Ecg Tutorial: Pacemakers: Official Reprint From Uptodate ©2020 Uptodate, Inc. And/Or Its Affiliates. All Rights Reserved

21/9/2020 ECG tutorial: Pacemakers - UpToDate
Official reprint from UpToDate®

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ECG tutorial: Pacemakers

Author: Jordan M Prutkin, MD, MHS, FHRS
Section Editor: Ary L Goldberger, MD
Deputy Editor: Gordon M Saperia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2020. | This topic last updated: Apr 18, 2019.
INTRODUCTION
Atrial and ventricular pacing can be seen on the electrocardiogram (ECG) as a pacing stimulus (spike) followed
by a P wave or QRS complex, respectively. The ECG has the ability to show normal and abnormal pacemaker
function.
ATRIAL PACING ONLY
Atrial pacing appears on the electrocardiogram (ECG) as a single pacemaker stimulus followed by a P wave
(waveform 1) (see "Modes of cardiac pacing: Nomenclature and selection") The morphology of the P wave
depends upon the location of the atrial lead; it may be normal, diminutive, biphasic, or negative. The PR interval
and configuration of the QRS complex are similar to those seen in sinus rhythm. They are independent of the
atrial pacemaker; thus, the duration and configuration are determined by the intrinsic characteristics of the
patient's conduction system.
There is 100 percent capture if the rhythm is entirely paced. However, there may be intermittent capture when
the atrial pacemaker is in a demand mode and is activated only when the intrinsic atrial rate falls below a preset
level. In these cases, a paced beat will be seen after a pause that is equal to this lower predetermined heart
rate. For example, if the pacemaker is set at 60 beats/min, the pacemaker will only pace if the rate falls below
60 beats/min or if there is a pause of one second (60 beats/min ÷ 60 sec/min).
VENTRICULAR PACING ONLY
Ventricular demand pacing appears on the electrocardiogram (ECG) as a single pacemaker spike followed by a
QRS complex that is wide, bizarre, and resembles a ventricular beat (waveform 2). (See "Modes of cardiac
pacing: Nomenclature and selection".) The pacemaker lead is usually in the right ventricular apex; thus, the
paced QRS complex has a left bundle branch block (LBBB) configuration since right ventricular activation
occurs before activation of the left ventricle, and is negative in the inferior leads. Rarely, there may be a right
bundle branch block pattern with pacing in the right ventricular apex, though there is the possibility the lead was
placed in the left ventricle if this is seen. Sometimes, the lead may be placed higher up in the right ventricular
septum or outflow tract, and while there is still an LBBB pattern, the inferior leads may have variable axis.
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Another option is that the lead is placed to pace the His bundle. In this location, the paced QRS complex is
narrow and looks similar to a native beat (see 'His bundle pacing' below). With ventricular pacing, there may or
may not be atrial activity noted, depending upon the nature of the patient's underlying rhythm, the atrial rate,
and the occurrence of ventriculoatrial conduction via the atrioventricular (AV) node. If intrinsic or native atrial
activity is present with a single chamber ventricular-only pacemaker, it occurs at a rate that differs from the
ventricular rate since it is dissociated from the QRS complex. Frequently, ventricular demand pacing is used in
association with atrial fibrillation.
There may be episodic pacing in patients who have a ventricular demand pacemaker. The pacemaker is
activated and delivers a stimulus only when the intrinsic ventricular rate falls below a predetermined lower limit;
pacemaker activity is suppressed when the intrinsic heart rate is faster. The escape interval (the time between
the last intrinsic beat and the paced beat) is equivalent to the rate at which the pacemaker is set to activate.
Similar to atrial pacing, if the pacemaker is set at 60 beats/min, the pacemaker will only pace the ventricle if the
rate falls below 60 beats/min or there is a pause of one second (60 beats/min ÷ 60 sec/min). If the native rate is
slow, there will be 100 percent ventricular pacing (figure 1). The ECG may have evidence of fusion or
pseudofusion beats if the pacemaker rate and intrinsic heart rate are nearly identical, and the native and paced
QRS complex occur simultaneously.
Fusion beats show a QRS morphology that is a mixture of the native and paced QRS complex. Pseudofusion
beats show a native QRS with a pacing spike just after the beginning of the QRS complex, giving the
appearance of pacing, but since the pacing spike is after the ventricle has started to depolarize, the pacing
stimulus is delivered during the refractory period and does not capture the heart. Pseudofusion is when a
pacing stimulus from the opposite chamber falls near the onset of a native signal, such as when a premature
ventricular complex/contraction (PVC; also referred to as premature ventricular beats or premature ventricular
depolarizations)occurs at the same time as an atrial paced beat.
DUAL CHAMBER ATRIOVENTRICULAR SEQUENTIAL PACING
Atrioventricular (AV) sequential pacing appears on the electrocardiogram as pacemaker spikes before the P
wave and QRS complex (waveform 3). (See "Modes of cardiac pacing: Nomenclature and selection".) If the
native atrial rate is faster than the programmed lower rate of the pacemaker, there will be no pacing spike prior
to the P wave, since the P wave originates from the sinus node (or another atrial location). Depending on device
programming and AV conduction, there is either a paced or a native QRS. The paced QRS has a bizarre
morphology resembling a left bundle branch block (LBBB) or a ventricular complex (waveform 4). If there is a
native QRS, the morphology is normal and narrow, but may be wide if there is an underlying bundle branch
block.
The morphology of the P wave depends upon the location of the lead within the right atrium; it may be upright,
biphasic, or negative and the amplitude may be normal, increased, or diminutive. The PR interval is determined
by the pacemaker and represents the delay between the atrial and ventricular stimuli; the pacemaker is
essentially functioning as the AV node. The second or ventricular spike is followed by a QRS complex that is
bizarre and usually has an LBBB morphology since the ventricular lead is typically in the right ventricle. If the
ventricular lead is pacing the His bundle, it will look like an intrinsic narrow QRS. (See 'His bundle pacing'
below.)

BIVENTRICULAR PACING
Standard ventricular pacing is from the right ventricle. Hence, the QRS complex has a left bundle branch block
(LBBB) morphology as the impulse originates from the right ventricle and is conducted to the left ventricle (a
right to left direction). This produces a tall and broad R wave in leads I, V5, and V6, and a deep QS complex in
lead V1.
With biventricular pacing, also known as cardiac resynchronization therapy, there are pacing leads in the right
atrium, right ventricle, and the coronary sinus, which results in stimulation of the left ventricle (waveform 5).
(See "Cardiac resynchronization therapy in heart failure: Implantation and other considerations".)
Sometimes the coronary sinus lead is replaced by an epicardial or endocardial left ventricular lead. Ventricular
pacing occurs from both the right ventricular and coronary sinus/left ventricular leads. The timing between the
leads can be changed so that one lead is paced prior to the other or they can be paced simultaneously.
Depending on the timing of pacing between the two leads, the QRS axis and morphology may change
significantly.
Assuming left ventricular pacing occurs simultaneously or prior to right ventricular pacing, activation of the left
ventricle precedes right ventricular activation. Therefore, the initial impulse is directed left to right, producing a
large Q wave or QS complex in lead I. In addition, leads V5-V6 also frequently demonstrate a QS complex.
However, this is not definitive for biventricular pacing, as an LBBB may be associated with a QS complex in
these leads also. Biventricular pacing will also produce a tall R wave in lead V1, as the impulses are directed
toward this lead. However, this QRS complex morphology may be seen with a right ventricular pacing electrode
located at the interventricular septum. Therefore, while a QS complex in leads V5-V6 and a tall R wave in lead
V1 are strongly suggestive of a biventricular pacemaker, an initial Q wave or a QS complex in lead I is more
definitive for left or biventricular pacing. In addition, if there is a significant difference between right and left
ventricular pacing stimuli, two ventricular pacing spikes may be seen, with the second one occurring after the
start of the QRS. This may be confused with pacemaker malfunction.
HIS BUNDLE PACING
There is renewed interest in physiologic pacing with direct pacing of the His bundle. Pacing in this location
causes ventricular activation to occur through the normal His-Purkinje system, often leading to a normal QRS
complex and normal ventricular synchrony. This method can be used for those needing a pacemaker for native
conduction system disease, for those undergoing atrioventricular node ablation and pacing for rapid atrial
fibrillation, and as an alternative to cardiac resynchronization therapy. (See "Atrial fibrillation: Atrioventricular
node ablation".)
In addition, it is possible for a bundle branch block to be corrected with His bundle pacing if the level of block is
in the fibers of the proximal His bundle destined to become the right or left bundle and pacing is in the distal His
bundle [1].
The ECG in His bundle pacing can be variable depending on whether there is selective, nonselective, or
noncapture of the His bundle [2].
Selective His bundle pacing — Selective His bundle pacing is when there is only pacing of the His bundle.
There will be a paced QRS morphology similar to the native QRS complex. If the native QRS is normal, then

selective His bundle pacing will also have a normal QRS, since conduction is through the same pathway.
However, if the baseline QRS has a fascicular or bundle branch block, the paced QRS complex may also have
the fascicular or bundle branch block or may narrow the QRS complex. The pacing stimulus is not coincident
with the onset of the QRS, but is usually >35 msec, which is equal to the native His-bundle-to-QRS-complex
time (waveform 6).
Nonselective His bundle pacing — With nonselective His bundle pacing, the His bundle and the local
myocardium are both captured with pacing. The QRS duration is longer than the native QRS duration with the
appearance of a pseudo-delta wave. The stimulus-to-QRS onset is zero since the myocardium at the tip of the
pacemaker lead on the antero-septum is also captured. The axis of the QRS complex matches the axis of the
native QRS. However, it is possible for nonselective His bundle pacing to narrow the QRS complex if the native
QRS has underlying fascicular or bundle branch block. This is manifested if the paced QRS has a shorter
duration QRS than native QRS, there is a pseudo-delta wave, and the stimulus-to-QRS onset is zero (waveform
7).
Noncapture of the His bundle — Noncapture of the His bundle is not a desired outcome, but if the His bundle
is not captured due to inadequate pacing output, lead dislodgement, or failure to locate the His bundle for
pacing, then there is right ventricular pacing only. The QRS will be widened with a short stimulus to QRS
duration, similar to pacing from anywhere else in the right ventricle.
PACER MALFUNCTION
Pacemakers may malfunction either by failure of capture or sensing. (See "Pacing system malfunction:
Evaluation and management".)
Loss of capture — Pacemaker malfunction with inconsistent capturing (atrium or ventricle) can be diagnosed
from the electrocardiogram (ECG) when there are pacemaker spikes that are not followed immediately by either
a P wave or QRS complex (figure 2). Non-capture may be intermittent, so that only occasional non-captured
pacemaker stimuli are seen, or persistent, where no native complexes follow pacing spikes. In the latter cases,
if intrinsic cardiac activity is present, the pacemaker stimuli are dissociated from the native P waves or QRS
complexes. There may be no underlying cardiac activity in severe cases of loss of capture and asystole is seen.
Loss of capture may be due to lead dislodgement or malposition, inflammation or fibrosis at the lead/tissue
interface, low pacemaker output, lead failure, or battery depletion.
Failure of sensing — Pacemakers may have undersensing of native cardiac activity or oversensing of non-
physiologic signal (waveform 8). In undersensing, the pacemaker does not see the native electrical signal in the
chamber of interest, and will deliver a pacing stimulus at the lower rate for the atrium or after the programmed
atrioventricular delay in the ventricle. Therefore, there will be a pacing spike in the middle of or after the
beginning of the native P wave or QRS, or have no relation to the underlying cardiac activity. Depending on the
refractoriness of the tissue, this pacing spike may or may not capture. The interval between the native and
paced complexes is variable. Note that when pacemakers are turned to asynchronous modes (eg, AOO, VOO,
DOO), they are programmed not to sense intrinsic cardiac signal and will have the appearance of undersensing.
It may seem that there is failure to sense a premature atrial or PVC in some cases that are not actually
representative of pacemaker malfunction. It may be dependent instead upon the timing of the premature beat,
which may not be sensed by the pacemaker if the signal falls within a refractory period.

Oversensing may occur when the device sees a signal that does not originate from within the chamber of
interest. This may be from electromagnetic interference, such as from electrocautery or other electrical
interference, diaphragmatic myopotentials, pectoral muscle myopotentials if in a unipolar mode, lead fracture, or
far field signals from another cardiac chamber. In oversensing, the device inhibits pacing. Therefore, no pacing
spikes are seen at the expected time on the ECG, and unless there is intrinsic cardiac activity, there will be
asystole.
SUMMARY
● Pacemaker leads may be placed in the right atrium, right ventricle, and coronary sinus/left ventricle.
● If there is native cardiac activity faster than the programmed intervals, the P wave and QRS complex will
resemble normal patterns. If there is slow cardiac activity, the electrocardiogram shows a pacing spike
followed by a P wave or QRS complex. The morphology of a paced P wave may resemble or look different
than the native P wave. The morphology of a paced QRS with the lead in the right ventricular apex has a
left bundle branch block configuration and is usually negative in the inferior leads.
● The QRS complex with biventricular pacing will vary depending on right and left ventricular timing, but often
has a tall R wave in V1 and an initial Q wave or QS complex in lead I.
● In selective His bundle pacing, the QRS duration and morphology match the native QRS with a stimulus-to-
QRS time matching the underlying His-bundle-to-QRS time. With nonselective His bundle pacing, the QRS
is longer than the native QRS with a pseudo-delta wave and pacing stimulus-to-QRS time of zero.
● Loss of pacemaker capture is defined by a pacing spike with no P wave or QRS complex, when the
myocardium is physiologically capable of being depolarized.
● Undersensing occurs when the pacemaker does not see native cardiac activity and paces inappropriately
in the middle of or after a P wave or QRS complex, or has no relationship to the native cardiac signal.
● Oversensing occurs when the pacemaker sees non-physiology activity and inhibits pacing. No pacing
spikes are seen at the expected times.
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REFERENCES
1. Huang W, Su L, Wu S, et al. Long-term outcomes of His bundle pacing in patients with heart failure with
left bundle branch block. Heart 2019; 105:137.
2. Vijayaraman P, Dandamudi G, Zanon F, et al. Permanent His bundle pacing: Recommendations from a
Multicenter His Bundle Pacing Collaborative Working Group for standardization of definitions, implant
measurements, and follow-up. Heart Rhythm 2018; 15:460.
Topic 2122 Version 16.0

GRAPHICS
Atrial pacing
A single pacemaker spike (marked by red lines) is followed by a P wave, normal

PR interval, and normal QRS complex.
Graphic 82560 Version 3.0
Sinus rhythm
The normal P wave in sinus rhythm is slightly notched since activation of the
right atrium precedes that of the left atrium. The P wave is upright in a
positive direction in leads I and II. A P wave with a uniform morphology
precedes each QRS complex. The rate is between 60 and 100 beats per
minute and the cycle length is uniform between sequential P waves and QRS
complexes. In addition, the P wave morphology and PR intervals are identical
from beat to beat.

Ventricular demand pacemaker tutorial
A single pacemaker spike (marked by red lines) is followed by a QRS complex

which is wide and bizarre and resembles a ventricular beat. There are some
normal intervening QRS complexes that suppress the pacemaker when they
occur faster than the rate set for the pacemaker.
Sinus rhythm
from beat to beat.

Ventricular pacing with 100 percent capture
Every QRS complex is preceded by a pacemaker stimulus (marked by red lines).

The QRS complex is abnormal, wide, and bizarre, resembling a ventricular beat.
The QRS complexes usually have a left bundle branch block configuration since
the ventricular lead is most commonly located in the right ventricle.
Sinus rhythm
from beat to beat.

Dual chamber atrioventricular sequential pacing
Two pacemaker spikes are seen within each complex; there is an atrial spike
(marked by red lines) and an associated P wave, followed by a ventricular spike
(marked by green lines) and an associated paced QRS complex. The P wave
morphology is variable, depending upon the location of the wire within the right
atrium.
Sinus rhythm
from beat to beat.

Dual chamber atrial sensing pacemaker
There is a normal or intrinsic P wave which, after a preset PR interval, is

followed by a pacemaker spike and a paced QRS complex that has a bizarre
morphology resembling a left bundle branch block or a ventricular complex.
Sinus rhythm
from beat to beat.
https://www.uptodate.com/contents/ecg-tutorial-pacemakers/print?search=ECG tutorial&source=search_result&selectedTitle=8~15&usage_typ… 10/16

Single lead electrocardiogram (ECG) showing

biventricular pacing
Courtesy of Dr. Jordan Prutkin.

Selective His bundle pacing
The paced QRS duration is 96 milliseconds and matches the native QRS morphology (not shown). The time from the pacing-stimulus-
to-QRS onset is about 50 milliseconds, which matches the native His bundle to QRS time.
Courtesy of Jordan Prutkin, MD.

Nonselective His bundle pacing
The paced QRS duration is slightly widened at 130 milliseconds, with a stimulus-to-QRS duration of zero and the appearance of a
pseudo-delta wave.
Courtesy of Jordan Prutkin, MD.

Pacemaker failure to capture
Courtesy of Dr. Jordan Prutkin.

Pacemaker malfunction - non-sensing
The second and fourth paced QRS complexes occur earlier than expected based
upon the lower rate limit of the pacemaker. The pacemaker has failed to sense
the preceding native complexes, and is therefore not inhibited by them. Thus,
the pacemaker will fire and stimulate the atria or ventricles at its own
predetermined rate, independently of the intrinsic rhythm. The interval between
the native and paced complexes is variable while the intervals of the pacing
spikes is constant.
Sinus rhythm
from beat to beat.

Contributor Disclosures
Jordan M Prutkin, MD, MHS, FHRS Nothing to disclose Ary L Goldberger, MD Other Financial Interest: Elsevier book
royalties [Clinical electrocardiography]. Gordon M Saperia, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the content.
Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
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21/9/2020 ECG tutorial: Pacemakers - UpToDate

Official reprint from UpToDate®

ECG tutorial: Pacemakers

ATRIAL PACING ONLY

VENTRICULAR PACING ONLY

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DUAL CHAMBER ATRIOVENTRICULAR SEQUENTIAL PACING

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HIS BUNDLE PACING

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A single pacemaker spike (marked by red lines) is followed by a P wave, normal

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Ventricular demand pacemaker tutorial

A single pacemaker spike (marked by red lines) is followed by a QRS complex

Graphic 66752 Version 3.0

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Ventricular pacing with 100 percent capture

Every QRS complex is preceded by a pacemaker stimulus (marked by red lines).

Graphic 78390 Version 2.0

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Dual chamber atrioventricular sequential pacing

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Dual chamber atrial sensing pacemaker

There is a normal or intrinsic P wave which, after a preset PR interval, is

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Single lead electrocardiogram (ECG) showing

Courtesy of Dr. Jordan Prutkin.

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Selective His bundle pacing

Courtesy of Jordan Prutkin, MD.

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Nonselective His bundle pacing

Courtesy of Jordan Prutkin, MD.

Graphic 121097 Version 1.0

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Pacemaker failure to capture

Courtesy of Dr. Jordan Prutkin.

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Pacemaker malfunction - non-sensing

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