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Chapter 4

Atrial Arrhythmias

OVERVIEW • Supraventricular tachycardia

• Paroxysmal supraventricular tachycardia
Atrial rhythms originate in the atria. Their common • Atrial flutter
electrocardiogram (ECG) features are P waves that dif- • Atrial fibrillation
fer in appearance from sinus P waves and normal- • Wolff-Parkinson-White
duration QRS complexes if no ventricular conduction
disturbances are present.
Atrial rhythms described in this chapter include:
Clinical Tip:
• Wandering atrial pacemaker
All ECG strips in this chapter were recorded in
• Multifocal atrial tachycardia
lead II.
• Premature atrial contraction
• Atrial tachycardia

WANDERING ATRIAL PACEMAKER ■

• The pacemaker site transfers from the sinoatrial (SA) node to other latent pacemaker sites in the atria and the
atrioventricular (AV) junction and then moves back to the SA node.

Rate: Normal (60–100 beats/minute [bpm]) Rhythm: Irregular

P Waves: At least three different PR Interval: Variable; determined QRS: Normal (0.06–0.10 seconds
forms, determined by focus in atria by focus [sec])

Clinical Tip:
Wandering atrial pacemaker may occur in normal hearts as a result of fluctuations in vagal tone. It may also be
seen in patients with heart disease or chronic obstructive pulmonary disease (COPD).

39
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40 ECG Mastery

MULTIFOCAL ATRIAL TACHYCARDIA ■

• This form of wandering atrial pacemaker is associated with a ventricular response of greater than 100 bpm.
• Multifocal atrial tachycardia may be confused with atrial fibrillation; however, multifocal atrial tachycardia has a
visible P wave.

Rate: Fast (greater than 100 bpm) Rhythm: Irregular

P Wave: At least three different PR Interval: Variable; determined QRS: Normal (0.06–0.10 sec)
forms, determined by focus in atria by focus

Clinical Tip:
Multifocal atrial tachycardia is commonly seen in patients with chronic obstructive pulmonary disease but may
also occur in acute myocardial infarction.

PREMATURE ATRIAL CONTRACTION ■

• A single contraction occurs earlier than the next expected sinus contraction.
• After the premature atrial contraction (PAC), sinus rhythm usually resumes.

Rate: Depends on rate of underlying rhythm Rhythm: Irregular whenever a PAC occurs
P Waves: Present; in the PAC, may PR Interval: Varies in the PAC; QRS: Normal (0.06–0.10 sec)
have a different shape otherwise normal (0.12–0.20 sec)

Clinical Tip:
In patients with heart disease, frequent PACs may precede paroxysmal supraventricular tachycardia, atrial
fibrillation, or atrial flutter.
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Chapter 4 Atrial Arrhythmias 41

ATRIAL TACHYCARDIA ■

• A rapid atrial rate overrides the SA node and becomes the dominant pacemaker.
• Some ST wave and T wave abnormalities may be present.

Rate: 150–250 bpm Rhythm: Regular

P Waves: Normal (upright and PR Interval: May be short (less QRS: Normal (0.06–0.10 sec) but
uniform) but differ in shape from than 0.12 sec) in rapid rates can be aberrant at times
sinus P waves

SUPRAVENTRICULAR TACHYCARDIA ■

• Supraventricular tachycardia has such a fast rate that the P waves may not be seen. They are frequently buried
in the T waves.

Rate: 150–250 bpm Rhythm: Regular

P Waves: Frequently buried in PR Interval: Usually not possible QRS: Normal (0.06–0.10 sec)
preceding T waves and difficult to measure but may be wide if abnormally
to see conducted through ventricles

Clinical Tip:
Supraventricular tachycardia may be related to caffeine intake, nicotine, stress, or anxiety in healthy adults.

Clinical Tip:
Some patients may experience angina, hypotension, lightheadedness, palpitations, and intense anxiety.
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42 ECG Mastery

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA ■

• Paroxysmal supraventricular tachycardia is a rapid rhythm that starts and stops suddenly.
• For accurate interpretation, the beginning or end of the paroxysmal supraventricular tachycardia must be seen.
• Paroxysmal supraventricular tachycardia is sometimes called paroxysmal atrial tachycardia.

Rate: 150–250 bpm Rhythm: Irregular

P Waves: Frequently buried in PR Interval: Usually not possible QRS: Normal (0.06–0.10 sec)
preceding T waves and difficult to measure but may be wide if abnormally
to see conducted through ventricles

Clinical Tip:
The patient may feel palpitations, dizziness, lightheadedness, or anxiety.

ATRIAL FLUTTER ■

• The AV node conducts impulses to the ventricles at a 2:1, 3:1, 4:1, or greater ratio (rarely 1:1).
• The degree of AV block may be consistent or variable.

Rate: Atrial: 250–350 bpm; ventricular: variable. Rhythm: Atrial: regular; ventricular: variable
P Waves: Flutter waves have a PR Interval: None, not QRS: Usually normal (0.06–
saw-toothed appearance; some may measurable 0.10 sec), but may appear widened
not be visible, being buried in QRS if flutter waves are buried in the
QRS

Clinical Tip: Clinical Tip:

The presence of atrial flutter may be the first Signs and symptoms depend on the ventricular
indication of cardiac disease. response rate.
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Chapter 4 Atrial Arrhythmias 43

ATRIAL FIBRILLATION ■

• Rapid, erratic electrical discharge comes from multiple atrial ectopic foci.
• No organized atrial depolarization are detectable.

Rate: Atrial: equal to or greater than 350 bpm; Rhythm: Irregular

ventricular: variable
P Waves: No true P waves; chaotic PR Interval: None QRS: Normal (0.06–0.10 sec)
atrial activity

Clinical Tip: Clinical Tip:

Atrial fibrillation is often a chronic arrhythmia Signs and symptoms depend on the ventricular
associated with underlying heart disease. response rate.

WOLFF-PARKINSON-WHITE SYNDROME ■

• In Wolff-Parkinson-White Syndrome, an accessory conduction pathway is present between the atria and the
ventricles. Electrical impulses may be rapidly conducted to the ventricles.
• These rapid impulses create a slurring of the initial portion of the QRS; the slurred effect is called a delta wave.

Rate: Depends on rate of underlying rhythm
P Waves: Normal (upright and
uniform) unless atrial fibrillation is
present
Rhythm: Regular unless associated with atrial
fibrillation
PR Interval: Short (less than QRS: Wide (greater than 0.10 sec);
0.12 sec) delta wave present

Clinical Tip:
Wolff-Parkinson-White Syndrome is associated with narrow-complex tachycardias, including atrial flutter and
atrial fibrillation.
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44 ECG Mastery

It is important to distinguish the variables with each arrhythmia to properly identify the ECG. The summary
of identifying ECG features for atrial arrhythmias is presented in TABLE 4-1.

Table 4.1 ■ ATRIAL ARRHYTHMIAS: IDENTIFYING FEATURES

Name Rate Rhythm P Waves PR Interval QRS

Wandering atrial Normal (60– Irregular At least three Variable; Normal (0.06–
pacemaker 100 bpm) different forms, determined 0.10 sec)
determined by by focus
focus in atria
Multifocal atrial Fast (greater Irregular At least three Variable; Normal (0.06–
tachycardia than different forms, determined 0.10 sec)
100 bpm) determined by by focus
focus in atria
Premature atrial Depends on Irregular Present; in Varies in Normal (0.06–
contraction rate of whenever the PAC, may the PAC; 0.10 sec)
underlying a PAC have a differ- otherwise
rhythm occurs ent shape normal
(0.12–
0.20 sec)
Atrial tachycardia 150–250 bpm Regular Normal (upright May be short Normal (0.06–
and uniform) (less than 0.10 sec) but
but differ in 0.12 sec) in can be aberrant
shape from rapid rates at times
sinus P waves
Supraventricular 150–250 bpm Regular Frequently buried Usually not Normal (0.06–
tachycardia in preceding possible to 0.10 sec) but
T waves and measure may be wide
difficult to see if abnormally
conducted
through
ventricles
Paroxysmal 150–250 bpm Irregular Frequently buried Usually not Normal (0.06–
supraventricular in preceding possible to 0.10 sec) but
tachycardia T waves and measure may be wide
difficult to see if abnormally
conducted
through
ventricles
Atrial flutter Atrial: 250– Atrial: Flutter waves None, not Usually normal
350 bpm; regular; have a measurable (0.06–0.10 sec),
ventricular: ventricular: saw-toothed but may appear
variable variable appearance; widened if
some may not flutter waves
be visible, are buried in
being buried the QRS
in QRS
Atrial fibrillation Atrial: equal Irregular No true P waves; None Normal (0.06–
to or chaotic 0.10 sec)
greater than atrial
350 bpm; activity
ventricular:
variable
Wolff-Parkinson- Depends on Regular Normal (upright Short (less Wide (greater
White Syndrome rate of unless and uniform) than than 0.10 sec);
underlying associated unless atrial 0.12 sec) delta wave
rhythm with atrial fibrillation is present
fibrillation present
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Chapter 4 Review
This review tests your understanding of the content
introduced in this chapter. Follow the instructions for
each exercise and check your answers at the end of
the chapter.
MULTIPLE CHOICE: ATRIAL ARRHYTHMIAS
Select the best answer for each of the following ques-
tions by circling the letter.
1. The pacemaker site transfers from the SA node
to other latent pacemaker sites in the atria and
the AV junction and then moves back to the
SA node.
A. Multifocal atrial tachycardia
B. Premature atrial contraction
C. Wandering atrial pacemaker
D. Wolff-Parkinson-White Syndrome
2. This form of wandering atrial pacemaker is asso-
ciated with a ventricular response of greater than
100 bpm.
A. Premature atrial contraction
B. Wolff-Parkinson-White Syndrome
C. Atrial flutter
D. Multifocal atrial tachycardia
3. P waves have a saw-toothed appearance; some
may not be visible, being buried in the QRS.
A. Atrial flutter
B. Wandering atrial pacemaker
C. Wolff-Parkinson-White Syndrome
D. Multifocal atrial tachycardia
ECG PRACTICE STRIPS: ATRIAL ARRHYTHMIAS
For instructions on analyzing the ECG strips, please see the guidelines given at the end of Chapter 2.
ECG 4•1
Rate:
P Waves: PR Interval:
Interpretation:
Chapter 4 Atrial Arrhythmias 45
4. Rapid, erratic electrical discharge comes from
multiple atrial ectopic foci; no true P waves,
chaotic atrial activity; no PR interval and
irregular R-R intervals.
A. Wolff-Parkinson-White Syndrome
B. Atrial fibrillation
C. Normal sinus rhythm
D. Atrial tachycardia
5. A rapid atrial rate overrides the SA node and
becomes the dominant pacemaker; the P waves
are normal (upright and uniform) but differ in
shape from sinus P waves.
A. Wolff-Parkinson-White Syndrome
B. Atrial tachycardia
C. Normal sinus rhythm
D. Premature atrial contraction
6. This arrhythmia has such a fast rate that the
P waves may not be seen; the rate is between
150–250 bpm.
A. Normal sinus rhythm
B. Premature atrial contraction
C. Supraventricular tachycardia
D. Wolff-Parkinson-White Syndrome
7. A single contraction occurs earlier than the next
expected sinus contraction.
A. Premature atrial contraction
B. Wandering atrial pacemaker
C. Wolff-Parkinson-White Syndrome
D. Premature ventricular contraction
■
Rhythm:
QRS:
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46 ECG Mastery

ECG 4•2

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•3

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•4

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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Chapter 4 Atrial Arrhythmias 47

ECG 4•5

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•6

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•7

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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48 ECG Mastery

ECG 4•8

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•9

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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Chapter 4 Atrial Arrhythmias 49

ECG CHALLENGE PRACTICE STRIPS ■

Take the ECG challenge! The following ECG strips build on what you learned from Chapter 3: Sinoatrial Node
Arrhythmias and Chapter 4: Atrial Arrhythmias.

ECG 4•10

H i n t : Notice the P waves are normal but encroach on the preceding T waves.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•11

H i n t : Look closely at the ST segment depression and inverted T waves.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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50 ECG Mastery

ECG 4•12

H i n t : A peaked T wave usually indicates hyperkalemia.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•13

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•14

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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Chapter 4 Atrial Arrhythmias 51

ECG 4•15

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•16

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•17

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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52 ECG Mastery

ECG 4•18

H i n t : Notice the pause after beats 3 and 5.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•19

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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Chapter 4 Atrial Arrhythmias 53

ECG 4•20

H i n t : Look closely for the “U” waves.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•21

H i n t : Use the Precise Heart Rate Calculation: 1,500/39 = 38.46 rounded to 38. Or, 38 bpm.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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54 ECG Mastery

ECG 4•22

H i n t : Notice the ST segment elevation.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•23

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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Chapter 4 Atrial Arrhythmias 55

ECG 4•24

H i n t : Notice the change in rhythm at the 3-sec mark.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•25

H i n t : Notice the block between beats 6 and 7.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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56 ECG Mastery

ECG 4•26

H i n t : Notice the ST segment depression.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•27

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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Chapter 4 Atrial Arrhythmias 57

ECG 4•28

H i n t : Notice the change in rhythm at the 3-sec mark.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

ECG 4•29

H i n t : Remember sinus arrhythmia has an irregular rhythm that varies with respiration.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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58 ECG Mastery

ECG 4•30

H i n t : Notice the long PR interval.

Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:

Answers to Chapter 4 Review ■ ECG 4•2

Rate: 94 bpm (1,500/16 = 93.75 rounded to 94)
MULTIPLE CHOICE Rhythm: Regular
P Waves: Flutter waves
1. C
PR Interval: None
2. D QRS: 0.10 sec
Interpretation: Atrial flutter with 3:1 AV block (every
3. A third flutter wave is buried in the QRS—this can
be seen by marching out the flutter waves with
4. B calipers)
5. B
■ ECG 4•3
6. C Rate: 214 bpm (1,500/7 = 214.28 rounded to 214)
Rhythm: Regular
7. A P Waves: Not clearly visible, buried in T waves
PR Interval: None, not measurable
QRS: 0.08 sec
ECG PRACTICE STRIPS AND ECG
Interpretation: Supraventricular tachycardia with
CHALLENGE ■ ST segment depression
■ ECG 4•1
Rate: 214 bpm (1,500/7 = 214.28 rounded to 214) ■ ECG 4•4
Rhythm: Regular Rate: 140 bpm (counting all beats), 188 bpm in beats
P Waves: Buried in T waves 1 through 10, 83 bpm in beats 11 through 14
PR Interval: None, not measurable Rhythm: Irregular (due to change in rhythm)
QRS: 0.08 sec P Waves: Buried in T waves in beats 1 through 10,
Interpretation: Supraventricular tachycardia normal in beats 11 through 14
PR Interval: None in beats 1 through 10, 0.16 sec in
beats 11 through 14
QRS: 0.10 sec
Interpretation: Paroxysmal supraventricular tachy-
cardia (supraventricular tachycardia converting to
normal sinus rhythm)
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Chapter 4 Atrial Arrhythmias 59

■ ECG 4•5 ■ ECG 4•11

Rate: 60 bpm Rate: 88 bpm
Rhythm: Irregular (due to R-R intervals) Rhythm: Regular
P Waves: None P Waves: Normal
PR Interval: None PR Interval: 0.20 sec
QRS: 0.10 sec QRS: 0.10 sec
Interpretation: Atrial fibrillation (irregular with Interpretation: Normal sinus rhythm with
fibrillatory baseline) ST segment depression and inverted T waves

■ ECG 4•6 ■ ECG 4•12

Rate: 50 bpm (counting PACs) Rate: 79 bpm
Rhythm: Irregular (due to PACs) Rhythm: Regular
P Waves: Normal P Waves: Normal
PR Interval: 0.20 sec PR Interval: 0.12 sec
QRS: 0.08 sec QRS: 0.08 sec
Interpretation: Sinus bradycardia with two bigeminal Interpretation: Normal sinus rhythm with peaked
PACs at beats 2 and 4 T waves

■ ECG 4•7 ■ ECG 4•13

Rate: 50 bpm Rate: 50 bpm
Rhythm: Irregular (due to the variable AV block) Rhythm: Regular
P Waves: Flutter waves P Waves: Normal
PR Interval: None PR Interval: 0.20 sec
QRS: 0.08 sec QRS: 0.08 sec
Interpretation: Atrial flutter with variable AV block Interpretation: Sinus bradycardia

■ ECG 4•8 ■ ECG 4•14

Rate: 180 bpm Rate: 40 bpm
Rhythm: Irregular (due to R-R intervals) Rhythm: Regular
P Waves: None P Waves: Normal
PR Interval: None PR Interval: 0.16 sec
QRS: 0.08 sec QRS: 0.10 sec
Interpretation: Atrial fibrillation (irregular with Interpretation: Sinus bradycardia
fibrillatory baseline)
■ ECG 4•15
■ ECG 4•9 Rate: 125 bpm
Rate: 120 bpm Rhythm: Regular
Rhythm: Irregular (due to change in rhythm) P Waves: Normal
P Waves: Normal in first three beats, buried in PR Interval: 0.12 sec
T waves in remaining beats QRS: 0.08 sec
PR Interval: 0.16 sec in first three beats Interpretation: Sinus tachycardia
QRS: 0.10 sec
Interpretation: Paroxysmal supraventricular tachy- ■ ECG 4•16
cardia (sinus bradycardia converting to supraven- Rate: 125 bpm
tricular tachycardia) Rhythm: Regular
P Waves: Normal
■ ECG 4•10 PR Interval: 0.16 sec
Rate: 136 bpm QRS: 0.10 sec
Rhythm: Regular Interpretation: Sinus tachycardia with ST segment
P Waves: Normal but encroach on preceding T waves depression
PR Interval: 0.12 sec
QRS: 0.08 sec
Interpretation: Sinus tachycardia
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60 ECG Mastery

■ ECG 4•17 ■ ECG 4•23

Rate: 100 bpm Rate: 47 bpm
Rhythm: Irregular (due to R-R intervals) Rhythm: Regular
P Waves: None P Waves: Normal
PR Interval: None PR Interval: 0.16 sec
QRS: 0.10 sec QRS: 0.10 sec
Interpretation: Atrial fibrillation with ST segment Interpretation: Sinus bradycardia
depression and inverted T waves
■ ECG 4•24
■ ECG 4•18 Rate: 70 bpm; 120 bpm in first section, 39 bpm in
Rate: 70 bpm (counting pauses) second section
Rhythm: Irregular (due to pauses) Rhythm: Irregular (due to change in rhythm)
P Waves: Normal P Waves: Normal
PR Interval: 0.16 sec PR Interval: 0.16 sec
QRS: 0.08 sec QRS: 0.10 sec
Interpretation: Normal sinus rhythm with two Interpretation: Sinus tachycardia changing to sinus
1.28 second pauses (sinus arrest) after beats 3 bradycardia
and 5
■ ECG 4•25
■ ECG 4•19 Rate: 110 bpm (counting block), 125 bpm in
Rate: 50 bpm (counting PAC), 47 bpm in underlying underlying rhythm
rhythm Rhythm: Irregular (due to block)
Rhythm: Irregular (due to PAC) P Waves: Normal
P Waves: Normal PR Interval: 0.16 sec
PR Interval: 0.16 sec QRS: 0.08 sec
QRS: 0.10 sec Interpretation: Sinus tachycardia with a sinoatrial
Interpretation: Sinus bradycardia with ST segment (SA) block (0.92 second block) between beats
depression, inverted T waves, and a PAC at beat 2 6 and 7

■ ECG 4•20 ■ ECG 4•26

Rate: 65 bpm Rate: 79 bpm
Rhythm: Regular Rhythm: Regular
P Waves: Normal P Waves: Normal
PR Interval: 0.20 sec PR Interval: 0.16 sec
QRS: 0.08 sec QRS: 0.08 sec
Interpretation: Normal sinus rhythm with U waves Interpretation: Normal sinus rhythm with
ST segment depression
■ ECG 4•21
Rate: 38 bpm (calculated by 1,500/39 = 38) ■ ECG 4•27
Rhythm: Regular Rate: 50 bpm
P Waves: Normal Rhythm: Irregular (due to sinus arrhythmia)
PR Interval: 0.16 sec P Waves: Normal
QRS: 0.10 sec PR Interval: 0.16 sec
Interpretation: Sinus bradycardia QRS: 0.08 sec
Interpretation: Sinus bradycardia with sinus
■ ECG 4•22 arrhythmia with inverted T waves
Rate: 88 bpm
Rhythm: Regular ■ ECG 4•28
P Waves: Normal Rate: 60 bpm (counting all beats); 38 bpm in first
PR Interval: 0.18 sec section, 98 bpm in second section
QRS: 0.08 sec Rhythm: Irregular (due to change in rhythm)
Interpretation: Normal sinus rhythm with ST segment P Waves: Normal
elevation PR Interval: 0.16 sec
QRS: 0.10 sec
Interpretation: Sinus bradycardia changing to
normal sinus rhythm
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Chapter 4 Atrial Arrhythmias 61

■ ECG 4•29 ■ ECG 4•30

Rate: 50 bpm Rate: 40 bpm
Rhythm: Irregular (due to sinus arrhythmia) Rhythm: Regular
P Waves: Normal P Waves: Normal
PR Interval: 0.12 sec PR Interval: 0.52 sec
QRS: 0.08 sec QRS: 0.10 sec
Interpretation: Sinus bradycardia with sinus Interpretation: Sinus bradycardia with first-degree
arrhythmia AV block