0.10 sec Interpretation: Paroxysmal supraventricular tachy-

QRS: 0.08 sec Interpretation: Sinus tachycardia

cardia (sinus bradycardia converting to supraven-

Rate: 125 bpm

tricular tachycardia)

Rhythm: Regular

P Waves: Normal

ECG 4•10

PR Interval: 0.16 sec

Rate: 136 bpm

QRS: 0.10 sec

Rhythm: Regular

Interpretation: Sinus tachycardia with ST segment

P

Waves: Normal but encroach on preceding T waves

depression

PR Interval: 0.12 sec QRS: 0.08 sec Interpretation: Sinus tachycardia

60 ECG Mastery

ECG 4•17

Rate: 100 bpm

Rhythm: Irregular (due to R-R intervals)

P Waves: None

PR Interval: None QRS: 0.10 sec Interpretation: Atrial fibrillation with ST segment depression and inverted T waves

ECG 4•18

Rate: 70 bpm (counting pauses)

Rhythm: Irregular (due to pauses)

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.08 sec Interpretation: Normal sinus rhythm with two 1.28 second pauses (sinus arrest) after beats 3 and 5

ECG 4•19

Rate: 50 bpm (counting PAC), 47 bpm in underlying rhythm Rhythm: Irregular (due to PAC)

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.10 sec Interpretation: Sinus bradycardia with ST segment depression, inverted T waves, and a PAC at beat 2

ECG 4•20

Rate: 65 bpm Rhythm: Regular

P Waves: Normal

PR Interval: 0.20 sec QRS: 0.08 sec Interpretation: Normal sinus rhythm with U waves

ECG 4•21

Rate: 38 bpm (calculated by 1,500/39 = 38) Rhythm: Regular

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.10 sec Interpretation: Sinus bradycardia

ECG 4•22

ECG 4•23

Rate: 47 bpm Rhythm: Regular

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.10 sec Interpretation: Sinus bradycardia

ECG 4•24

Rate: 70 bpm; 120 bpm in first section, 39 bpm in second section Rhythm: Irregular (due to change in rhythm)

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.10 sec Interpretation: Sinus tachycardia changing to sinus bradycardia

ECG 4•25

Rate: 110 bpm (counting block), 125 bpm in underlying rhythm Rhythm: Irregular (due to block)

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.08 sec Interpretation: Sinus tachycardia with a sinoatrial (SA) block (0.92 second block) between beats 6 and 7

ECG 4•26

Rate: 79 bpm Rhythm: Regular

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.08 sec Interpretation: Normal sinus rhythm with ST segment depression

ECG 4•27

Rate: 50 bpm

Rhythm: Irregular (due to sinus arrhythmia)

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.08 sec Interpretation: Sinus bradycardia with sinus arrhythmia with inverted T waves

Rate: 88 bpm

Rhythm: Regular

ECG 4•28

P Waves: Normal

PR Interval: 0.18 sec QRS: 0.08 sec Interpretation: Normal sinus rhythm with ST segment elevation

Rate: 60 bpm (counting all beats); 38 bpm in first section, 98 bpm in second section Rhythm: Irregular (due to change in rhythm)

P Waves: Normal

PR Interval: 0.16 sec QRS: 0.10 sec Interpretation: Sinus bradycardia changing to

normal sinus rhythm

Chapter 4

Atrial Arrhythmias

61

ECG 4•29

Rate: 50 bpm Rhythm: Irregular (due to sinus arrhythmia) P Waves: Normal PR Interval: 0.12 sec QRS: 0.08 sec Interpretation: Sinus bradycardia with sinus arrhythmia

ECG 4•30

Rate: 40 bpm Rhythm: Regular P Waves: Normal PR Interval: 0.52 sec QRS: 0.10 sec Interpretation: Sinus bradycardia with first-degree AV block