ECG arrhythmias

SINUS RHYTHM
Rhythm RATE RHYTHM P wave before Length of PR Are all QRS
QRS? P waves interval complexes equal?
upright and Length of QRS
uniform? complex

Normal sinus 60-100 bpm Atrial and Yes 0.12-0.20 Yes

rhythm ventricular seconds
rhythm regular (3-5 small 0.06-0.12 seconds
squares) (1 and a half to 3
small squares)

Sinus Less than Atrial and Yes 0.12-0.20 Yes

bradycardia 60bpm ventricular seconds
rhythm regular (3-5 small 0.06-0.12 seconds
squares) (1 and a half to 3
small squares)
Caused by: hypothyroidism, medication,
hypoglycaemia
Symptoms: syncope, dizziness, chest pain,
shortness of breath, exercise intolerance
Risk of reduced cardiac output
Treated with atropine

Sinus Higher than Atrial and Yes 0.12-0.20 Yes

tachycardia 100bpm ventricular seconds
rhythm regular (3-5 small 0.06-0.12 seconds
squares) (1 and a half to 3
small squares)
Sinus tachycardia is a fast heartbeat
related to a rapid firing of the SAN.

Caused by: damage to heart tissues from

heart disease, hypertension, fever, stress,
excess alcohol, caffeine, nicotine or
recreational drug abuse (cocaine), side
effect of medications, hyperthyroidism
and electrolyte imbalances.
Symptoms: palpitations, chest pain, dizziness, shortness of breath, syncope
Cardiac output may fail due to inadequate ventricular filling time
Myocardial oxygen demand increases which can ppt myocardial ischaemia
Treated with beta blockers and calcium channel blockers but need to find underlying cause
Sinus 60-100bpm Irregular yes 0.12-0.20 Yes
arrhythmia seconds 0.06-0.12 seconds
(3-5 small (1 and a half to 3
squares) small squares)

Sinus arrhythmia is a normal variation in the beating of your heart. A sinus arrhythmia refers to an irregular or
disorganised heart rhythm. This rate usually increases with inspiration and decreases with expiration

It is usually asymptomatic and treatment is

not usually required.

ATRIAL RHYTHMS
Atrial flutter Atrial: 250- Atrial: regular Normal P waves Not Yes
400bpm Ventricular: may are absent measurable 0.06-0.12 seconds
Ventricular: be irregular Sawtooth (1 and a half to 3
variable pattern are small squares)
flutter waves
It occurs most often in people over the age
of 60 with cardiovascular disease e.g.
hypertension, coronary heart disease and
cardiomyopathy and diabetes mellitus.

Atrial flutter is a coordinated rapid beating

of the atria.

Symptoms: palpitations, shortness of

breath, anxiety, weakness, angina and syncope
There is a risk of clot formation as the atria are not completely emptying leading to stroke or pulmonary
embolism. Treatment: cardioversion, antiarrhythmic drugs e.g. digoxin, beta-blockers, calcium channel
blockers, potassium channel blockers and sodium channel blockers e.g. procainamide, disopyramide and
quinidine (class IA) – anticoagulation needed
Atrial fibrillation Atrial: 350- Irregular R-R Normal P waves Not discernible Yes
400bpm intervals due to are absent 0.06-0.12 seconds
Ventricular: irregular (1 and a half to 3
variable conduction of small squares)
impulses to
ventricles
Atrial fibrillation often starts as brief periods of abnormal beating which become longer and constant over
time (paroxysmal to persistent to permanent)
Causes: hypertension, congestive heart failure, hyperthyroidism, excessive alcohol or caffeine consumptions,
coronary artery disease
Symptoms: heart palpitations, fainting, light-headedness, shortness of breath, chest pain, confusion, difficulty
breathing when lying down
Associated with an increased risk of stroke and heart failure. It is a type of supraventricular arrhythmia

At fast heart rates, AF may look more regular which may make it difficult to separate from ventricular
tachycardia (differential diagnosis)
Diagnosis:
Arrange ambulatory electrocardiography if paroxysmal AF is present.
 A 24 hour ECG monitor is used in people with asymptomatic episodes (i.e. no breathlessness or
palpitations) or in patients with symptomatic episodes less than 24 hours apart.
 A Holter monitor
records the heart
rhythm for 24
hours to 7 days
(completely
painless).
Atrial flutter and fibrillation
are treated the same way
Rate control if AF lasted
longer than 48 hours – offer a beta blocker (not sotalol) or a rate-limiting calcium channel blocker
Consider digoxin monotherapy for people with non-paroxysmal AF only if they do very little exercise. If
monotherapy doesn’t control symptoms consider combination therapy with 2 of: a beta blocker, diltiazem
and digoxin.
Rhythm control if AF lasted less than 48 hours – amiodarone (potassium channel blocker class III)
Supraventricula Atrial: 150- Regular Usually not Usually not Yes
r tachycardia 250bpm discernible, discernible 0.06-0.12 seconds
Ventricular: becomes hidden (1 and a half to 3
150-250bpm in QRS small squares)
Supraventricular tachycardia is an abnormally fast heart rhythm arising from improper electrical activity in the
atria. There are four main types: atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia and
Wolff-Parkinson White syndrome. It is usually due to re-entry mechanisms.

Causes: stress, hypokalaemia, stimulants

Symptoms: palpitations, chest tightness, dizziness, shortness of breath, sweating, tiredness
Treat with adenosine, class IA, IC, II, III and IV drugs

Premature atrial Regular Irregular Upright but 0.12-0.20 Yes

contractions abnormal shape seconds (3-5 0.06-0.12 seconds
(ectopic beats) small boxes) (1 and a half to 3
small squares)
Premature heartbeats originate in the atria. While the SAN typically regulates the heartbeat during normal
sinus rhythm, PACs occur when another region of the atria depolarises before the sinoatrial node (ectopic
pacemaker activity due to increased sympathetic activity is the underlying mechanism) and triggers a ectopic
baet. PACs commonly occur in healthy young and elderly people without heart disease but can lead to other
heart conditions. PACs are often
asymptomatic and not treatment is
needed.

VENTRICULAR RHYTHMS
Ventricular 101-250bpm Atrial rhythm is No Not Wide and bizarre
tachycardia not measurable (>0.12 seconds)
distinguishable
Ventricular
rhythm is usually
regular
High ventricular rate caused by intraventricular re-entry. It is characterised by a widened QRS.

Treated with class Ib e.g. IV lidocaine, II and III drugs

Ventricular tachycardia may result in cardiac arrest and turn into ventricular fibrillation.
Causes: electrolyte imbalance, congestive heart failure, myocardial ischaemia or infarction, certain
medications may prolong
QT interval
Symptoms: chest
discomfort, syncope,
dizziness, palpitations,
shortness of breath,
absent or rapid pulse,
hypotension.

Ventricular Not Rapid, No None None

fibrillation discernible unorganised
(MEDICAL
EMERGENCY)

No coordinated ventricular contraction due to multiple weak ectopic foci in the ventricles. Electrical impulses
are initiated by multiple ventricular sites and impulses are not transmitted through the normal conduction
pathway.
Caused by untreated ventricular tachycardia, myocardial ischaemia, drug toxicity, electrolyte imbalances
Symptoms: absent pulse of loss of consciousness
The risk is death and treatment: cardiopulmonary resuscitation, DC defibrillator.
The heart quivers instead of pumps due to disorganised electrical activity in the ventricles. An important
differential diagnosis is torsades de pointes.
A strong high-voltage (1000V) electrical current passed through the ventricles for a fraction of a second can
return the heart to normal sinus rhythm. The current is passed through large electrodes placed on two sides
of the heart. It stimulates all parts of the ventricles simultaneously and causes all of them to become
refractory.

Patients who have a high

risk of VF can have a
cardioverter defibrillator
implanted near the heart
with electrode wires in
the ventricle of the
patient’s heart. If VF is
detected the ICD can
revert it by delivering a
small impulse to the heart
through these wires.
Torsades de Ventricular: Regular or No Not Wide and bizarre,
Pointes 150-250bpm irregular measurable some deflecting
downward and
some deflecting
upward
Torsades de Pointes is associated with a prolonged QT interval. It usually terminates spontaneously and may
degenerate into ventricular fibrillation. The rhythm on an ECG shows an upward and downward deflection of
the QRS complex around the baseline. Torsades de Pointes means twisting about the points.

It is caused by: prolonged QT interval, drugs for treating VT, electrolyte disturbances especially hypokalaemia
which delays repolarisation

https://utmc.utoledo.edu/depts/nursing/pdfs/Basic%20EKG%20Refresher.pdf