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.• Bradyarrhythmias are rhythms in which the heart rate is 60 bpm. They arise from disorders of impulse formation or impaired impulse conduction.

to a rate 60 bpm. • Pathologic sinus bradycardia can result from either intrinsic SA node disease or extrinsic factors that affect the node. as a result of decreased firing of the sinoatrial (SA) node.SINUS BRADYCARDIA • Sinus bradycardia is a slowing of the normal heart rhythm. .

light-headedness. . confusion.• Mild sinus bradycardia is usually asymptomatic and does not require treatment. or syncope. a pronounced reduction of the heart rate can produce a fall in cardiac output with fatigue. • However.

who are also susceptible to supraventricular tachycardias (SVTs).SICK SINUS SYNDROME • Intrinsic SA node dysfunction that causes periods of inappropriate bradycardia is known as sick sinus syndrome • SSS is common in elderly patients. This combination is known as the bradycardia– tachycardia syndrome and is thought to result from atrial fibrosis that impairs function of the SA node and predisposes to AF and fl utter. . most commonly atrial fibrillation (AF).

retrograde P waves may be observed as an impulse propagates from the more distal pacemaker backward to the atrium. They are characterized by a normal. • Ventricular escape rhythms are characterized by even slower rates (30 to 40 bpm) and widened QRS complexes. However. The complexes are wide because the ventricles are not depolarized by the normal rapid simultaneous conduction over the right and left bundle branches but rather from a more distal point in the conduction system. and when they occur in sequence (termed a junctional escape rhythm) • The QRS complexes are not preceded by normal P waves because the impulse originates below the atria. narrow QRS complex.ESCAPE RHYTHMS • Junctional escape beats arise from the AV node or proximal bundle of His. .


4. the 1:1 relationship between P waves and QRS complexes is preserved. • In this situation. shown in Figure 12. which is 5 small boxes on the ECG).FIRST-DEGREE AV BLOCK • First-degree AV block. such that the PR interval is lengthened (0.2 sec. . indicates prolongation of the normal delay between atrial and ventricular depolarization. The impairment of conduction is usually within the AV node itself and can be caused by a transient reversible infl uence or a structural defect.

In Möbitz type I block (also termed Wenckebach block. • There are two forms of seconddegree AV block. . Möbitz type I block almost always results from impaired conduction in the AV node (rather than more distally in the conduction system).SECOND-DEGREE AV BLOCK • Second-degree AV block is characterized by intermittent failure of AV conduction. resulting in some P waves not followed by a QRS complex.

12. 12. in which case it is known as highgrade • AV block (Fig.6). without preceding graduallengthening of the PR interval (Fig. Möbitz type II block is usually caused by conduction block beyond the AV node (in the bundle of His or more distally in the Purkinje system). and the QRS pattern often is widened in a pattern of right or left bundle branch block.• Möbitz type II second-degree AV block is characterized by the sudden intermittent loss of AV conduction. • The block may persist for two or more beats (i. two sequential P waves not followed by QRS complexes). .e..7).

there is no relationship between the P waves and QRS complexes because the atria depolarize in response to SA node activity. • In adults. while a more distal escape rhythm drives the ventricles independently. 12. the most common causes are acute myocardial infarction and chronic degeneration of the conduction pathways with age. . also termed complete heart block (Fig. • Third-degree AV block electrically disconnects the atria and ventricles.8).THIRD-DEGREE AV BLOCK • Third-degree AV block. is present when there is complete failure of conduction between the atria and ventricles.