Electrocardiogram Rhythm Tutor

CREDITS

SINUS RHYTHM AND ITS DISTURBANCES

Rhythm 1

Normal Sinus Rhythm

Impulses originate in the SA node regularly at a rate 60-100 per minute in adults and at faster
rates in older children (90-110), small children (100-120) and infants (120-160). P waves
upright in L2 and negative in AVR and of uniform size and contour from beat to beat. PR
interval 0.12-0.20 sec and constant when A-V conduction normal; PR prolonged and/or
variable when A-V block present. Each P followed by QRS with resulting P:QRS ratio 1:1
QRS ratio 1:1. QRS less than 0.11 sec or QRS wide and bizarre when bundle branch block
present. RR intervals may be slightly irregular especially in the young and elderly.

Rhythm 2

Sinus Arrhythmia

Similar to normal sinus rhythm except that PP and RR intervals are irregular because the SA
node discharges at a variable frequency. In children and young adults the irregularity is cyclic
or related to respiration with the rate increasing during inspiration and decreasing during
expiration. A cyclic sinus arrhythmia disappears upon exercise or breath holding and is
accentuated by deep breathing. In elderly subjects the irregularity is frequently due to organic
heart disease.

Rhythm 3

Sinus Bradycardia

Similar to normal sinus rhythm except that the rate is less than 60/min in adults and older
children or less than 80 in younger children. The PR interval may be slightly prolonged
and/or P wave abnormally wide. Physiological bradycardia occurs in healthy individuals
(usually athletes) with increased vagal tone. Exercise or atropine always increase the rate to
normal. Pathological bradycardia occurs in subjects with acute myocardial infarction
(especially inferior) or other heart disease involving the SA node, in subjects taking drugs

such as digitalis or beta blockers and in elderly subjects. Exercise or atropine often fail to
increase the rate to normal.

Rhythm 4

Sinus Tachycardia

Impulses originate in the SA node at a rate 100-160/min in adults (and up to 200 or more in
children). P upright in L2 and negative in AVR with identical or slightly different size and
contour from beat to beat. At very rapid rates P superimposed on preceding T. When P
recognizable, P:QRS ratio 1:1. Tachycardia usually appears and subsides gradually. Vagal
stimulation produces gradual slowing which reverses when pressure is released. Exercise
further increases the rate.

ATRIAL ARRHYTHMIAS
Rhythm 5

Atrial Premature Beat (APB)

The impulse is discharged prematurely by some irritable focus in the atria giving rise to a
distorted P wave (wide, narrow, notched, inverted or superimposed on the preceding T wave).
The further from the SA node the ectopic focus is, the more abnormal will be P'
configuration. PR interval normal or slightly prolonged. Premature P followed by QRS less
than 0.11 sec except when very premature P is not conducted; occasionally QRS may be wide
with RBBB configuration due to aberrancy. The pause between APB and the next sinus beat
is usually noncompensatory, i.e., the RR interval between two QRS enclosing APB is less
than twice the normal RR interval.

Rhythm 6

Atrial Tachycardia (AT)

Impulses originate in an atrial pacemaker at a rate 140-250/min. Atrial activity may be

represented by upright P in L2 or by P superimposed on T or ST segment of the preceding

beat. At very rapid rates only every second P may be followed by QRS (2:1 AV block) with
the resulting ventricular rate half the atrial. QRS usually less than 0.11 sec; wide and bizarre
QRS mat be due to preexisting BBB or WPWS or due to aberrancy common at rapid rates.
Onset and termination of AT is often abrupt. Vagal stimulation frequently terminates AT.

Rhythm 7

Atrial Flutter

Impulses originate in an atrial pacemaker at a rate 240-340/min but some of them are blocked
regularly at the AV junction. Atrial activity is represented by sawtooth-like deflections (F
waves) not separated by an isoelectric segment and best seen in L2, L3 and AVF. Usually
only every second F is conducted to the ventricles (2:1 AV block) with the resulting
ventricular rate half the atrial rate; rarely the AV conduction is 3:1, 4:1, 1:1 or variable. Vagal
stimulation may have no effect or slow ventricular rate by increasing AV block or terminate
flutter. Exercise increases HR by decreasing the block.

Rhythm 8

Atrial Fibrillation

Impulses originate in multifocal atrial pacemaker at a rate 300-600/min but only some of them
are conducted to the ventricles. The atrial activity is represented by numerous, irregularly
spaced small deflections of varying configuration (f waves) best seen in L2, L3 AVF and V1.
Occasionally, f waves may be prominent ("coarse" fibrillation) resembling atrial flutter or no
atrial activity is discernible ("fine" fibrillation). Only some f waves pass through the AV
junction and activate ventricles in a completely irregular fashion. Vagal stimulation may have
no effect or may slow the ventricular rate by increasing the AV block.

A-V JUNCTIONAL ARRHYTHMIAS

Rhythm 9

Junctional Premature Beats (JPB)

The impulse prematurely discharged from an irritable focus in or near the AV junction spreads
backward (retrograde) to the atria and forward (antegrade) to the ventricles. An inverted P
wave may precede QRS by less than 0.12 sec ("upper" junctional beat ) or inverted P wave
may follow QRS ("lower" junctional beat) or P wave may be buried in QRS ("middle"
junctional beat). Premature QRS is less than 0.22 sec but often slightly distorted;
occasionally QRS is wide and has RBBB configuration due to aberrancy. The pause
following JPB is noncompensatory as explained for APB.

Rhythm 10

Idiojunctional Rhythm

The SA pacemaker is suppressed or its impulses are blocked and the heart is controlled by
impulses originating at the AV junction. Such impulses spread to the ventricles and also to the
atria (in retrograde fashion). P waves are negative L2 and positive AVR and occur regularly at
a rate 40-60. Depending upon whether retrograde conduction to the atria is faster, slower or
similar to antegrade conduction to the ventricles, P waves either precede QRS complexes, the
PR interval is less than 0.12 sec or follow QRS complexes by no more than 0.20 sec or are
buried in the QRS complexes. Occasionally there is a block above the junctional focus so that
the atria are under the control of sinus or atrial impulses (AV dissociation).

Rhythm 11

Junctional Tachycardia

Impulses originate in the AV junctional pacemaker at a rate 140-220/min and are conducted
retrograde to the atria and antegrade to the ventricles. P waves are negative in L2 and positive
in AVR and may closely precede, follow or coincide with normal QRS complexes. When P
waves precede QRS complexes, the PR interval is less than 0.12 sec; when P waves follow
QRS complexes, they appear as splinters deforming the ST segment; when P waves coincide
with QRS complexes, they are not discernible. The paroxysmal form of tachycardia is
characterized by a ventricular rate 140-220, sudden onset and offset and sudden termination
or no change upon vagal stimulation; the nonparoxysmal form is characterized by a
ventricular rate 100-140, gradual onset and gradual slowing or no change upon vagal
stimulation.

Rhythm 12

Supraventricular Tachycardia

Impulses originate in a supraventricular pacemaker (above the bifurcation of the the common
bundle) at a rate 150-250. P waves cannot be positively identified either because they merge
with preceding T waves or because they are buried in QRS complexes so the the
differentiation between atrial and junctional tachycardia is impossible. QRS complexes are
less than 0.11 sec; occasionally QRS are wide and have RBBB configuration due to
aberrancy. Vagal stimulation may have no effect or may terminate tachycardia abruptly.

VENTRICULAR ARRHYTHMIAS
Rhythm 13

Ventricular Premature Beat (VPB)

An irritable focus in the left or right ventricle fires prematurely and the impulse spreads to the
opposite ventricle with delay producing a bizarre QRS complex, wider than 0.11 sec and of
bundle branch block configuration. The VPB originating in the LV usually produces the
pattern of RBBB while that originating in the RV produces the pattern of LBBB. The P wave
is usually buried in the VPB but occasionally it may be seen as a notch or splinter deforming
some part of the QRS-T complex. The pause after the VPB is usually compensatory, i.e., the
RR interval between the QRS complexes surrounding the VPB is twice the normal RR
interval. VPB's are often the forerunners of ventricular tachycardia when they are frequent
(more than 5/min), occur in groups of two or three, are multifocal or have a very short
coupling (i.e. the VPB falls on a T wave). When every other beat is a VPB, the rhythm is
called bigeminy. When every third beat is a VPB or when each normal beat is followed by
two VPB's, the rhythm is called trigeminy.

Rhythm 14

Ventricular Tachycardia

Impulses originating in the SA node control the atria but fail to reach the ventricles; the latter
are activated by their own pacemaker firing 100-250/min; rarely ventricle-borne impulses are
also conducted to the atria. P waves are frequently indiscernible or may appear as notches at

various points on the QRS-T complexes; if P waves are recognizable, they are usually of
normal configuration, occur regularly at a rate 60-100 and bear no fixed relation to the QRS
complexes (AV dissociation). Rarely, when the atria are controlled by the ventricular
pacemaker, the P waves are inverted and follow QRS complexes at a constant RP interval.
When the rate is less than 150, the SA-borne impulse may be occasionally conducted through
the AV junction and it can activate the ventricles thus producing a QRS complex whose
configuration and width are intermediate between the normal and abnormal complexes (fusion
beat or partial capture). QRS complexes are usually wider than 0.12 sec and bizarre. RR
intervals are usually regular but may vary up to 0.03 sec. Vagal stimulation has no effect on
the rate. An ECG prior to tachycardia showing premature beats of identical configuration
favors ventricular origin of the tachycardia.

CONDUCTION DISTURBANCES
Rhythm 15

First Degree AV Block

Rhythmic impulses originating in the SA node are conducted abnormally slow through the AV
junction to the ventricles. The rhythm pattern is similar to normal sinus rhythm except that
the PR interval is prolonged beyond 0.20 sec in adults and 0.18 sec in children. With a severe
(i.e. greater than 0.5 sec) lengthening of the PR interval or with a rapid rate, the P wave may
be superimposed on the preceding T wave. Occasionally the rate may be slower than
60/minute. Frequently associated with vagotonia (in which case it disappears after exercise or
atropine).

Rhythm 16

Second Degree AV Block Type I (Wenckebach)

Rhythmic impulses originating in the SA node are conducted through the AV junction at
progressively slower (decremental) speed. P waves are positive in L2 and negative in AVR
and occur regularly at a rate 60-100. A blocked P wave occurs after 2-5 conducted P waves
and this so-called Wenckebach cycle or period is repeated. The P:QRS ratio of 3:2, 4:3, 5:4
may be constant in all cycles or may vary from cycle to cycle. The PR interval immediately
following a dropped QRS complex is the shortest and may be normal or prolonged; with each
successive beat the PR interval becomes progressively longer until a P wave is blocked. QRS
complexes may be normal or wide and bizarre if BBB is present.

Rhythm 17

Second Degree AV Block Type II (Mobitz)

Rhythmic impulses originating in the SA node are intermittently blocked at the AV junction.
P waves are positive in L2 and negative in AVR and occur regularly at a rate 60-100. Only
every second (or rarely third, fourth, etc.) P wave is followed by a QRS complex resulting in
the P:QRS ratio 2:1, 3:1, 4:1, etc. and the ventricular rate 20-60. Rarely the AV conduction
and the P:QRS ratio may be 3:2, 4:3, 5:2 or other and may vary in the same tracing. The PR
interval of the conducted beats is normal or prolonged and usually constant. QRS complexes
are frequently wide and have RBBB configuration because the lesion extends below the AV
junction.

Rhythm 18

Third Degree (Complete) AV Block

Impulses originate in the SA node or in an atrial pacemaker but none of them is conducted
through the AV junction to the ventricles. P waves are positive in L2 and negative in AVR and
occur regularly at a rate 60-100; rarely atrial activity is represented by inverted (ectopic) P
waves, F waves of f waves. Since all P waves are blocked, the ventricles are activated by
impulses activated by impulses arising (through escape mechanism) in pacemaker cells below
the bifurcation of the common bundle. The resulting QRS complexes are wide, slurred,
frequently of RBBB configuration and occur regularly at a rate 20-40 (the so-called
idioventricular rhythm). P waves occurring at a faster rate are completely unrelated to QRS
complexes (AV dissociation).

Rhythm 19

Atrioventricular (AV) Dissociation

There is no fixed temporal relationship between P waves and QRS complexes due to the
existence of two independent pacemakers, one in the SA node (or in the atria) which controls
the beating of atria and other in the AV junction (or in the ventricles) which controls the
beating of ventricles. When the atria are beating faster than the ventricles, AV dissociation is

due to complete AV block; when the ventricles are beating faster than the atria, AV
dissociation is due to ectopic tachycardia (junctional or ventricular). In complete AV
dissociation no atrial impulse is conducted to the ventricles; in incomplete AV dissociation
some atrial impulses may be conducted to the ventricles resulting in ventricular captures.

Rhythm 20

Bundle Branch Block (BBB)

Impulses originate in the SA node and spread normally through the atria and AV junction,
however, the conduction through the right (R) or left (L) branches of the bundle of His is
blocked. In RBBB the right ventricle is activated late through the septum this being reflected
by M-shaped QRS complex or wide notched or slurred R in V1-V2 and wide slurred S in V5V6. In LBBB the left ventricle is activated late through the septum this being relected by Mshaped QRS or wide notched or slurred R in V5-V6 and wide slurred S or QS in V1-V6. QRS
duration 0.11 sec or more. ST segment depressed and T inverted in leads with M-shaped
QRS.

Rhythm 21

Ventricular Preexcitation

Also called Wolff-Parkinson-White Syndrome (WPWS). Impulses originating in the SA node

spread over the atria and then bypass the AV junction through an accessory bundle. Premature
activation of a small portion of the ventricles produces stepwise notching or slurring of the
initial part of the QRS complex (the delta wave). QRS complexes and delta waves upright in
all precordial leads are associated with type A of WPWS; QRS complexes and delta waves
negative in V1-V2 and positive in V5-V6 are associated with type B. The QRS duration 0.11
sec or more. The PR interval usually less than 0.12 sec due to early onset of QRS as a delta
wave. ST segment depressed and T wave inverted in leads with tall R waves. Frequent
attacks of supraventricular tachycardia.

CREDITS
July 11, 1997
AUTHOR:

Joseph Wartak MD
Tables of Cardia Arrhythmias, 3rd Revised Edition,
SOURCE:
1983 (Courtesy of Squibb Canada Inc.)
SCANNING: Ciorsti MacIntyre
HTML:
D. John Doyle MD PhD, Ciorsti MacIntyre