E.C.G.

Course – III
Atrial rhythms

Dr. Michael Kassirer

”Dept. Internal Medicine ”D

Tel-Aviv Medical center
 Objective
By the end of lesson 3 the student will:
 Be able to identify sinus rhythms: NSR, Sinus
bradycardia, Sinus tachycardia and sinus
arrhythmia.
 Understand re-entry circle, and its electro-
physiological implication on supra-ventricular
arrhythmias formation.
 Be able to diagnose atrial fibrillation and flutter.
 Understand the difference and clinical implication
of wide vs. narrow complex tachycardia.
Normal Sinus Rhythm
))NSR

 Each P is followed by QRS

 Each QRS is preceded by P wave.
 P wave –form and PR interval are constant
 HR = 60-80 (limits: 50-100)
 Sinus Bradycardia

 Each P is followed by QRS

 Each QRS is preceded by P wave.
 HR < 50 bpm
 Reasons for Sinus
Bradycardia
 Hypothermia
 Drugs: β blockers, Ca Blockers,
Digoxin etc.
 Hypothyroidism
 ↑ Vagal activation - ↑ I.C.P,
Glaucoma
 Inf. Wall MI
 Sinus Tachycardia

 Each P is followed by QRS

 Each QRS is preceded by P wave.
 HR > 100 bpm
 Reasons for Sinus
Tachycardia
↑ Sympathetic activation:
 High output state – Exercise,
Pregnancy, Thyrotoxicosis, Fever.
 Compensatory – Anemia,
Hypovolemia, H.F
 Stress – hypoxia, Pain, Anxiety
 Sinus Arrhythmia

 Normal variant – esp. in young

 ↑ HR in Inspiration, ↓ HR on
Expiration
 Tachycardia
 3 or more complexes at rate > 100
bpm
Impulse propagation (re-entry)
Impulse formation – enhanced
automaticity
- triggered
activity
)Atrial Fibrillation )A.Fib
 Chronic Vs. Paroxysmal
 Disorganized atrial activity (rate:350-
600)
 Irregular irregularity rhythm
 Reasons for Atrial
Fibrillation
 Normal Heart (Uncommon) –
Following surgery, Alcohol
intoxication,
 Triggered by hypoxia, metabolic,
homodynamic derangement.
thyrotoxicosis
 Persistent AF = Cardiovascular
disease (esp. mitral disease, RHD,
Enlarged LA)
Re-entry
S.V.T = AVNRT
SupraVentricular Tachycardia
S.V.T = AVNRT
 Multifocal Atrial
Tachycardia

 Tachycardia – irregular rhythm

 Changing P shape and PR interval
 Typical with Rt. Heart strain –
COPD, P.E.
Pre-excitation syndrome
))WPW
 AVN bypass tract
 Paroxysmal
tachycardia
 Typical ECG
pattern:
 Shrt PR (<
0.12)
 Delta wave
 Wide QRS
 2° ST-T
changes
Pre-excitation syndrome
))WPW
 Premature atrial contraction
))PACs / APBs
 Normal Heart (Uncommon) –
Following surgery, Alcohol
intoxication,
 Triggered by hypoxia, metabolic,
homodynamic derangement.
thyrotoxicosis
 Persistent AF = Cardiovascular
disease (esp. mitral disease, RHD,
Enlarged LA)