Introduction to ECGs: Rhythm Analysis

Written by Jason Waechter MD FRCPC

Clinical Assistant Professor Depts. of Anesthesia and Critical Care Written in 1999 Last Revised July/2012 2012, Jason Waechter

Introduction to ECG: Rhythm Analysis

This package is designed to be an overview of single lead ECG's (as opposed to 12 lead ECGs). I have tried to use a simple organized approach to interpreting ECG's to help you become more thorough and accurate in your diagnoses. If you feel more comfortable with your own style that is different than the one presented here, by all means feel free to use it. I have included only one method of interpreting ECG's A single lead ECG provides less information than a 12 lead ECG and therefore some diagnoses will not be able to be made with only a single lead. Examples of diagnoses than cannot be made from a single lead include: myocardial ischemia or infarction, axis determination, hypertrophy, or bundle branch block (LBBB or RBBB) and electrolyte abnormalities to name a few. However, rhythm strips (single leads) are usually pretty good for diagnosing dysrhythmias. An outstanding textbook for 12 lead ECGs is 12 Lead ECGs: The Art of Interpretation by Tomas Garcia. This booklet is a continuous work in progress. I appreciate any feedback or questions: jwaech@yahoo.ca. Jason Waechter

How does the ECG work? ECG stands for electrocardiogram: electro = electrical; cardio = heart; gram = recording. Therefore, the ECG records electrical activity of the heart. When the heart beats, the cells of the heart depolarize. When depolarization occurs, positively and negatively charged ions (Na+, Ca2+, K+, and Cl-) move in and out of the heart cells. This movement of ions creates electrical changes on the surface of each cell. At any given time, one could imagine that the myocytes that are depolarizing are causing microscopic electrical charges at each individual cell. Adding up all those microscopic charges, you get a total electrical charge. It is this total charge that can be measured from the skin as an ECG. The size of this charge will be determined by how many microscopic charges are being added up at a given time. The position in space of the total charge moves as the wave of depolarization moves through the heart. The ECG measures movement of the electrical charge.

teachingmedicine.com This teaching resource is free to use.

The Leads:
There are 3 electrodes that are placed on the chest. From these 3 points, 3 leads are generated. Each lead is simply an electrical comparison of 2 points on the chest. The letters A,B,C can be ignored. They are included for teaching only.

Lead I (c is not used)

Lead II

Lead III

Putting these 3 leads together would give you Einthovens triangle.

3 more leads can be constructed using the average of 2 leads against the 3rd:

Lead aVF (to the Foot) (average of A and B)

Lead aVL (Left arm)

Lead aVR (Right arm)

These 6 leads are called the limb leads. Simple ECG machines still place the electrodes on the chest. In 12 lead ECG machines, the points A and B are usually measured using electrodes on the wrists and point C is measured using 1 electrode on each ankle.

teachingmedicine.com This teaching resource is free to use.

This diagram is a representation of all 6 limb leads. Note that the front end of the arrows are designated as positive. An electrical charge traveling in that direction will make a positive (upward) deflection in that lead on the ECG. Note where 0 is and which direction is positive (clockwise). This will be important in 12 lead analysis, but for now is not important for rhythm analysis. Note also that all leads are separated by 30.

There are 6 more leads called the precordial leads (precordium = front of chest) and are designated V1 (vee one as opposed to Lead I which is lead one) through V6. The precordial leads will be discussed in section 2, which is 12 lead analysis and this lecture is given to 3rd year medical students. Generally speaking, you do not need to know which lead you are looking at when doing a single lead analysis. However, some leads show details better than other leads. Lead II is the lead used most commonly for single lead analysis because it usually shows P waves better than the other leads. Lead V1 is also good because it also shows the P waves well. Assume that all ECG examples provided in this handout are taken from Lead II.

teachingmedicine.com This teaching resource is free to use.

Electrical Physics of the ECG One issue that gives trouble to those first learning ECGs is the positive and negative aspects of the leads and the differences between the leads. There are some fundamental principles: 1) If a charge is moving toward the positive electrode, an upward deflection will result. 2) If a charge is moving away from the positive electrode, a downward deflection will result. 3) If a charge is not moving no deflection will result. 4) If a charge is moving toward but at an angle to the positive electrode, an upward but smaller deflection will result (the opposite is true for away and downward). Examples using a sphere (instead of a heart) demonstrate these principles. The 2 black dots are the 2 ECG electrodes which together make up one ECG lead. The principle is the same whether the leads were to be placed right against the heart or at a distance from the heart on the skin. Direction of movement Deflection

teachingmedicine.com This teaching resource is free to use.

Direction of movement

Deflection

teachingmedicine.com This teaching resource is free to use.

Anatomy The heart structures that you must know in order to understand rhythm strips are: sinoatrial (SA) node atria (singular is atrium) atrioventricular (AV) node ventricular conducting pathways (i.e. bundle of His, right and left bundle branches) ventricles

Physiology A normal heart beat follows this sequence: 1. 2. 3. 4. 5. the SA node generates an electrical current this current travels through the atria the current then enters the AV node, where is slows down for a little delay the current enters the ventricular conduction pathways where it travels rapidly and the ventricles contract 6. and then the ventricles relax

teachingmedicine.com This teaching resource is free to use.

Matching the ECG to the electrical activity of the heart (see also previous page for anatomy diagram):

teachingmedicine.com This teaching resource is free to use.

Automaticity Many cells in the heart have the capacity to be pacemaker cells. This property is known as automaticity. This is a very important concept! Although any cell could be the pacemaker for the heart, in healthy hearts only the SA (sinoatrial or sinus) node performs this function. The SA node is the normal pacemaker because it is the fastest pacemaker. The sinus node paces at a rate of about 60-100 beats per minute (bpm). The fastest pacemaker will override all other slower pacemakers and reset them to zero. Therefore, the slower pacemakers would theoretically never fire. The next fastest pacer is the atrioventricular (AV) node also called the junctional pacemaker (because it is at the junction of the atria and the ventricles). It paces at a rate of 40-60 bpm. The slowest pacers are the purkinje fibres and ventricular muscle, which pace from 20-40 bpm. The atria can also become pacemakers, and in diseased states, they can be very fast. When any part of the heart other than the sinus node is the pacemaker, the new beats are called ectopic beats and the pacemaker is designated as an ectopic pacemaker. When the beats are earlier than the next expected normal beat, they are called premature. When they occur later than the expected beat (which can only occur if the expected normal beat doesn't happen) then they are called escape beats. The location and timing of an ectopic beat determines how it will be named. For example, an early beat from the atrium is called a premature atrial contraction. A late beat from the AV node is called a junctional escape beat. Ectopic beats can occur in isolation (one at a time) on a background of sinus rhythm, or they can completely take over the pacemaking function and generate a new rhythm.

Fibrillation Sometimes the heart cells do not participate in coordinated pacemaking activity. At times, the electrical activity of the heart can become chaotic with countless electrical charges being generated and conducted. When this occurs, the chamber does not contract, but instead, quivers like a bag of worms and is called fibrillation. Either the atria or the ventricles can participate in fibrillation and are called atrial fibrillation (a. fib or AF) and ventricular fibrillation (v. fib or VF).

teachingmedicine.com This teaching resource is free to use.

Electrical Conduction In order for the heart to effectively beat, the electrical charge must be conducted properly through the different anatomical structures of the heart. The electrical charge travels quickly through conducting pathways and slowly through heart muscle (the ventricles). The electrical charge must also travel through the AV node, where it is slowed down to give the atria time to contract before the ventricles contract. Abnormalities of the conduction pathway are very common. Conduction can be slowed down too much. For example, when this occurs in the AV node, the PR interval becomes long. Conduction can also be completely stopped. This is called a block. If an ectopic beat occurs, the electrical charge might not be able to use the normal conducting pathways. This occurs with ventricular ectopic beats. The electrical charge must travel through ventricle muscle which is slow and the QRS ends up being spread out over more time and appears wide on the ECG. The Approach Although some ECGs are easy to diagnose at a single glance, it is worthwhile to go through a thorough approach for every ECG to make sure that nothing obvious is overlooked. I suggest memorizing the following approach and for each ECG, fill in the blanks: 1. 2. 3. 4. 5. Rate Rhythm P wave PR interval QRS complex Rate Normal rate is 60-100. Slower than 60 is called bradycardia and faster than 100 is called tachycardia. An easy way to calculate rate is to count how many big squares are between each QRS complex. Then divide 300/number of squares. If there are 2 squares then the rate is 300/2 = 150. If there are 5 squares, then the rate is 300/5 = 60. FYI only (this will not be on an exam): The number 300 is derived because the ECG paper speed is 25 mm/second. Each big square is 5 mm. Therefore, 5 big squares = 1 sec; one beat every 5 big squares is a rate of 60 beats per minute. A beat on every big square would have a rate of 5 x 60 = 300.

teachingmedicine.com This teaching resource is free to use.

10

In the strip below, there are about 4 squares between each QRS, so 300/4 = 75 bpm.

In the strip below, there are about 2 (plus a little) squares between each QRS so 300/2 = 150 bpm (maybe 140).

In the strip below, there are about 10 squares between each QRS so 300/10 = 30 bpm.

teachingmedicine.com This teaching resource is free to use.

11

Rhythm There are 3 types of rhythms: regular irregular with a pattern irregular without a pattern Regular rhythm

Regular rhythm with one early beat

Irregular with a pattern: 2 beats then one early beat (3rd, 6th and 9th beats are early)

teachingmedicine.com This teaching resource is free to use.

12

Irregular with no pattern: R-R distance (distance between each beat) is always changing

P Waves There are 4 questions to ask when analyzing the P waves: 1. 2. 3. 4. Are there P waves present? Are the P waves all the same shape and size? Are there more or fewer P waves than QRS complexes? What is the relationship between the P wave and the QRS complex? (see also PR interval)

Normal P waves, all same size/shape, 1 P wave for every 1 QRS, constant relationship between P wave and QRS.

No P waves

teachingmedicine.com This teaching resource is free to use.

13

P waves present, all same shape and size. More Ps than QRS. Some Ps have no QRS.

No Paves, but lots of background activity.

P waves present. There are more P waves (6 that you can easily see + 2 that are hiding) than QRS complexes. Not related to QRS at all. Some P waves are buried under the QRS if you map them out.

P waves all same size/shape (dont confuse the T wave). Many more P waves than QRS complexes.

teachingmedicine.com This teaching resource is free to use.

14

P waves same size/shape but are inverted. 1 P wave for every QRS, constant relationship between P wave and QRS.

P wave is after the QRS and superimposed on the ST segment. P wave is inverted.

PR Interval To analyze the PR interval, ask: 1. Is the PR interval short, normal or long? Short is less than 3 little squares (< 0.12 sec) Normal is 3-5 little squares (0.12 to 0.20 sec) Long is more than 5 little squares (> 0.20 sec) 2. Does the PR interval change or is it constant? if there are no P waves, then the PR interval doesnt exist and cannot be analyzed. if there are more P waves than QRS complexes, then some P waves wont have a PR interval, because there will be no R from the absent QRS remember that the PR interval starts at the beginning of the P wave (see page 8).

PR interval = 4 little squares = 4 times 0.04 = 0.16 sec and is normal. PR interval is constant.

teachingmedicine.com This teaching resource is free to use.

15

PR interval = 7 little squares = 7 times 0.04 = 0.28 sec and is long. PR interval is constant.

PR interval is changing. Shortest is on the 3rd beat = 4 little squares = normal. Longest is on 2nd and 5th beats and is 8-9 little squares and is long. 2 P waves have no QRS and therefore no PR interval.

PR interval is about 2.5 little squares = 2.5 times 0.04 = 0.10 sec = short. PR interval is constant.

teachingmedicine.com This teaching resource is free to use.

16

QRS Complex There is only one question for the QRS complex for single lead ECG: Is the width of the QRS complex narrow (normal) or wide? Normal QRS is less than or equal to 3 little squares (0.12 sec). The cause of a wide QRS (> 3 little squares) is due to: a conduction delay through the normal conducting system or a beat that is conducted through cardiac muscle (slowly) instead of through the conducting system (fast).

QRS duration is 2 little squares = 0.08 sec. = narrow = normal.

QRS duration is 4 little squares = 0.16 sec. = wide = abnormal.

QRS duration is 2 little squares = 0.08 sec. = narrow = normal. For a diagram showing how the QRS is produced, please see The QRS complex and T Wave handout on my website. For diagrams about a wide QRS, see A Wide QRS.

teachingmedicine.com This teaching resource is free to use.

17

Naming the QRS Naming the parts of the QRS complex is not required for rhythm analysis. However, the multi-directional aspect of the QRS often confuses people. If the first deflection is upward, it is an R wave. If the first deflection is downward, it is a Q wave.

R wave

Q wave

The second deflection is named according to the first deflection. It always goes in alphabetical order.

QR wave

QR wave

RS wave

RS wave

teachingmedicine.com This teaching resource is free to use.

18

If there are 3 deflections and the first deflection is an R wave, then the 3rd deflection is called R prime and designated as R.

QRS wave

RSR wave

Worry about it later (but still read this) Please note that not all parts of the ECG are included in the analysis for rhythm analysis. In particular, you do not need to analyze the following parts of the ECG: 1. The up/down components of the QRS complex. Although you can now differentiate the different QRS waves, it is not part of the rhythm analysis. 2. The ST segment. You can completely ignore it for now UNLESS is has a buried P wave in it. In this case, you are still analyzing the P wave. 3. The T wave. It is important to recognize the difference between the T wave and the P wave (which is sometimes difficult). Naming the Rhythm There is some logic with how cardiac rhythms are named, which makes it easier to understand them. The following information is often part of the name of a rhythm: the pacemaker the speed (too fast or too slow) the timing (early or late) For example, the normal rhythm that most people have is normal sinus rhythm. The word sinus is used because the sinus node is the pacemaker. Other examples to help you understand (after you learn more about the diagnostic criteria of the rhythms, this list will be more meaningful): sinus bradycardia: pacemaker = sinus node, speed = too slow PAC or premature atrial contraction: pacemaker = atrium, timing = early ventricular tachycardia: pacemaker = ventricle, speed = too fast atrial fibrillation: pacemaker = atria junctional escape beat: pacemaker = AV node, timing = late

teachingmedicine.com This teaching resource is free to use.

19

IMPORTANT!
How to Think About the Rhythm When you are trying to diagnose the rhythm of the ECG, the first step is to identify all the normal and abnormal components of the ECG as outlined above using an organized approach. The next (very important) step is to try to visualize 2 things: 1. where the pacemaker is and 2. what path the electrical activity travels after being started Note that sometimes, the pacemaker may be 2 (or more) pacemakers, or can be an entire cardiac chamber (fibrillation). It is not easy to learn where the pacemaker is. In fact, this is the hardest component of interpreting ECGs, so we will spend a bit of time on this task. First, there are the 5 pieces of information that you have to collect. You need all this information. If you neglect one piece of information, it could result in an inaccurate result: 1. Rate 2. Rhythm 3. P wave 4. PR interval 5. QRS complex Second, there are 4 options where the pacemaker can exist: 1. 2. 3. 4. SA node Atria AV node Ventricles

Lets begin by describing the characteristics of what the ECG would look like if the pacemaker was located in each of the 4 locations. SA node: 1. the maximum physiological heart rate that can be obtained in the SA node is approximately 220 minus your age. Therefore, the pacemaker is unlikely to be the SA node if the heart rate > 200. 2. in order for the electrical signal to pass into the ventricles, the signal must travel through the atria. This will create P waves. Therefore, SA node pacemakers generate P waves. 3. in order for the electrical signal to pass into the ventricles, the signal must also travel through the AV node. This will create a normal delay and will
teachingmedicine.com This teaching resource is free to use.

20

contribute to the PR interval. Therefore, a very short PR interval is unlikely to be generated from a pacemaker in the SA node. 4. as a result of the signal passing first through the atria and then subsequently through the ventricles, there will be a P wave that is followed by a QRS. 5. the SA node paces using automaticity. This is a regular process and therefore generates a rhythm that is regular. Atria: 1. Electrical signals from the atria must pass through the AV node. The AV node has an important refractory period and limits how frequent the signals enter the ventricles. Therefore, a heart rate > 200 is unlikely to be a pacemaker in the atria. 2. The atria do not demonstrate automaticity. The only way they can be pacemakers is to be pathological. This occurs as a result of a re-entry circuit developing within the atria. Re-entry circuits are usually fast. Therefore, atrial pacemakers are usually fast. 3. A pacemaker in the atria must conduct the signal through the rest of the atrial tissue and therefore, atrial pacemakers generate P waves. 4. Atrial pacemakers are located in a different location within the atria than is the SA node. Therefore, an atrial pacemaker will often generate a P wave that is a different size or shape. 5. Fibrillation occurs when there are multiple re-entry circuits occurring all at the same time. There are very fast. They are also mathematically very complicated and appear chaotic with no rhythm. Therefore, atrial fibrillation results in an irregular rhythm with no pattern. 6. Fibrillation is so chaotic that no organized P waves occur. Therefore, atrial fibrillation does not generate P waves, but does generate a chaotic baseline. AV Node: 1. The AV node can produce electrical signal through automaticity. This results in a slow heart rate. 2. The AV node can also generate re-entry circuits. Therefore, a pacemaker in the AV node can also generate a fast heart rate. 3. If a re-entry circuit develops in the AV node, it does not follow the normal rules of the AV node refractory period. Therefore, heart rates can be > 200 beats a minute. 4. When the AV node is the pacemaker, the electrical signal will escape upwards to the atria and downwards to the ventricles. However, a very important point is to recognize that AV node conduction is slow. Therefore: a. if the pacemaker within the AV node is near the top of the AV node, the signal will escape to the atria before it will escape to the ventricles b. if the pacemaker is in the middle of the AV node, the signals to the atria and ventricles will escape at the same time c. if the pacemaker is near the bottom of the AV node, the signal will escape first to the ventricles before the signal escapes upward to the atria

teachingmedicine.com This teaching resource is free to use.

21

d. the preceding 3 conditions will create the following results: i. P wave before QRS but with short PR interval ii. P wave not seen (superimposed on the QRS) iii. P wave appears AFTER the QRS (within the ST segment) 5. The P wave is usually upside down because it is travelling in the opposite direction compared to when it is generated in the SA node. Ventricles: 1. The pacemaker signal starts in ventricular muscle. When it travels through the myocardium, it does not use the conducting system. Therefore, it travels slowly. Therefore, it will take a long time. Therefore, the QRS will be wide. A narrow QRS cannot be a ventricular pacemaker. 2. A pacemaker in the ventricle will usually not generate a signal that goes up to the atria. Therefore, there is no P wave associated with the QRS. A second pacemaker (like the SA node) can sometimes produce P waves that are dissociated from the QRS. 3. A pacemaker in the ventricle does not pass through the AV node. Therefore, it is possible to have heart rates faster than 200. Most of the time, heart rates are less than 200, however. General Important Notes: conduction block through one bundle branches (the right or the left) results in one ventricle receiving its electrical signal slowly from the other ventricle and this creates a wide QRS. Therefore, bundle branch blocks create a wide QRS. These pacemakers are never the ventricle, since the conducting system is being used; therefore, SA node, atria, and AV node pacemakers can generate a wide QRS and they usually have a P wave associated with the QRS, which makes them different from the wide QRS generated by a ventricular pacemaker. heart rates > 200 usually exclude the SA node and atria from being the pacemaker because of the refractory period of the AV node. Summary Rate Rhythm P waves PR interval QRS SA node < 200 regular yes > 0.12* narrow** Atria < 200 AF = irreg yes, abnormal > 0.12* narrow** AV Node any regular sometimes, abnormal < 0.12 narrow** Ventricles any regular none none wide AF = atrial fibrillation * could be short if a co-existing accessory pathway (WPW) is present. Units = millisec. **will be wide if a co-existing bundle branch block is present

teachingmedicine.com This teaching resource is free to use.

22

Table of Rhythms Sinus rhythms Normal sinus rhythm (NSR) Sinus arrhythmia Sinus bradycardia Sinus tachycardia Sick Sinus Syndrome First degree block Second degree block type I (Wenckebach) Second degree block type II Third degree block Interventricular delays (bundle branch block) Atrial rhythms (Paroxysmal) atrial tachycardia Atrial flutter Atrial fibrillation (a. fib.) Supraventricular tachycardia (SVT or PSVT) Premature atrial contraction (PAC) Wandering pacemaker Junctional (AV node pacemaker) Junctional rhythm Premature junctional contraction (PJC) Junctional escape beats Ventricular Premature ventricular beats (PVCs) Ventricular tachycardia (v. tach. or VT) Ventricular fibrillation (v. fib. or VF) Ventricular escape beats Idioventricular rhythm Agonal rhythm Torsade de pointes Other Asystole Bigeminy Wolff-Parkinson-White (WPW) Page 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

teachingmedicine.com This teaching resource is free to use.

23

Normal Sinus Rhythm Rate Rhythm P waves PR Interval QRS complex 60-100 (normal) regular (normal) upgoing, all the same, 1 P for every QRS (normal) 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

The SA node is the pacemaker. SA node activity produces no deflection on the ECG. The atria are depolarized from the SA node which produces an upgoing P wave in leads II and V1. The impulse through the AV node has a normal delay, forming the PR interval of normal duration. The conducting system of purkinje fibers conducts the depolarization through the ventricles rapidly producing a narrow QRS complex. Example 1

Example 2

Example 3

teachingmedicine.com This teaching resource is free to use.

24

Sinus Arrhythmia Rate 60-100 (normal) Rhythm* irregular with a pattern (faster with inspiration, slower with expiration) P waves upgoing, all the same, 1 P for every QRS (normal) PR Interval 3-5 little squares, constant (normal) QRS complex narrow, < 3 little squares (normal) * shows the abnormality required for the diagnosis Sinus arrhythmia is a normal rhythm found in healthy children and adults. With ventilation, the intrathoracic pressures change and with the change in pressures comes a change in filling and preload. Baroreceptors in the atria are stretched more with increased filling during inspiration and cause in increase in heart rate (HR). Patients with autonomic dysfunction (for example, diabetics) may not demonstrate sinus arrhythmia. Take your pulse and try it. This trick is helpful for exam questions!

Example 1

teachingmedicine.com This teaching resource is free to use.

25

Sinus Bradycardia Rate* Rhythm P waves PR Interval QRS complex < 60 regular (normal) upgoing, all the same, 1 P for every QRS (normal) 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

The definition of bradycardia is a HR less than 60 beats per minute (bpm). Sinus bradycardia is caused by the SA node firing at a rate of less than 60 bpm. The remaining electrical activity downstream is normal. Rates less than 60 bpm are commonly found in healthy adults. Athletes often have a sinus bradycardia and have an appropriately low heart rate. Rates that are inappropriately low can cause hypotension and need to be treated.

Example 1:

Example 2: (P waves are small. Can you see them?)

teachingmedicine.com This teaching resource is free to use.

26

Sinus Tachycardia Rate* Rhythm P waves PR Interval QRS complex 100-180 (maybe up to 200) regular (normal) upgoing, all the same, 1 P for every QRS (normal) 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

Tachycardia is defined as a HR > 100. Sinus tachycardia is caused by the SA node firing at a rate greater than 100 bpm. The remaining electrical activity downstream from the SA node is normal. Rates greater than 100 bpm are commonly found in healthy children and adults during activity or exercise, fear and pain. The maximum sinus rate is about 180-200 bpm. As a general rule, rates faster than 200 are not sinus (except in babies). Advanced: Other causes of sinus tachycardia include volume depletion (dehydration, acute blood loss), increased metabolic demand (hyperthermia, hyperthyroid, pheochromocytoma), impaired cardiac filling (tension pneumothorax, pericardial tamponade), and decreased afterload (anaphylaxis, septic shock). Example 1:

Example 2:

teachingmedicine.com This teaching resource is free to use.

27

Sick Sinus Syndrome Rate* Rhythm* P waves PR Interval QRS complex very low - 180 irregular upgoing, all the same, 1 P for every QRS (normal) 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

Sick sinus syndrome can include sinus bradycardia, sinus tachycardia, sinus block (sinoatrial block), and sinus arrest. Sinus block is when the SA node paces but the impulse does not exit the SA node. Sinus arrest is when the SA node fails to pace. Both sinus block and sinus arrest appear as nothing on the ECG because the SA node does not cause any deflection on the ECG. Some causes of sick sinus syndrome include: hypoxia, myocardial ischemia or infarction, hyperkalemia and digoxin toxicity. Because sinus bradycardia, block and arrest all result in increased time with no electrical activity, it is common to see escape beats. Escape beats are always late beats and can be atrial, junctional or ventricular in origin. Escape beats are always non-sinus pacemakers.

Example 1: sinus bradycardia with sinus arrest or sinus block, followed by a junctional escape beat. The drifting baseline (seen twice) is artifact from breathing.

teachingmedicine.com This teaching resource is free to use.

28

First Degree Heart Block Rate Rhythm P waves PR Interval* QRS complex 60-100 (normal) regular (normal) upgoing, all the same, 1 P for every QRS (normal) > 5 little squares (> 0.20 sec.), constant narrow, < 3 little squares (normal)

First degree heart block demonstrates a long PR interval. This occurs because the delay through the AV node is too long due to slow conduction in the AV node. The remaining electrical system functions normally. All the P waves are conducted and are associated with a QRS complex (compare to 2nd and 3rd degree blocks). Ischemia or fibrosis of the AV node can cause AV node dysfunction and result in a first degree block. A first degree block is abnormal. It may co-exist with other abnormalities, such as sinus bradycardia (see example 2). Example 1:

Example 2:

teachingmedicine.com This teaching resource is free to use.

29

Second Degree Heart Block Type I (Wenckebach) Rate Rhythm* P waves* PR Interval* QRS complex 60-100 (normal) irregular with a pattern: regularly missing QRS complexes upgoing, all the same, some dropped QRS complexes. More Ps than QRS complexes increasing from normal and long narrow, < 3 little squares (normal)

Second degree heart blocks are defined as follows: some but not all of the P waves are conducted to the ventricles. In type I (Wenckebach), the PR interval increases with each heart beat until it is so long that the signal doesnt reach the ventricles and the depolarization is blocked at the AV node. This beat will show a P wave with no QRS following it. Following the blocked (dropped) beat, the AV node starts again with a normal or near normal PR interval and the cycle repeats itself. Example 1:

Example 2:

teachingmedicine.com This teaching resource is free to use.

30

Second Degree Heart Block Type II Rate Rhythm* P waves* PR Interval QRS complex 60-100 (normal) regular with random missing QRS complexes upgoing, all the same, some dropped QRS complexes. More Ps than QRS complexes 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

Second degree heart blocks are defined as follows: some but not all of the P waves are conducted to the ventricles. In type II, P waves are randomly blocked just below the AV node. The PR interval is constant, which contrasts with the type I block. 2nd degree type II blocks are more likely to develop into 3rd degree blocks than are 2nd degree type I blocks and are therefore considered to be more dangerous. You need to know the differences between 2nd degree, type I and type II. Example 1:

teachingmedicine.com This teaching resource is free to use.

31

Third Degree Heart Block (Complete Heart Block, AV Disassociation) Rate * Rhythm P waves* PR Interval* QRS complex* atrial rate different than ventricular rate (which is usually <40) regular or irregular upgoing, all the same, no association with QRS, more Ps than QRS complexes, may be buried in QRS complex, ST segment or T wave random, no conducted P waves so no true PR interval Wide, > 3 little squares

In third degree block, no P waves are conducted to the ventricles. The SA node generates atrial contractions and P waves. The P waves are 100% unrelated to the QRSs. Because the ventricles are not being depolarized, an ectopic site within ventricular muscle becomes the new ventricular pacemaker. The ventricular rate is determined by the ventricular ectopic while the atrial rate is determined by the sinus node. The ventricular beats do not travel retrograde through the AV. The atrial rate is usually faster than the ventricular rate. Because the ventricular electrical impulse is conducted through myocardium and not through the conducting system, the impulse is conducted slowly and gives rise to a wide QRS complex. Rarely, a low junctional (AV node) pacemaker will give rise to the ventricular beats and will result in a narrow QRS that is completely dissociated from the P waves. Example 1: (note the buried P wave in 3rd ST segment)

Example 2:

teachingmedicine.com This teaching resource is free to use.

32

Intraventricular Delays (bundle branch block or aberrancy) Rate Rhythm P waves PR Interval QRS complex* 60-100 (normal) regular (normal) upgoing, all the same, 1 P for every QRS (normal) 3-5 little squares, constant (normal) wide, > 3 little squares

The only abnormality on single lead ECG of intraventricular delays or bundle branch blocks is the finding of a wide QRS complex. The QRS complex is wide because of slow conduction through the purkinje system or because one of the bundle branches is blocked and therefore the blocked ventricle receives it depolarization from the other ventricle which is conducted through cardiac muscle and therefore slow. Left ventricular hypertrophy (LVH) causes thickening of the ventricle which results in an increased distance (and therefore time) for the electrical impulse to travel across the ventricle. LVH is a cause of a wide QRS, but is usually not as wide as a slowly conducted beat. Left bundle branch block (LBBB) Right bundle branch block (RBBB)

It is not possible to fully evaluate the location of the intraventricular delay or blockage with a single lead ECG, although there are some differences (not listed here). The most important aspect of intraventricular delay is to differentiate it from 3rd degree heart block. Both rhythms have a wide QRS complex. Intraventricular delay rhythms demonstrate conduction from the P waves (i.e. a P wave is before each QRS) and are usually faster because the SA node sets the pace (60-100), while in 3rd degree block, the ventricular pacemaker sets the pace (20-40) and the P waves are not related to the QRS. Example 1:

(Paroxysmal) Atrial Tachycardia

teachingmedicine.com This teaching resource is free to use.

33

(Paroxysmal) Atrial Tachycardia Rate* Rhythm P waves* PR Interval QRS complex 150-250 regular (normal) abnormal shape, all the same, 1 P for every QRS (normal) 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

Atrial tachycardia is driven by a pacemaker in the atrium. The location of the pacemaker is the reason the P waves are an abnormal shape. The direction of depolarization through the atria determines (in part) the shape of the P wave. A pacemaker located away from the sinus node will produce a different shaped P wave than the sinus node will. Atrial rates can be faster than sinus rates. With rapid rates, the P wave can be very difficult or impossible to see. Paroxysmal means sudden onset. Example 1:

teachingmedicine.com This teaching resource is free to use.

34

Atrial Flutter Rate* Rhythm* P waves* PR Interval QRS complex atrial rate usually 300, ventricular rate 150/100/75 depending on block regular but irregular if AV block is variable sawtooth or flutter waves, many more P waves than QRS 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

Atrial flutter can be thought of as extreme atrial tachycardia. Atrial rates are usually 300, which exceeds the rate at which the AV node can conduct. Therefore, there is a physiological block at the AV node due to the inherent refractory period of the AV node. Note that this is not considered to be a 2nd degree block which is a pathological block. Often the AV node blocks every 1 of 2 atrial impulses, resulting in an atrial rate of 300 and ventricular rate of 150. This is called a 2:1 block and is common in atrial flutter. If the AV node blocks every 2 of 3 atrial beats, a 3:1 block with an atrial rate of 300 and ventricular rate of 100 results. 4:1 and 5:1 blocks also exist. If the AV node varies between differing levels of block, then the ventricular rhythm will be irregular. At higher rates, P waves may not be obvious. A regular ventricular rate of 150 should raise suspicion of atrial flutter (example 2). Example 1: Atrial flutter with atrial rate 300, 4:1 AV block, and ventricular rate of 75

Example 2: Atrial flutter with 2:1 block. Difficult to see P waves

teachingmedicine.com This teaching resource is free to use.

35

Atrial Fibrillation (a. fib. or AF) Rate (*) Rhythm* P waves* PR Interval* QRS complex usually >80 but not required for diagnosis irregular with no pattern no P waves, noisy background doesnt exist narrow, < 3 little squares (normal)

See section on fibrillation (page 8). When part of the heart fibrillates, there is no contraction. However, there is a very high amount of uncoordinated electrical activity which results in quivering. It is this quivering that gives rise to the noisy background in atrial fibrillation. The high amount of uncoordinated electrical activity literally bombards the AV node. The AV node conducts these impulses when it can, as fast as it can. Because of the erratic nature of the electrical input to the AV node from the atria and the refractory period of the AV node, the impulses that do get conducted down into the normal ventricular conducting system have an irregular rhythm with no pattern and are usually tachycardic. Blood clots can form in the atria during atrial fibrillation which can embolise to the systemic circulation (brain, kidneys, mesentery) and therefore management of a. fib includes anti-coagulation, rate control and sometimes cardioversion (back to sinus). Example 1:

Example 2:

teachingmedicine.com This teaching resource is free to use.

36

(Paroxysmal) Supraventricular Tachycardia (PSVT or SVT) Rate* Rhythm P waves* PR Interval* QRS complex > 150 (if 100-150, then usually can see the P waves) regular (normal) hard to see, may be absent unable to determine narrow, < 3 little squares (normal)

SVT is a blanket statement for any narrow QRS complex tachycardia in which the P waves are not obvious. The most important learning point regarding SVT is that it is not one rhythm, but rather a classification that encompasses many rhythms. The term is used to differentiate these tachycardias from VT (ventricular tachycardia) which is a wide QRS tachycardia, is usually more dangerous and is treated with different drugs. There are many rhythms that could be SVTs. They include: sinus tachycardia, atrial tachycardia, atrial flutter, atrial fibrillation and re-entry tachycardias to name a few examples (see also Re-entry Circuits handout on my website). The hallmark of SVT is a narrow QRS complex tachycardia which appears regular but is so fast that the P waves cannot be adequately visualized. Of note, a. fib is an irregular rhythm but at high rates it can mimic a regular rhythm. Example 1:

Example 2:

teachingmedicine.com This teaching resource is free to use.

37

Premature Atrial Contraction (PAC) Rate Rhythm* P waves* PR Interval QRS complex 60-100 (normal) regular with one early beat P wave for early beat is present and can have different size or shape 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

PACs are seen on a background of sinus rhythm. An atrial ectopic pacemaker fires before the sinus node, but only fires once. This produces an atrial contraction moving in a different direction (vector) and therefore changes the shape of the P wave. The beats occur before the next predicted sinus beat and send the atria and AV node into a refractory period so that the next impulse from the SA node enters the atria but stops immediately and does not show on the ECG. Because the SA node does not get reset, the space between the 2 beats before and after the PAC are exactly 2 sinus beats apart. FYI: Because there is less filling time for the PAC, the peripheral pulse generated by the PAC is often less than a sinus beat, or sometimes absent. In contrast, the sinus beat following the PAC has more time to fill and often is the beat that is felt by the patient.

Example 1: Note that the P wave for the early beat is slightly smaller. Also note that this PAC is occurring on a background of sinus bradycardia. Sinus bradycardia is not required for the diagnosis of PACs.

teachingmedicine.com This teaching resource is free to use.

38

Wandering Pacemaker Rate(*) Rhythm(*) P waves* PR Interval QRS complex 60-100 (normal), but can be < 60 close to regular, or regular different size and shaped P waves, 1 P for every QRS 3-5 little squares, constant (normal) narrow, < 3 little squares (normal)

Wandering pacemaker is a rhythm that has a changing pacemaker which can be exclusively atrial or can be a combination involving the atria and the SA node or AV node. Because the location of the pacemaker changes, the P wave shape and size changes also. Wandering atrial pacemaker is distinct from multifocal atrial tachycardia (MAT), another arrhythmia with multiple different P waves. In wandering atrial pacemaker the rate is normal or slow. In MAT it is rapid.

Example 1: note that all P waves are different!

teachingmedicine.com This teaching resource is free to use.

39

Junctional Rhythm (Nodal Rhythm) Rate* Rhythm P waves* PR Interval* QRS complex 40-60 (if HR > 60 then it is called accelerated junctional rhythm) regular (normal) may be inverted, absent (buried in QRS) or after QRS in ST segment short (<3 little squares) or non existant narrow, < 3 little squares (normal)

In junctional rhythm, the pacemaker is the AV node. From the AV node, the impulse is transmitted in directions: up to the atria (retrograde) and down to the ventricles through the normal conducting system. Because the atria are depolarized from the bottom up, the P wave is usually inverted. The impulse going to the ventricles is occurring at the same time as the impulse going to the atria. Therefore, 1 of 3 things can happen: 1) the atria beat first, 2) the atria and ventricles beat simultaneously, or 3) the ventricles beat first. In the first situation, the artia only just before the ventricles and so the PR interval is short. In the second situation, the P wave is buried in the QRS and is not seen. In the third situation, the P wave is founding the ST segment, after the QRS. Example 1: absent P waves (buried in QRS). Note the rate is accelerated

Example 2: P wave buried in ST segment. Note the rate is accelerated

Example 3: inverted P waves, short PR interval. This is a normal junctional rate.

teachingmedicine.com This teaching resource is free to use.

40

Premature Junctional Beat (PJC) Rate Rhythm* P waves* PR Interval* QRS complex 60-100 (normal) regular with one early beat For early beat: may be inverted, absent (buried in QRS) or after QRS in ST segment 3-5 little squares, constant (normal); early beat will be short or absent narrow, < 3 little squares (normal)

The concept is the same as for PAC, except that the early beat originates from the AV node instead of from the atrium. All other considerations for junctional beats as mentioned under Junctional Rhythm apply to PJCs.

Example 1: Which beat is the PJC?

teachingmedicine.com This teaching resource is free to use.

41

Junctional Escape Beats Rate Rhythm* P waves* PR Interval* QRS complex 60-100 (normal) regular with one late beat for the late beat: may be inverted, absent (buried in QRS) or after QRS in ST segment 3-5 little squares, constant (normal); for late beat will be short or absent narrow, < 3 little squares (normal)

Escape beats are beats that occur when an expected sinus beat does not. Therefore, escape beats could be considered as late beats in contrast to premature beats which occur earlier than the expected sinus beat. Escape beats (regardless of origin) can only occur in the setting of a pause in the underlying rhythm. All other considerations for junctional beats as mentioned under Junctional Rhythm apply to junctional escape beats.

Example 1: Compare junctional escape beats with premature junctional beats

teachingmedicine.com This teaching resource is free to use.

42

Premature Ventricular Beats (PVC) Rate Rhythm* P waves* PR Interval* QRS complex* 60-100 (normal) regular with one early beat upgoing, all the same, 1 P for every QRS; no P wave for early beat 3-5 little squares, constant (normal); none for early beat early beat will have be wide (> 3 little quares)

PVCs occur on a background of sinus rhythm. They are wide because the ectopic impulse is conducted through ventricular myocytes which conduct slowly and not through the normal conducting system which conducts quickly. Therefore, the impulse requires more time to travel through the ventricles and appears wider on the ECG. Premature beats occur before the next predicted sinus beat. Unifocal PVCs all originate from the same ectopic focus and have the same size and shape. Multifocal PVCs originate from multiple ectopics sites and therefore the QRS complexes that represent the PVCs will be different shapes and sizes because electrical activity will have different starting points and different directions of travel. 2 PVCs in a row are called a couplet. Many PVCs in a row are sometimes called a nonsustained V. tach.

Example 1: 2 unifocal PVCs with compensatory pauses (after the PVC) on a background of normal sinus rhythm

teachingmedicine.com This teaching resource is free to use.

43

Ventricular Tachycardia (V. tach. or VT) Rate* Rhythm P waves* PR Interval* QRS complex* 100-250 regular (normal) none none wide, > 3 little squares (0.12 sec.)

Ventricular tachycardia results from a sustained ventricular ectopic pacemaker. As in PVCs, the QRS complex is wide because the ectopic impulse is conducted through ventricular myocytes which conduct slowly and not through the normal conducting system which conducts quickly. Therefore, the impulse requires more time to travel through the ventricles and appears wider on the ECG. Bottom line: wide QRS and fast. V tach is dangerous and can easily cause cardiac arrest. Call a code blue immediately! Advanced note: An important distinction must be made between an SVT with interventricular delay vs. ventricular tachycardia. In SVT with interventricular delay, you will see a wide complex tachycardia but there will be P waves before every QRS. However, the P waves can sometimes be difficult or impossible to see. Atrial fibrillation with interventricular delay would have no P waves and a wide QRS but would have an irregular rhythm with no pattern. It can get tricky. Example 1:

Example 2: (sinus rhythm that deteriorates into v. tach)

teachingmedicine.com This teaching resource is free to use.

44

Ventricular Fibrillation (V. fib. or VF) Rate* Rhythm* P waves* PR Interval* QRS complex* 0 none none none uncoordinated activity only

See section on fibrillation (page 8). When part of the heart fibrillates, there is no coordinated contraction. However, there is a very high amount of uncoordinated electrical activity which results in quivering. It is this quivering that gives rise to the noisy ECG signal in ventricular fibrillation. There are no ventricular contractions and therefore no cardiac output, no pulse, and no blood pressure. V. fib is one example of cardiac arrest. Call a code blue and fire up the defibrillator (named after this very rhythm). The earlier you shock them, the higher the chance of good recovery. Do not delay. Extra seconds = permanent brain injury in this setting! Note an important difference between v. fib and a. fib: in a. fib, only the atria are fibrillating; therefore, the ventricles continue to contract: cardiac output, pulse, and blood pressure are usually well preserved provided that the heart rate is not too high. Example 1: coarse v. fib

Example 2: fine v. fib

teachingmedicine.com This teaching resource is free to use.

45

Ventricular Escape Beats Rate Rhythm* P waves* PR Interval* QRS complex* 60-100 (normal) regular with one late beat upgoing, all the same, 1 P for every QRS; no P wave for late beat 3-5 little squares, constant; none for late beat late beat will have be wide (> 3 little squares)

Escape beats are beats that occur when an expected sinus beat does not. Therefore, escape beats could be considered as late beats in contrast to premature beats which occur earlier than the expected sinus beat. The late beat will be a ventricular beat and will have no P wave and will have a wide QRS. There will be a background of sinus rhythm with a missing sinus beat.

Example 1:

teachingmedicine.com This teaching resource is free to use.

46

Idioventricular Rhythm Rate* Rhythm* P waves* PR Interval* QRS complex* 20-40 regular none none wide (>3 little squares)

An idioventricular rhythm is simply a rhythm driven by a ventricular ectopic pacemaker. The rate is 20-40 which is the intrinsic rate of a ventricular pacemaker. The QRS is wide because the conducting fibers are not used. There are no P waves because the electrical impulse is not conducted up through the AV node. The difference between an idioventricular rhythm and ventricular tachycardia is the rate. Ventricular tachycardia is driven by a pathological pacemaker while an idioventricular rhythm is paced by a physiological pacemaker because all other faster pacemakers have failed for some reason. See also agonal rhythm (next page) for a discussion regarding the similarities and differences of an agonal rhythm compared to an idioventricular rhythm. Although the term is not used, an idioventricular rhythm can be thought of as ventricular bradycardia.

Example 1:

teachingmedicine.com This teaching resource is free to use.

47

Agonal Rhythm Rate* Rhythm* P waves* PR Interval* QRS complex* < 20 irregular with no pattern none none very wide (>3 little squares)

An agonal rhythm is a slow ventricular rhythm. It is the last stage before asystole and could be considered to be asystole with occasional beats. It often has no pulse or blood pressure because the heart is so weak that it cannot contract with enough force to generate a palpable pulse. This rhythm has similarities to an idioventricular rhythm. The differences are that an idioventricular rhythm is not a dying heart and can sometimes produce a strong pulse. An idioventricular rhythm will occur at a rate that is equal to the intrinsic rate of the ventricular pacemaker, which is 20-40 while an agonal rhythm can be much slower and even less than 10 beats per minute. The QRS complex of an agonal rhythm is usually very wide and could be wider than an idioventricular rhythm. An agonal rhythm is from a dying heart and is 99+% of the time, not recoverable.

Example 1:

teachingmedicine.com This teaching resource is free to use.

48

Torsade de Pointes Rate* Rhythm P waves* PR Interval* QRS complex* >100 regular (normal) none none wide, > 3 little squares, getting bigger and smaller: twisting

Torsade is a deadly form of ventricular tachycardia. The QRS complexes are not all the same and are changing amplitude and direction with each heartbeat. The net effect is an appearance of twisting around, the way a spiral corkscrew might appear if viewed from the side. Torsade occurs because the conduction of each contraction is slightly different than the one before it: the path of conduction changes. Torsade produces no useful mechanical contraction of the ventricles and therefore there is no cardiac output, no pulse and no blood pressure. This is one form of cardiac arrest and torsade can be a cause of sudden death.

Example 1:

teachingmedicine.com This teaching resource is free to use.

49

Asystole Rate* Rhythm* P waves* PR Interval* QRS complex* 0 none none none none

Asystole is the absence of any systolic function. Therefore, there are no atrial or ventricular contractions. It is a flat line. Asystole is the last stage of deterioration of the heart. In a typical progression of deterioration of the heart, the following rhythms can be thought of as bad to worse. In an electrically failing heart, not all steps will necessarily occur (i.e. could go from bradycardia straight to asystole): brady or narrow complex tachy v. tach. v. fib. agonal asystole

Except in very special circumstances, an asystolic heart cannot be resuscitated. Usually, the patient has been in a pulseless rhythm for a period of time and has sustained hypoxic damage to the heart and brain to the point where recovery is no longer possible. When asystole is seen on a screen, the following 3 steps must be carried out to ensure that asystole does exist in the patient and there is not an equipment problem: 1. increase the gain/amplitude of the ECG (to rule out fine v. fib.) 2. check that the leads are all properly attached to the patient 3. check other leads (I, II, III) in case one lead is not reading very well these 3 steps are part of a course called Advanced Cardiac Life Support (ACLS)

Call a code blue for legal reasons, but call the morgue for practical reasons Example 1:

teachingmedicine.com This teaching resource is free to use.

50

Bigeminy Rate 60-100 (normal) Rhythm* irregular with a pattern (1 sinus, 1 premature beat) P waves** upgoing, all the same, 1 P for every QRS (normal) PR Interval** 3-5 little squares, constant (normal) QRS complex** narrow, < 3 little squares (normal) ** depends on the type of premature beat: atrial, junctional or ventricular Bigeminy is the term to describe a rhythm in which there is a normal sinus rhythm with a premature beat following every sinus beat. The premature beat could be atrial, junctional or ventricular. The rhythm will have a pattern of alternating sinus beats with premature beats and there will be a fixed interval both before and after the premature beat. The rhythm will be sinus premature pause. Trigeminy is a pattern of 2 sinus beats followed by a premature beat. Quadrigeminy is a pattern of 3 sinus beats followed by a premature beat. Example 1: ventricular bigeminy. Early beat is from the ventricle. Premature beat is wide with no P wave (dont confuse the T wave of the sinus beat). Can you see the sinus beat premature beat pause pattern?

Example 2: atrial trigeminy. The P waves of the premature beat are very slightly different. Early beats are from the atrium. 3rd, 6th and 9th beats are the atrial beats. All other beats are sinus beats.

teachingmedicine.com This teaching resource is free to use.

51

Wolff Parkinson White Syndrome (WPW) Rate Rhythm P waves PR Interval* QRS complex* 60-100 (normal) regular (normal) upgoing, all the same, 1 P for every QRS (normal) <3, short wide or borderline wide, > 3 little squares with a delta wave

WPW occurs because there is an extra electrical connection between the atria and ventricles. This connection is called an accessory pathway and labeled the Bundle of Kent. It serves to short circuit the AV node. The impulse comes from the SA node to the atria and then travels through the Bundle of Kent and the AV node. However, there is no delay through the accessory pathway and the ventricle begins to contract early. This is the reason why the PR interval is short. The electrical impulse first enters ventricle muscle and begins to travel through ventricle muscle at a slow rate, causing the initial portion of the QRS to be slurred and not very steep. However, when the impulse traveling through the AV node enters the conducting system, the ventricles then become rapidly depolarized and this fast moving wave overtakes the initial impulse that started off in ventricle muscle. The net effect is a QRS that starts off like a wide complex but then gets converted to a narrow complex. The first part of the QRS is slurred and this is called a delta wave. Overall, the QRS is usually wide or borderline wide. People with WPW are at risk for developing large re-entry circuits (see handout on my website).

Example:

teachingmedicine.com This teaching resource is free to use.

52