Arrhythmias

• Sinus node arrhythmias

• Atrial arrhythmias
• Junctional arrhythmias
• Ventricular arrhythmias
• Atrioventricular blocks
 SA node
• Acts as primary pacemaker
• Inherent firing rate of 60 to 100 times/ minute in a
resting adult
• Supplied by blood from the right coronary artery and
left circumflex artery
 Sinus arrhythmia
Characteristics
• Rhythms: Irregular, corresponding to the respiratory cycle
• Rates: Within normal limits; vary with respiration
• Other parameters: QT interval variations

Treatment
• No treatment if asymptomatic
• Correction of the underlying cause
 Sinus bradycardia
Characteristics
• Rhythms: Regular
• Rates: Less than 60 beats/minute
• Other parameters: Normal

Treatment
• No treatment if asymptomatic
• Correction of the underlying cause
• Temporary pacing to increase heart rate
• Atropine or epinephrine to maintain heart rate
• Dopamine for hypotension
• Permanent pacing if necessary
Sinus bradycardia
 Sinus arrest
• The SA node fails to generate an impulse.
• Such failure may result from a number of conditions, including
acute infection, heart disease, and vagal stimulation.
• Sinus arrest may be associated with sick sinus syndrome.
 Sinus arrest
Characteristics
• Rhythms: Regular, except for missing PQRST complex
• Rates: Equal and usually within normal limits; may vary as a result of pauses
• P wave: Normal and constant when P wave is present; not measurable when P
wave is absent
• QRS complex: Normal when present; absent during pause
• T wave: Normal when present; absent during pause
• QT interval: Normal when present; ab- sent during pause

Treatment
• No treatment if asymptomatic
• Correction of the underlying cause
• Atropine or epinephrine to maintain heart rate
• Temporary pacemaker to maintain ad- equate cardiac output and perfusion
• Permanent pacemaker if necessary
 sinoatrial blocks
• The SA node discharges impulses at regular intervals. Some
of those impulses, though, are delayed on their way to the
atria.
• Based on the length of the delay, SA blocks are divided into
three categories: first-, second-, and third-degree. Second-
degree block is further divided into type I and type II.
• First-degree SA block consists of a delay between the firing
of the sinus node and depolarization of the atria. Because
the ECG doesn’t show sinus node activity, you can’t detect
first-degree SA block. However, you can detect the other
three types of SA block.
 Second-degree type I block
• Conduction time between the sinus node and the sur- rounding atrial
tissue becomes progressively longer until an entire cycle is dropped.
• The pause is less than twice the shortest P-P interval.
 Second-degree type II block

• Conduction time between the sinus node and atrial tis- sue is
normal until an impulse is blocked. The duration of the pause
is a multiple of the P-P interval
 Third-degree block
• Some impulses are blocked, causing long sinus pauses. The pause isn’t a multiple
of the sinus rhythm.
• On an ECG, third-degree SA block looks similar to sinus arrest but results from a
different cause.
• Third-degree SA block is caused by a failure to conduct impulses; sinus arrest
results from failure to form impulses.
• Failure in each case causes atrial activity to stop.
• In sinus arrest, the pause commonly ends with a junctional escape beat.
• In third- degree block, the pause lasts for an indefinite period and ends with a
sinus beat.
sinus arrest
 Sick sinus syndrome
Characteristics
• Rhythms: Irregular with sinus pauses and abrupt rate changes
• Rates: Fast, slow, or combination of both
• P wave: Variations with rhythm and usually before QRS complex
• QRS complex: Normal
• T wave: Normal
• QT interval: Normal; variations with rhythm changes

Treatment
• No treatment if asymptomatic
• Correction of the underlying cause
• Atropine or epinephrine for symptom- atic bradycardia
• Temporary or permanent pacemaker if necessary
• Antiarrhythmics, such as metoprolol and digoxin, for tachyarrhythmias
• Anticoagulants if atrial fibrillation develops
sick sinus syndrome
 sick sinus syndrome
• Rhythms: Irregular with sinus
pauses
and abrupt rate changes
• Rates: Fast, slow, or combination
of both
• P wave: Variations with rhythm
and
usually before QRS complex
• QRS complex: Normal
• T wave: Normal
• QT interval: Normal; variations
with
rhythm changes
Treatment
• No treatment if asymptomatic
• Correction of the underlying cause
• Atropine or epinephrine for
symptomatic
bradycardia
• Temporary or permanent
pacemaker if
necessary
• Antiarrhythmics, such as metoprolol
and digoxin, for tachyarrhythmias
• Anticoagulants if atrial fibrillation
develops
 Atrial arrhythmias
Premature atrial contractions
(PACs)
Characteristics
Treatment
• Rhythms: Irregular as a result of PACs
• P wave: Premature with an abnormal • No treatment if
configuration; may be buried in the asymptomatic
previous
T wave
• Correction of the
• PR interval: Usually normal; may be underlying cause
slightly shortened or prolonged • Drugs, such as digoxin,
• QRS complex: Similar to the
underlying
procainamide,
QRS complex when PAC is conducted; and quinidine, to prolong
may not follow the premature P wave the atrial refractory
when a nonconducted PAC occurs
period
 Atrial tachycardia
Characteristics
• Rhythms: Atrial—regular, irregular in • Treatment
MAT; ventricular—regular when the • • Correction of underlying cause
block is constant and irregular when it
• • Monitoring of blood digoxin levels
isn’t
for
• Rates: Atrial—three or more successive
• Toxicity
ectopic atrial beats at a rate of 150 to
250 beats/minute; ventricular—varies • Valsalva’s maneuver • or carotid sinus
• P wave: A 1:1 ratio with QRS complex • massage
(unless a block is present); may not be • • Calcium channel blocker,
discernible; may be hidden in previous ST betaadrenergic
segment or T wave; in MAT, at least three • blocker, or digoxin; synchronized
different P waves seen • cardioversion
• PR interval: Sometimes not • • Atrial overdrive pacing to stop
measurable; varies in MAT • arrhythmia
• QRS complex: Usually normal
• T wave: Normal or inverted
• QT interval: Usually within normal
limits; may be shorter
Understanding carotid sinus
massage
Carotid sinus massage may be used to
diagnose atrial tachycardias. Massaging the
carotid sinus stimulates the vagus nerve,
which then inhibits firing of the sinoatrial
(SA) node and slows atrioventricular node
conduction. As a result, the SA node can
resume
its job as primary pacemaker. Risks of carotid
sinus massage include decreased heart rate,
vasodilation, ventricular arrhythmias, stroke,
and cardiac standstill.
 Atrial flutter
Characteristics
• Rhythms: Atrial—regular; ventricular
—
depends on the AV conduction pattern
• Rates: Atrial usually greater than
ventricular
• P waves: Abnormal with saw-toothed
appearance
• QRS complex: Usually normal; may be
widened if waves are buried in complex
• T wave: Unidentifiable
• QT interval: Unmeasurable
Treatment
• Anticoagulation therapy before
converting
rhythm if flutter is present for
more than 48 hours
• Digoxin, diltiazem, or
amiodarone to control
rate if heart function is impaired;
synchronized
cardioversion or amiodarone to
convert rhythm if less than 48
hours
 Atrial fibrillation
Characteristics Treatment
• Rhythms: Irregularly irregular
• Rates: Atrial—usually greater than • Same guidelines as for
400 atrial flutter
beats/minute; ventricular—varies
from
100 to 150 beats/minute but can be
lower
• P waves: Absent
• f waves: Seen as uneven baseline on
ECG rather than distinguishable P
waves
• R-R intervals: Wide variation
 Wandering pacemaker
Characteristics Treatment
• Rhythms: Irregular
• Rates: Usually normal or below 60 • No treatment if
beats/minute asymptomatic
• P wave: Changes in size and shape • Correction of the
• PR interval: Varies; always less than
underlying cause
0.20 second
• QRS complex: Usually normal; less
than
0.12 second
• QT interval: Sometimes varies
Junctional tachycardia

In junctional tachycardia, three or more PJCs occur in

a row. This supraventricular tachycardia occurs when
an irritable focus from the AV junction has enhanced
automaticity, overriding the SA node to function as the
heart’s pacemaker.
In this arrhythmia, the atria are depolarized by means
of retrograde conduction, and conduction through the
ventricles is ormal. The rate is usually 100 to 200
beats/ minute.
 Junctional tachycardia
• Characteristics
• • Rhythms: Regular
• • Rates: 100 to 200 beats/minute
• • P wave: Inverted in leads II, III,
aVF;
• location varies around QRS complex
• • PR interval: Shortened at less than
• 0.12 second or unmeasurable
• • QRS complex: Normal
• • T wave: Usually normal; may
contain
• P wave
• • QT interval: Usually normal
• Treatment
• • Correction of the underlying
cause
• • Discontinuation of digoxin if
indicated
• • Temporary or permanent
pacemaker
• insertion if symptomatic
• • Vagal maneuvers or drugs such
• as verapamil to slow heart rate if
• symptomatic
 Junctional arrhythmias
• Originate in the AV junction
• Occur when the SA node is suppressed or conduction is
blocked
• Impulses cause retrograde depolarization and inverted P waves
in leads II, III,and aVF
 Wolff-Parkinson-White syndrome
Characteristics Treatment
• PR interval: Less than • No treatment if
0.10 second asymptomatic
• QRS complex: Greater • Treatment of
than 0.10 second; tachyarrhythmias as
beginning of complex may indicated
have • Radiofrequency ablation
slurred appearance (delta if resistant to
wave) other treatments
 PJC
Characteristics
Treatment
• Rhythms: Irregular with PJC
appearance • No treatment if
• Rates: Vary with underlying rhythm
asymptomatic
• P wave: Inverted; occurs before,
during, • Correction of the
or after QRS complex; may be absent
underlying cause
• PR interval: Less than 0.12 second or
unmeasurable • Discontinuation of
• QRS complex: Usually normal digoxin if indicated
• T wave: Usually normal
• QT interval: Usually normal • Reduction or elimination
• Other: Sometimes a compensatory of caffeine intake
pause after PJC
 Junctional escape rhythm
Characteristics Treatment
• Rhythms: Regular
• Correction of the underlying
• Rates: 40 to 60 beats/minute
• P wave: Inverted in leads II, III, and
cause
aVF; • Atropine for symptomatic
can occur before, during, or after QRS bradycardia
complex
• Temporary or permanent
• PR interval: Less than 0.12 second if P
wave comes before QRS complex
pacemaker
• QRS complex: Normal; less than 0.12 insertion if arrhythmia
second refractory to drugs
• T wave: Normal • Discontinuation of digoxin if
• QT interval: Normal
indicated
 Accelerated junctional rhythm
Characteristics Treatment
• Rhythms: Regular
• Rates: 60 to 100 beats/minute • Correction of the
• P wave: Inverted in leads II, III, and underlying cause
aVF (if present); occurs before, during,
or
• Discontinuation of
after QRS complex digoxin if indicated
• PR interval: Measurable only with P • Temporary pacemaker
wave that comes before QRS complex;
0.12 second or less
insertion if
• QRS complex: Normal symptomatic
• T wave: Normal
• QT interval: Normal