Normal Sinus Rhythm

Normal Sinus Rhythm

the P wave is negative in lead aVR and positive in lead II The heart rate is between 60 and 100 beats/min.

P - aVR

P+ DII

Major Tachyarrhythmias

Major Tachyarrhythmias
Narrow QRS complex
Sinus tachycardia Paroxysmal supraventricular tachycardias (PSVTs)
Atrial tachycardias Multifocal atrial tachycardia AV nodal reentrant tachycardia (AVNRT) AV reentrant tachycardia

Atrial flutter Atrial fibrillation

Wide QRS complex

Ventricular tachycardia Aberrant ventricular conduction Bundle branch block Atrioventricular bypass tract

Supraventricular Arrhythmias

Sinus Tachycardia

Sinus Tachycardia
Sinus tachycardia is simply sinus rhythm with a heart rate 100 beats/min In adults the heart rate with tachycardia is generally between sinus

100 -180 beats/min

Sinus tachycardia.
1. Each QRS complex is preceded by a P wave. 2. P waves are positive in lead II. 3. at fast rates P may merge with the preceding T wave and become difficult to distinguish.

Conditions commonly associated with sinus tachycardia:

Anxiety, excitement, exertion, and pain Drugs that increase sympathetic tone Drugs that block vagal tone (e.g., atropine Fever, many infections, and septic shock Congestive heart failure (CHF) Pulmonary embolism Hyperthyroidism Alcohol intoxication or withdrawal TREATMENT of sinus tachycardia associated with a pathologic condition must be directed at the underlying cause (e.g., infection, hyperthyroidism, CHF, or alcohol withdrawal).

Sinus Arrhythmia

Sinus Arrhythmia
Respiratory sinus arrhythmia. Normally the heart rate increases slightly with inspiration and decreases slightly with expiration

Supraventricular Arrhythmias
Premature atrial and AV junctional beats Paroxysmal supraventricular tachycardias AV junctional rhythms

Atrial and AV Junctional (Nodal) Premature Beats

Atrial and AV Junctional (Nodal) Premature Beats

APBs have the following major features

premature atrial depolarization (occurr before the next normal P wave ) The QRS complex of the APB is often preceded by a visible P wave P wave usually has a slightly different shape and/or different PR interval from the P wave seen with normal sinus beats. The PR interval of the APB may be either longer or shorter than the PR interval of the normal beats. In some cases the P wave may be "buried" in the T wave of the preceding beat

After the APB a slight pause generally occurs before the normal sinus beat resumes The QRS complex of the APB is usually identical or very similar to the QRS complex of the preceding beats. Remember that with APBs the atrial pacemaker is in an ectopic location but the ventricles are usually depolarized in a normal way. This contrasts with VPBs, in which the QRS complex is usually very wide because of abnormal depolarization of the ventricles

Notice the atrial premature beat (APB) after the fourth sinus beat (arrow). B, Notice also the blocked atrial premature beat, again after the fourth sinus beat (arrow). The premature P wave falls on the T wave of the preceding beat and is not followed by a QRS complex because the atrioventricular node is still in a refractory state.

This rhythm strip shows sinus rhythm with three APB. The first two are conducted with RBBB aberrancy (rSR in lead V1). The third APB is conducted with normal ventricular activation. Notice how the first two premature P waves come so early in the cardiac cycle that they fall on the T waves of the preceding sinus beats, making these T waves slightly taller.

Atrial bigeminy in which each sinus beat is followed by an APB (or premature atrial complex).

Paroxysmal Supraventricular Tachycardias

Paroxysmal Supraventricular Tachycardias

A sudden run of three or more beats constitutes a paroxysmal supraventricular tachycardia (PSVT) - Notsustained (i.e., lasting from three beat up to 30 sec) - Sustained episodes (> 30 sec.) may last minutes, hours, or longer

ATRIAL TACHYCARDIA (AT)

ATRIAL TACHYCARDIA (AT)

AT is defined simply as three or more consecutive APBs pacemaker ectopic (nonsinus) that fires off "automatically" in a rapid way The atrial rate with AT may be as high as 200 beats/min (range: 100 to 250 beats/min). Symptoms: light-headedness or even syncope Short episodes may require no special therapy, but longer runs causing symptoms are usually treated initially with antiarrhythmic drugs.

AV NODAL REENTRANT TACHYCARDIA (AVNRT)

AV NODAL REENTRANT TACHYCARDIA (AVNRT)

The term reentry describes situations in which a cardiac impulse literally spins around and around and appears to "chase its own tail." AVNRT = rapid and regular rhythm with rates typically between 140 and 250 beats/min arrhythmia may occur with normal hearts or with underlying heart disease. Runs of AVNRT are generally initiated by an APB
Initial therapy usually involves attempts to increase vagal tone that can be increased with the Valsalva maneuver or with carotid sinus massage

In summary, a PSVT should be suspected when a rhythm strip shows a rapid and typically very regular rate at about 200 beats/min (range: 100 to 250 beats/min).

The mechanism may be due to reentry in the AV node (AVNRT) atrioventricular reentrant tachycardia (AVRT) with a concealed bypass tract ectopic AT.

AV Junctional Rhythms

AV Junctional Rhythms
ectopic pacemaker located in the atria outside the SA node When the AV junction is the cardiac pacemaker, the atria are stimulated in a retrograde fashion, from bottom to top This retrograde stimulation of the atria produces a positive P wave in lead aVR and a negative P wave in D II With AV junctional rhythm the ventricles are depolarized normally resulting in a narrow QRS complex.

AV junctional beats - patterns ECG

Retrograde P waves (positive in lead aVR , negative in lead II) immediately preceding the QRS complexes Retrograde P waves immediately following the QRS Absent P waves (buried in the QRS), so that the baseline between QRS complexes is flat

Atrioventricular junctional (nodal) beats produce P waves that point upward in lead aVR and downward in lead II. The P wave may just precede the QRS complex (A), follow it (B), or occur simultaneously with it (C). In the last instance no P wave is visible aVR

DII

AV JUNCTIONAL ESCAPE RHYTHMS An AV junctional escape rhythm is a consecutive run of AV junctional beats. The heart rate is usually slow (30 to 50 beats/min).

Atrial flutter and atrial fibrillation

Atrial flutter and atrial fibrillation

they are ectopic atria = stimulated from ectopic sites atrial flutter the atrial rate is 250 to 350 beats/min atrial fibrillation : 400 and 600 beats/min

Atrial Flutter

Atrial Flutter
atrial rate is about 300 beats/min ventricular rate with atrial flutter is about 150, 100, or 75 beats/min Atrial flutter with a ventricular response of 150 beats/min is called 2:1 flutter the atrial rate in atrial flutter may be considerably less than 250 beats/min (as low as 200 to 220 beats/min) in patients taking drugs that slow atrial conduction

With atrial flutter, the ECG shows the following: Characteristic "sawtooth" flutter waves " instead of discrete P waves
A constant or variable ventricular rate (e.g., one QRS complex with every fourth flutter wave, 4:1 flutter; one QRS with every two flutter waves, 2:1 flutter, and the ventricular rate half the atrial rate; or the rare 1:1 flutter, in which the ventricles contract about 300 times a minute)

Atrial Fibrillation

Atrial Fibrillation
most commonly seen arrhythmias the atria are stimulated (depolarized) at a very rapid rate, up to 600 beats/min This fibrillatory activity produces a characteristically irregular wavy pattern in place of the normal P waves The irregular waves are called fibrillatory or f waves

!!!!!! normal AV junction

the ventricular rate is generally between 110 and 180/min

In summary, AF has two ECG characteristics:

An irregular wavy baseline produced by the rapid f waves (fibrillatory waves) instead of P waves A ventricular (QRS) rate that is usually quite irregular.

AF occurs Paroxysmally (may last only minutes, hours, or days) Permanent Persistent Recurrent CLINICAL ASPECTS palpitations weakness dyspnea -heart failurestroke no specific complaints ( AF may first be discovered during a routine examination )

CLINICAL CONSEQUENCES Decreased Cardiac Output Atrial Thrombi and Embolization

ETIOLOGY
lone atrial fibrillation = without heart disease changes in autonomic tone organic (structural) heart disease coronary artery disease hypertensive heart disease valvular heart disease

Ventricular Arrhythmias

Ventricular Premature Beats

Ventricular Premature Beats

= premature depolarizations arising in the ventricles (right or left ventricle) the stimulus spreads through the ventricles in an aberrant direction the QRS complexes are wide with VPBs, just as they are with the BBB patterns

VPBs characteristics : They are premature and occur before the next normal beat is expected.

They are aberrant in appearance. The QRS complex is abnormally wide (usually 0.12 second or more), and the T wave and QRS complex usually point in opposite directions.

Two in a row are referred to as a pair or couplet Three or more in a row are, by definition, VT

Compensatory Pause
VPBs are usually followed by a pause before the next normal beat The pause after a VPB is usually but not always longer than the pause after an APB A fully compensatory pause indicates that the interval between the normal QRS complexes immediately before and immediately after the VPB is exactly twice the basic RR interval

Uniform and Multiform VPBs

Uniform VPBs = arise from the same anatomic site (focus) Uniform VPBs are uni focal Uniform VPBs may occur in normal hearts and hearts with underlying organic heart disease

multiform VPBs have different morphologies in the same lead Multiform VPBs often but not always arise from different foci Multiform VPBs usually indicate that organic heart disease is present

CLINICAL SIGNIFICANCE
VPBs are among the most common arrhythmias They may occur - in normal hearts and - with serious organic heart disease Individuals with VPBs may be - Asymptomatic or may complain of - palpitations (i.e., sensations of a "skipped" or "extrabeat).

Ventricular Tachycardia

Ventricular Tachycardia
VT is, by definition, simply a run of three or more consecutive VPBs

Classification of Ventricular Tachycardia Duration

Nonsustained (lasting three beats to 30 seconds) Sustained (lasting 30 seconds or more, or somewhat
shorter runs if associated with symptoms of syncope or near-syncope)

Morphology
Monomorphic Polymorphic
With long QT(U) syndrome: torsade de pointes Without long QT(U) syndrome: for example, polymorphic ventricular tachycardia with acute ischemia

Sustained VT (typically lasting more than 30 seconds) is usually a life-threatening arrhythmia for two major reasons: Most patients are not able to maintain an adequate blood pressure at very rapid ventricular rates and eventually become hypotensive. The condition may degenerate into VF causing immediate cardiac arrest.

THERAPY Pharmacologic

implantable cardioverter defibrillator (ICD)

Accelerated Idioventricular Rhythm

Accelerated Idioventricular Rhythm

heart rate : 50 and 100 beats/min, and the ECG shows wide QRS complexes without associated P waves.
The arrhythmia is generally short lived, lasting minutes or less, and usually requires no specific therapy particularly common with acute MI it may be a sign of reperfusion after the use of thrombolytic agents

Torsade de Pointes

Torsade de Pointes:
Specific Form of Polymorphic Ventricular Tachycardia
the direction of the QRS complexes appears to rotate cyclically, pointing downward for several beats and then twisting and pointing upward in the same lead. torsade de pointes occurs in the setting of delayed ventricular repolarization, evidenced by prolongation of the QT intervals or the presence of prominent U waves

Ventricular Fibrillation

Ventricular Fibrillation
VF is the most common cause of sudden cardiac death
the ventricles do not beat in any coordinated fashion but instead fibrillate or quiver asynchronously and ineffectively No cardiac output occurs, and the patient becomes unconscious immediately VF is one of the three major ECG patterns seen with cardiac arrest ( The other two are bradyasystolic patterns and electromechanical dissociation )

The ECG in VF shows characteristic fibrillatory waves with an irregular pattern that may be either coarse or fine VF requires immediate defibrillation with an

unsynchronized DC shock.

Bradyarrhythmias

Sinus Bradycardia

Sinus Bradycardia
sinus rhythm is present and the heart rate is less than 50 beats/min
* Some authors define sinus bradycardia as a heart rate of less than 60 beats/min

This arrhythmia commonly occurs in the following conditions:

Drugs that increase vagal tone (e.g., digitalis or edrophonium) or
Hypothyroidism Sick sinus syndrome Vasovagal reactions Moderate sinus bradycardia usually produces no symptoms. If the heart rate is very slow (i.e., 40 to 50 beats/min), lightheadedness and even syncope may occur. Treatment requires decreasing medication doses or even discontinuing drug therapy (e.g., beta blockers or calcium channel blockers) If inappropriate sinus bradycardia causes symptoms (as in sick sinus syndrome), an electronic pacemaker may be needed
that decrease sympathetic tone (e.g., beta blockers) (In addition, calcium channel blockers such as diltiazem and verapamil may cause marked sinus bradycardia.)

Major Classes of Bradyarrhythmias

Sinus bradycardia, sinoatrial block Atrioventricular (AV) heart block or dissociation Junctional (AV nodal) escape rhythms AF or flutter with a slow ventricular response Ventricular escape rhythms (idioventricular rhythms)

Atrioventricular Heart Block

Atrioventricular Heart Block

Heart block is the general term for atrioventricular (AV) conduction disturbances Heart block occurs when transmission through the AV junction is impaired either transiently or permanently

Classification of AV Heart Blocks First-degree block =Uniformly prolonged PR interval Second-degree block
= Intermittent conduction failure Mobitz type I =progressive PR prolongation Mobitz type II: sudden conduction failure

Third-degree block
=No atrioventricular conduction

With first-degree heart block the PR interval is prolonged above 0.2 second and is constant from beat to beat

Prolonged PR Interval (First-Degree Heart Block)

Second-Degree AV Block two types:

Mobitz type I block (also called Wenckebach block) Mobitz type II block.

MOBITZ TYPE I (WENCKEBACH) AV BLOCK

each stimulus from the atria to the ventricles appears to have a more difficult time passing through the AV junction. Finally the stimulus is not conducted at all. This blocked beat is followed by relative recovery of the AV junction, and the whole cycle starts again.

ECG :progressive lengthening of the PR interval from beat to beat until a beat is "dropped." The dropped beat is a P wave that is not followed by a QRS complex, indicating failure of
the AV junction to conduct the stimulus from the atria to the ventricles.

Mobitz Type I AV Blocks

Clinically

Patients with the Wenckebach type of AV block are usually without symptoms unless the ventricular rate is very slow The pulse rate is irregular.

MOBITZ TYPE II AV BLOCK

Its characteristic feature is the sudden

appearance of a nonconducted sinus P wave

MOBITZ TYPE II AV BLOCK

is generally a sign of severe conduction system disease involving regions below the AV node (i.e., His-Purkinje system) not seen with digitalis excess or inferior MI may be seen with anterior wall MI often progresses into complete heart block indication for a pacemaker

Advanced second-degree AV block

= refers to the ECG finding of two or more consecutive nonconducted P waves
For example, with sinus rhythm and 3:1 block, every third P wave is conducted; with 4:1 block, every fourth P wave is conducted

Third-Degree (Complete) Heart Block

Third-Degree (Complete) Heart Block

no stimuli are transmitted from the atria to the ventricles the atria and ventricles are paced independently The atria generally continue to be paced by the sinus node, or sinoatrial (SA), node The ventricles are paced by an escape pacemaker located somewhere below the point of block in the AV junction The resting ventricular rate with complete heart block may be lower than 30 beats/min or as high as 50 to 60 beats/min The atrial rate is generally faster than the ventricular rate.

As a general clinical rule

complete heart block with wide QRS complexes tends to be less stable than complete heart block with narrow QRS complexes because the ventricular escape pacemaker is usually slower and less consistent.

An arrhythmia occurs when: * The heart's natural pacemaker develops an abnormal rate or rhythm. * The normal conduction pathway is interrupted. * Another part of the heart takes over as pacemaker. Symptoms Arrhythmias can produce a broad range of symptoms, from barely perceptible to cardiovascular collapse and death. * A single premature beat may be felt as a "palpitation" or "skipped beat." * Premature beats that occur often or in rapid succession may cause a greater awareness of heart palpitations or a "fluttering" sensation in the chest or neck.

When arrhythmias last long enough to affect how well the heart works, more serious symptoms may develop: * Fatigue * Dizziness * Lightheadedness * Fainting (syncope) or near-fainting spells * Rapid heartbeat or pounding * A fluttering in the chest * A racing heartbeat (tachycardia) * A slow heartbeat (bradycardia) * Shortness of breath * Chest pain * Adam Stokes syndrome * In extreme cases, collapse and sudden cardiac arrest