ECG Rhythm Strip Interpretation, Basic-Lesson 4

Introduction
Atrial arrhythmias:

 are the most common cardiac rhythm disturbances

 are caused by impulses originating in atrial tissue outside the sinoatrial
(SA) node
 result from three mechanisms: altered automaticity, reentry, and
triggered activity.

Premature atrial contractions (PACs):

 are produced by an irritable focus in the atrium that fires before the SA
node and takes over as the heart's pacemaker for one or more beats.
 originate outside SA node from enhanced automaticity in atrial tissue

Conducted PAC

 Ventricular conduction is usually normal

 Early P wave followed by QRS complex

Nonconducted PAC

 No QRS complex
 P wave buried in preceding T wave

Causes can include:

 cardiac conditions
 respiratory conditions
 use of drugs (quinidine, procainamide, epinephrine, theophylline, digoxin)
 Non-cardiac and non-pulmonary causes
(hyperthyroidism, electrolyte imbalances, anxiety,
fatigue, fever, infection, alcohol, cocaine, caffeine, or
nicotine use).

Clinical significance

 With heart disease: can lead to atrial fibrillation, atrial flutter, or decreased cardiac output
 Without heart disease: rarely of clinical significance
 Treat the cause in patient's with frequent premature atrial contractions

Rhythm

 Underlying rhythm: may be regular

 Frequent PACs: often create an irregular rhythm
 Atrial and ventricular rhythms: irregular

Rate

Atrial and ventricular rates: vary with underlying rhythm

Premature P wave

 Abnormal configuration
 Varying configurations indicate more than one ectopic site
 May be hidden in preceding T wave

PR interval

 Usually within normal limits

 May be shortened or slightly prolonged

QRS complex

 Usually of a normal duration and configuration with

conducted PAC
  No QRS with nonconducted PAC

T wave

 Usually normal
 May appear distorted with a hidden P wave

QT interval

 Usually within normal limits

Other

 May occur as a single beat, in a bigeminal or trigeminal pattern, or in couplets

 Commonly followed by a pause as the SA node resets

ATRIAL TACHYCARDIA

Characterized by:

 impulses originating above the ventricles

 three or more successive ectopic atrial beats
at a rate of 150 to 250 beats/minute
 the rapid rate that shortens diastole, resulting
in a loss of atrial kick.

Three types include:

 atrial tachycardia with block

 multifocal atrial tachycardia
 paroxysmal atrial tachycardia.

Most atrial tachycardias are paroxysmal and self-limiting but in some patients may be present almost consistently.

Causes include:

 digoxin toxicity
 primary or secondary cardiac disorders
 other conditions (pulmonary embolism, cor pulmonale, hyperthyroidism, systemic hypertension, electrolyte
imbalance, hypoxia, physical or psychological stress)
 marijuana or cocaine use
 excessive stimulant use.

Clinical significance

 May be a forerunner of ventricular arrhythmias

 Results in decreased ventricular filling time, reduced cardiac output, increased myocardial oxygen consumption,
and decreased oxygen supply to the myocardium
 May produce rapid apical and peripheral pulse rates, palpitations, and signs and symptoms of reduced cardiac
output and hypotension

Atrial tachycardia with block

Rhythm

 Atrial: regular
 Ventricular: regular if the block is constant;
irregular if the block is variable

Rate

 Atrial: 150 to 250 beats/minute and multiple of

ventricular rate
 Ventricular: varies with block

P wave

 Slightly abnormal
 More than one P wave for each QRS complex
PR interval: Usually normal; may be hidden

QRS complex: Usually normal

T and QT wave: Indiscernible

Other: None

Multifocal atrial tachycardia

Rhythm: Irregular

Rate

 Atrial: typically 100 to 250 beats/minute, but

usually under 160 beats/minute
 Ventricular: usually 100 to 250 beats/minute

P wave: Configuration varies with at least three different

P-wave shapes appearing

PR interval: Varies

QRS complex: Usually normal; may become aberrant

T wave: Usually distorted

QT interval: May be indiscernible

Other: None

Paroxysmal atrial tachycardia

Rhythm: Brief periods of tachycardia, alternating

with periods of normal sinus rhythm

Rate: 140 to 250 beats/minute

P wave

 Abnormal
 Precedes each QRS complex
 May be hidden in previous T wave

PR interval: Identical for each cycle

QRS complex: May be aberrantly conducted

T wave: Indistinguishable

QT interval: Indistinguishable

Other

 Has a sudden onset and end

 Typically initiated by a premature atrial contraction

Atrial Flutter

Characterized by:

 an atrial rate of about 300 beats/minute

 flutter, or F, waves on ECG (hallmark of
atrial flutter).

Results from:

 circus reentry
 possibly increased automaticity.

Clinical significance

 Determined by the number of impulses conducted through the atrioventricular (AV) node; expressed as a
conduction ratio (2:1 or 4:1)
  May maintain normal peripheral and apical pulses since the pulse reflects the number of ventricular
contractions (not atrial impulses)

Rapid ventricular rate

 Faster the rate, the more dangerous the arrhythmia

 Produces symptoms due to reduced ventricular filling time and coronary perfusion
 Causes angina, heart failure, pulmonary edema, hypotension, and syncope

Normal ventricular rate: May be asymptomatic

Analyzing the ECG rhythm strip

Rhythm

 Atrial: regular
 Ventricular: typically regular, but
depends on AV conduction pattern

Rate

 Atrial: typically 250 to 400 beats/minute

 Ventricular: depends on degree of AV block; usually one-half to one-fourth of atrial rate; one of the most
commonly seen rates�a ventricular rate of 150 beats/minute with an atrial rate of 300 beats/minute�is
known as a 2:1 block

Atrial flutter

P wave

 Abnormal
 Saw-toothed pattern

PR interval: Unmeasurable

QRS complex

 Usually within normal limits in duration

 May be widened if flutter waves are within
complex

T wave: Unidentifiable

QT interval: Unmeasurable

Other: Atrial rhythm: may vary between a

fibrillatory line and flutter waves, referred to as
atrial fib-flutter

ATRIAL FIBRILATION

Characterized by:

 chaotic, asynchronous, electrical activity in

the atrial tissue
 the firing of 400 to 600 erratic impulses each minute from numerous ectopic atrial pacemakers
 the appearance of baseline fibrillatory waves, rather than P waves
 irregularly irregular ventricular response as the AV node blocks impulses
 a wide variation in R-R intervals.

Common causes include:

 cardiac surgery
 cardiac disorders
 respiratory disorders
 use of certain drugs (aminophylline or
digoxin)
 other conditions (hyperthyroidism, electrolyte imbalances, endogenous catecholamine release during exercise).
In otherwise healthy persons, may be caused by:

 fatigue
 obesity
 stress
 smoking
 coffee
 antihistamines
 nonprescription cold remedies
 alcohol use.

Clinical significance

 Loss of approximately 20% of normal end-

diastolic volume due to the loss of atrial kick
 Decreased diastolic filling time
 Reductions in cardiac output
 High potential for thrombus formation
 Can lead to a thrombotic stroke, cardiovascular collapse, and systemic arterial or pulmonary embolism
 Evaluation for anticoagulation therapy may be necessary

Rhythm

 Grossly irregular atrial and ventricular rhythms

 Typically described as "irregularly irregular"

Rate

 Atrial: exceeds 400 beats/minute; most

impulses aren't conducted through AV
junction
 Ventricular: varies from 100 to 150
beats/minute; can be less than 100
beats/minute

P wave: Appearance of erratic baseline fibrillatory

waves instead

PR interval: Indiscernible

QRS complex: Usually normal in duration and

configuration

T wave: Indiscernible

QT interval: Unmeasurable

Other: May develop atrial fib-flutter