COLLEGE OF ALLIED HEALTH SCIENCES

DEPARTMENT OF RESPIRATORY THERAPY

PATIENT ASSESSMENT AND ELECTROCARDIOGRAM

Unit 7
ATRIAL RHYTHM

Introduction

The atria are thin-walled, low-pressure chambers that receive blood from the systemic circulation
and lungs. There is normally a continuous flow of blood from the superior and inferior vena cavae into the
atria. About 70% of this blood flows directly through the atria and into the ventricles before the atria
contract. When the atria contract. an additional 30% is added to filling of the ventricles. This additional
contribution of blood because of atrial contraction is called atrial kick.

P waves reflect atrial depolarization. A rhythm that begins in the sinoatrial (SA) node has one
positive P wave before each QRS complex. A rhythm that begins in the atria will have a positive P wave
that is shaped differently than P waves that begin in the SA node. This difference in P wave configuration
occurs because the impulse begins in the atria and follows a different conduction pathway to the
atrioventricular (AV) node.

Learning Outcomes
At the end of this unit, students will be able to:
 Explain the concepts of abnormal automaticity, triggered activity, and reentry.
 Describe the electrocardiogram (ECG) characteristics, possible causes. signs and symptoms, and
initial emergency care for premature atrial complexes.
 Explain the difference between a compensatory and non-compensatory pause.
 Explain the terms wandering atrial pacemaker and multifoca1 atrial tachycardia
 Explain the terms paroxysmal atrial tachycardia and paroxysmal supraventricular tachycardia.
 List examples of vagal maneuver.
 Discuss the indications for synchronized cardioversion.
Topic 1: Ventricular Rhythm

Learning Objectives
At the end of this topic, students will be able to:
 Describe the electrocardiogram characteristics, possible causes, signs and symptoms, and initial
emergency care for wandering atrial pacemaker.
 Describe the electrocardiogram characteristics, possible causes, signs and symptoms, and initial
emergency care for multifocal atrial tachycardia
 Describe the ECG characteristics, possible causes, signs and symptoms and initial emergency care
for atrial flutter.
 Describe the ECG characteristics, possible causes, signs and symptoms and initial emergency care
for atrial fibrillation.

Presentation of Contents

Atrial dysrhythmias reflect abnormal electrical impulse formation and conduction in the atria They
result from abnormal automaticity, triggered activity, or reentry. Abnormal automaticity and triggered
activity are disorders in impulse formation. Reentry is a disorder in impulse conduction. Dysrhythmias
caused by disorders of impulse formation are often referred to as automatic. Dysrhythmias caused by a
disorder in impulse conduction are referred to as reentrant.

Abnormal automaticity occurs in normal pacemaker cells and in myocardial working cells that do
not normally function as pacemaker sites. With abnormal automaticity, these cells fire and initiate
impulses before a normal SA node impulse. If the rapid firing rare occurs for more than 50% of the day, it
is said to be incessant. The rapid firing rate may also occur periodically. In these cases, it is said to be
episodic. Atrial dysrhythmias associated with abnormal automaticity include PACs, multifocal atrial
tachycardia (MAT), and atrial fibrillation.

Research Work.
 1. Determine the causes of abnormal automaticity.

2. Explain if what is triggered activity and identify the possible causes.

3. Explain if what is reentry.

Premature beats appear early, that is, they occur before the next expected beat. Premature beats are
identified by their site of origin: Premature atrial complexes (PACs), Premature junctional complexes
(PJCs), Premature ventricular complexes (PVCs). The term complex is used instead of contraction to
correctly identify an early beat because the electrocardiogram (ECG) depicts electrical activity, not
mechanical function of the heart. Some practitioners prefer the term conduction instead of complex.
Premature beats may occur in patterns: Paired beats (couplet): Two premature beats in a row, Runs or
bursts: Three or more premature beats in a row, Bigeminy: Every other beat is a premature beat,
Trigeminy: Every third beat is a premature beat, Quadrigeminy: Every fourth beat is a premature beat.

Sinus tachycardia at 111 beats/min with three premature atrial complexes (PACs).

Research Work.
1. Determine the characteristics of Premature Atrial Complexes.
a. Rhythm

b. Rate
 c. P Waves

d. PR Interval

e. QRS duration

2. Differentiate the non-compensatory from compensatory pause.

3. Differentiate Aberrantly Conducted Premature Atrial Complexes from Non-conducted Premature

Atrial Complexes.

4. Identify the causes of Premature Atrial Complexes.

5. As a Respiratory Therapist, what will you recommend to manage and control the condition of the
patient?

Multiform atrial rhythm is an updated term for the rhythm formerly known as Wandering Atrial
Pacemaker. With this rhythm, the size, shape, and direction of the P waves vary, sometimes from beat to
beat. The difference in the look of the P waves is a result of the gradual shifting of the dominant
pacemaker among the SA node, the atria, and/or the AV junction. Wandering atrial pacemaker requires at
least three different P waves, seen in the same lead, for proper diagnosis.

Wandering atrial pacemaker is associated with a normal or slow rate and irregular P-P, R-R, and
PR intervals because of the different sites of impulse formation. The QRS duration is normally 0.11 second
or less because conduction through the ventricles is usually normal.

Wandering atrial pacemaker.

Research Work.

1.Determine the characteristics of Wandering atrial pacemaker.

a. Rhythm

b. Rate

c. P Waves

d. PR Interval

e. QRS duration

2. Identify the causes of Wandering atrial pacemaker.

 3. As a Respiratory Therapist, what will you recommend to manage and control the condition of the
patient?

When the wandering atrial pacemaker rhythm is associated with a ventricular rate of more than 100
beats/min, the dysrhythmia is called Multifocal Atrial Tachycardia (MAT). As evidenced by its name,
MAT is the result of the random and chaotic firing of multiple ectopic sites in the atria.

Multifocal atrial tachycardia.

Research Work.

1.Determine the characteristics of Multifocal Atrial Tachycardia.

a. Rhythm

b. Rate

c. P Waves

d. PR Interval

e. QRS duration
 2. Identify the causes of Multifocal Atrial Tachycardia.

3. As a Respiratory Therapist, what will you recommend to manage and control the condition of the
patient?

Supraventricular arrhythmias begin above the bundle of His; this means that supraventricular
arrhythmias include rhythms that begin in the SA node, atrial tissue, or the AV junction. The tern
Supraventricular Tachycardia (SVT) includes supraventricular rhythms with a ventricular rate faster than
100 beats/min at rest (Page et al, 2015).

The onset of SVT symptoms often begins in adulthood and can affect the quality of life depending
on the frequency and duration of episodes and whether symptoms occur not only with exercise but also at
rest (Page et al. 2015). Complaints of lightheadedness are common. A drop in blood pressure typically
occurs during SVT and is greatest in the first 10 to 30 seconds, normalizing within 30 to 60 seconds
despite minimal changes in heart rate (Page et al, 20 15).

Atrial Tachycardia (AT) is a regular rhythm that arises from an ectopic focus in the atria at a rate
faster than 100 beats/min and does not require the participation of the AV node to maintain the
dysrhythmia (Ellenbogen & Stambler, 2014). This rapid atrial rate overrides the SA node and becomes the
pacemaker. AT is often precipitated by a PAC. When three or more PACs occur in a row at a rate of more
than 100 beats/min, AT is present.

Paroxysmal supraventricular tachycardia that ends spontaneously with the abrupt resumption of sinus rhythm.
The P waves of the tachycardia (rate: about 150 beats/min) are superimposed on the preceding T waves.
Research Work.

1.Determine the characteristics of Atrial Tachycardia.

 a. Rhythm

b. Rate

c. P Waves

d. PR Interval

e. QRS duration

2. Identify the causes of Atrial Tachycardia.

3. As a Respiratory Therapist, what will you recommend to manage and control the condition of the
patient?

Atrial flutter is a reentrant rhythm in which an irritable site within the atria fires regularly at a very
rapid rate. Typical atrial flutter, also known as common atrial flutter or counterclockwise atrial flutter, is
caused by reentry in which an impulse circle around a large area of tissue, such as the entire right atrium,
in a counterclockwise direction (January et al, 2014). Atrial waveforms are produced that resemble the
teeth of a saw or a picket fence; these are called flutter waves or F waves. F waves are predominantly
negative in leads II, III, and aVF and positive in V1 (Fuster et al, 2011).
 A. Rhythm strip showing a narrow-QRS tachycardia with a ventricular rate just under 150 beats/ min.
B. The same rhythm shown In A with arrows added indicating possible atrial activity.
C. When carotid sinus massage (CSM) is performed, the rate of conduction through the atrioventricular (AV)
node slows, revealing atrial flutter.

Research Work.
1.Determine the characteristics of Atrial Flutter.

a. Rhythm

b. Rate

c. P Waves
 d. PR Interval

e. QRS duration

2. Identify the causes of Atrial Flutter.

3. Determine the conditions associated with atrial flutter.

4. As a Respiratory Therapist, what will you recommend to manage and control the condition of the
patient?

Atrial Fibrillation is the most common dysrhythmia treated in clinical practice and the most
common dysrhythmia for which patients are hospitalized (Morady & Zipes, 2015). AFib occurs because of
abnormal automaticity in one or several rapidly firing sites in the atria or reentry involving one or more
circuits in the atria (Fig. 4.21). Irritable sites in the atria fire at a rate of 300 to 600 times per minute. These
rapid impulses cause the muscles of the atria to quiver (i.e., fibrillate), thereby resulting in ineffectual atrial
contraction, decreased stroke volume, a subsequent decrease in cardiac output, and a loss of atrial kick.
The ventricular response to AFib depends on the electrophysiologic properties of the AV node and other
conducting tissues, the level of sympathetic and parasympathetic tone, the presence or absence of
accessory pathways, and the action of drugs (Fuster et al, 2011). AFib may occur alone or in association
with other atrial dysrhythmias (January et ai.. 2014).
 Atrial fibrillation with a ventricular response of 80 beats/min.

Atrial fibrillation with third-degree atrioventricular block. The ventricular rate is slow and regular because of the block.

Research Work.
1.Determine the characteristics of Atrial Fibrillation.

a. Rhythm

b. Rate

c. P Waves

d. PR Interval

e. QRS duration

2. Identify the causes of Atrial Fibrillation.

3. Determine the conditions that predispose patients to Atrial Fibrillation.

4. As a Respiratory Therapist, what will you recommend to manage and control the condition of the
patient?

Reference

1.Ellenbogen, K. A., 8c Stambl.er, B. S. (2014). Atrial tachycardia. In D. P. Zipe & J. Jalife (Eda.),
Cardiac Electrophysiology: From all to bedside (6th ed.) (pp. 699- 722). Philadelphia: Saunders.
2.Goel, R., Srivathaan, K., & Moobdam, M. (2013). Supraventricular and ventricular arrhythmias.
Primary Care 40(1), 43-71.
3.January, C. T., Wann. L. S., Alpert. J. S., Calkins, H. Ciguroa, J. E., Cleveland, J. C., & Yancy,
C. W. 2014 AHA/ACC/HRS guideline for the management of patient with atrial fibrillation:
a report of the American College of Cardiology/ American Heart Association Task Force on
Practice Guidelines and the Heart Rhythm Society. JAm CoR Cardlol, 64(21), e1-e76.
4.Link, M. S., Berkow, L. C., Kudenchuk, P. J., Halperin, H. R.., Heu, E. P., Moitra. V. K., &
Donnl.no. M. W. (2015, Oct). 2015 American Heart Association Guidelines for CPR & ECC.