L9 - ECG Rate & Rhythm

Course Code:19CCT205A
Course Title: Basic Cardiac Technology (T)
Course Leader:
I Monika Priya
monikapriya.ah.ls@msruas.ac.in
1
Faculty of Life and Allied health Sciences © Ramaiah University of Applied Sciences
Lecture 9
ECG Rate and Rhythm
Contents:
• Heart Rate
• Methods to calculate
• Rhythm
• Arrhythmias
2
Lecture 9
ECG Rate and Rhythm
At the end of the lecture, student will be able to:
• Describe ECG rate and rhythm
• Explain about types of rate – Tachycardia, Bradycardia
•Discuss ECG characteristics of normal & abnormal rhythm
•Identify normal and abnormal rhythm on ECG
•Discuss methods to calculate heart rate on ECG
3
Heart Rate
• Heart rate or pulse, is the number of times our heart beats
in 1 minute( 60 sec)
• The normal resting adult human Heart Rate ranges from 60–
100 bpm
• If the heart rate ranges < 60 bpm it is termed as Bradycardia
• If the heart rate ranges > 100 bpm it is termed as Tachycardia
• In children's heart rate depends on age
 Newborn: 110 – 150 bpm
 2 years: 85 – 125 bpm
 4 years: 75 – 115 bpm
 6 years+: 60 – 100 bpm
4
Factors Influence Heart Rate
• Weather :Your pulse may go up a bit in higher temperatures

and humidity levels
• Standing up : It might spike for about 20 seconds after you
first stand up from sitting
• Emotions: Stress and anxiety can raise your heart rate. It may
also go up when you’re very happy or sad
• Body size : People who have severe obesity can have a slightly
faster pulse
• Medications: Beta-blockers slow your heart rate. Too much
thyroid medicine can speed it up
• Caffeine and nicotine : Coffee, tea, and soda may raise your
heart rate
5
Determination of the heart rate
• ECG is usually and conventionally recorded at a paper speed

of 25mm/sec
• At this paper speed, five large squares represent 1 second

and fifteen large squares represent 3 seconds
(Most recording papers have every fifteenth large square – a 3sec interval
marked with a vertical line on the upper border)
• ECG rhythm strip:
250 SMALL squares = 50 LARGE squares = 10 seconds
6
Contd…
7
Methods to calculate heart rate on a ECG
• To calculate cardiac beats per minute (bpm),
1500 SMALL squares = 300 LARGE squares = 1 minute
300 Rule:
- Rate = 300 / number of LARGE squares between consecutive R
waves
300/RR ( large squares)
- Used to calculate regular rhythms
1500 Rule:
- Rate = 1500 / number of SMALL squares between consecutive
R waves
1500/ RR ( small squares )
- Used to calculate very fast rhythms
8
Contd…
6 Sec rule:
- Rate = Number of R waves X 10
10 Sec rule:
- Rate = Number of R waves X 6
- The number of complexes (count R waves) on the rhythm strip

gives the average rate over a ten-second period.
- This is multiplied by 6 (10 seconds x 6 = 1 minute) to give

the average Beats per minute (bpm)
- Used to calculate slow or irregular rhythms

9
Other methods include
1) Number of R-R or P-P intervals are counted in a 3-second

period and the figure multiplied by 20
2) Number of R-R or P-P intervals are counted in a 6-second

period and the figure multiplied by 10
3) The cardiac rate per minute may also be estimated by

dividing the figure of 6,000 by the duration of R-R or P-P
interval
Eg: If R-R interval measures 0.08sec, the rate is 6,000 / 80 = 75

per minute 10
Exercise - 1
Rhythm Strip
Rhythm Strip 11
Contd…
12
Contd…
13
Contd…
14
Contd…
15
16
17
Other paper speeds
• If ECG paper is recorded at a speed of 50mm/sec, then
- 1mm (small square) = 0.02 sec (20ms)
- 5mm (large square) = 0.1 sec (100ms)
- Doubling the standard speed will cause the ECG to appear

drawn out or wider complex
• If ECG paper is recorded at a speed of 10 mm/sec, then
- 1mm (small square) = 0.1 sec (100ms)
- 5mm (large square) = 0.5 sec (500ms)
- Decreasing the standard speed will cause the ECG to appear

narrow complex 18
Contd…
19
Rhythm
• Rhythm is termed as sequential beating of the heart as a
result of the generation of electrical impulses
• Cardiac rhythm can be classified as
- Normal rhythm (Sinus Rhythm)
- Abnormal rhythm (Arrhythmia)
 Regular Rhythm: Interval between the R waves is regular
 Irregular Rhythm: Interval between the R waves is not regular
 Regularly irregular rhythm
 Irregularly irregular rhythm

20
Contd…
• Sinus rhythms may manifest in the following forms:
1) Normal sinus rhythm
2) Sinus arrhythmia
3) Sinus tachycardia
4) Sinus bradycardia
21
Fundamental descriptive properties of cardiac
rhythm
• There are 3 fundamental aspects to every cardiac rhythm:
1. The rhythm has an anatomical origin
2. The rhythm has an discharge sequence
3. The rhythm has an conduction sequence
22
Normal Sinus Rhythm (NSR)
• The default heart rhythm
• Pacemaking impulses arise from the sino-atrial node and are
transmitted to the ventricles via the AV-node and His-Purkinje
system
• This results in a regular, narrow-complex heart rhythm at 60-
100 bpm
23
Contd…
• Rate and rhythm of the heart is controlled by SA

node(dominant pacemaker)
Sinus Rhythm:
• Rhythm is said to be sinus when the impulses originating from
SA node are conducted to the ventricles via AV node
ECG characteristics:
• P wave : Upright in all standard leads(except aVR )
Upright in all precordial leads(except lead V1-biphasic)
• P-P & R-R intervals remain constant
• Heart Rate:60-100 bpm
• There is no ectopic activity
24
Sinus Arrhythmia
• Sinus arrhythmia is characterized by alternating periods of
slow and rapid rates
• It is due to an irregular fluctuating discharge of the SA node
• This condition is commonly associated with the phases of

respiration – respiratory sinus arrhythmia
• The periods of faster heart rate occur towards the end of

inspiration and the periods of slower heart rate occur towards
the end of expiration
• The mechanism is mediated by reflex stimulation of the vagus

nerve from receptors in the lungs 25
ECG characteristics or Diagnosis
• Sinus arrhythmia is characterized by normal P- QRS – T

complexes with alternating periods of gradually lengthening
and gradually shortening P-P intervals
26
Contd…
27
Contd…
• Sinus arrhythmia can be accentuated by vagotonic procedures

such as digitalis administration & carotid sinus compression
• It can be abolished by vagolytic procedures, namely exercise

atropine and amyl nitrate
Significance:
• Respiratory sinus arrhythmia is a normal physiological

phenomenon & is most marked in young persons
• It may cause considerably irregular pulse in childhood
28
Sinus Tachycardia
• Sinus Tachycardia in the absence of a complicating conduction

disturbance, characterized by normal P – QRS – T complexes,
which are recorded in a rapid succession
• It varies with emotion, respiration & exercise
• Vagotonic procedures, e.g. carotid sinus compression, result

in slight gradual slowing
29
Contd…
30
Contd…
Significance:
• It is normal physiological response to exercise & emotion
• If it persist at rest is usually an expression of some underlying

disorder
(Failure to develop sinus tachycardia with exercise or fever may

be an expression of structural nodal disease – so called “Sick
sinus syndrome”
31
Contd…
Physiological Pharmacological
•Exercise •Beta-agonists: adrenaline,
•Pain, anxiety isoprenaline,salbutamol,
•Hypoxia, hypercarbia dobutamine
•Acidaemia •Sympathomimetics: ampheta
•Sepsis mines, cocaine,
•Pulmonary embolism methylphenidate
•Hyperthyroidism •Antimuscarinics: antihistamin
es, TCAs, carbamazepine,
atropine
•Others: caffeine, theophylline
32
Sinus Bradycardia
• Sinus bradycardia, in the absence of a complicating
conduction disturbance, is characterized by normal P – QRS –
T complexes, which are recorded in slow succession
• Ventricular rate is usually < 60 bpm
• It is commonly associated with respiratory sinus arrhythmia
33
34
Contd…
35
Contd…
Physiological Pathological
• During sleep • Myocardial ischemia /
• Well – trained individuals infarction
displays bradycardia • Sinus node dysfunction
• at rest due to high vagal • Drug effect
tone. • Hypothyroidism
• During vasovagal syncope ( • Hypothermia
intense emotional stress ) • Hyperkalemia
36
Contd…
Significance:
• Sinus bradycardia occurs as a normal phenomenon in athletes
• It is physiological response during sleep
• A common presentation in patients administering with beta

blockers
• In the presence of structural nodal disease of the SA node

associated with sinus bradycardia should be considered
37
Abnormal rhythm or irregular rhythm
 If SA node fails or defaults, the AV node takes over the control

of the cardiac rhythm
• The rhythm produced by AV node pacemaker is called

“NODAL RHYTHM or ESCAPE RHYTHM”
 In case AV node fails to conduct sinus beats the control of

cardiac rhythm is taken either by Bundle of His or Ventricular
Myocardium-the rhythm produced is called “IDIONODAL or
IDIOVENTRICULAR RHYTHM”
38
39
Types of abnormal rhythm
• Depending on the site of origin, the abnormal rhythm is
divided into two types:
 Supraventricular rhythm: An abnormal rhythm that originates

from any site above the bundle of His
- It includes abnormal rhythms from atria & AV node
- See narrow QRS complex
40
Contd…
 Ventricular rhythm: An abnormal rhythm that originating from

the bundle branches or ventricular myocardium or there is
retrograde conduction through the ventricle
- Depolarization wave spreads through ventricular myocardium

or purkinje fibers which is slow & poor conducting tissue
- Hence, QRS complex is wide & bizzare & repolarization is also

abnormal, so T wave is of abnormal shape
41
Arrhythmia
• Any rhythm other than normal sinus rhythm is

called as an arrhythmia
42
43
44
45
46
Summary
• The normal resting adult human Heart Rate ranges from 60–
100 bpm
• Determining the methods of heart Rate
• A sequential beating of the heart as a result of the generation

of electrical impulses
• Normal sinus rhythm
• Sinus bradycardia and tachycardia
47
Reference
•Leo schamroth – 7th edition.

•Practical Electrocardiography
48
Disclaimer
• All data and content provided in this presentation are taken

from the reference books, internet – websites and links, for
informational purposes only.
49

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Course Code:19CCT205A

Course Title: Basic Cardiac Technology (T)

•Discuss ECG characteristics of normal & abnormal rhythm

•Identify normal and abnormal rhythm on ECG

•Discuss methods to calculate heart rate on ECG

• Weather :Your pulse may go up a bit in higher temperatures

• ECG is usually and conventionally recorded at a paper speed

• At this paper speed, five large squares represent 1 second

- Rate = Number of R waves X 10

- Rate = Number of R waves X 6

- The number of complexes (count R waves) on the rhythm strip

- This is multiplied by 6 (10 seconds x 6 = 1 minute) to give

- Used to calculate slow or irregular rhythms

1) Number of R-R or P-P intervals are counted in a 3-second

2) Number of R-R or P-P intervals are counted in a 6-second

3) The cardiac rate per minute may also be estimated by

Eg: If R-R interval measures 0.08sec, the rate is 6,000 / 80 = 75

- 1mm (small square) = 0.02 sec (20ms)

- 5mm (large square) = 0.1 sec (100ms)

- Doubling the standard speed will cause the ECG to appear

• If ECG paper is recorded at a speed of 10 mm/sec, then

- 1mm (small square) = 0.1 sec (100ms)

- 5mm (large square) = 0.5 sec (500ms)

- Decreasing the standard speed will cause the ECG to appear

• Cardiac rhythm can be classified as

- Normal rhythm (Sinus Rhythm)

- Abnormal rhythm (Arrhythmia)

 Regular Rhythm: Interval between the R waves is regular

 Irregular Rhythm: Interval between the R waves is not regular

 Regularly irregular rhythm

 Irregularly irregular rhythm

• Sinus rhythms may manifest in the following forms:

1) Normal sinus rhythm

• There are 3 fundamental aspects to every cardiac rhythm:

1. The rhythm has an anatomical origin

2. The rhythm has an discharge sequence

3. The rhythm has an conduction sequence

• Rate and rhythm of the heart is controlled by SA

• It is due to an irregular fluctuating discharge of the SA node

• This condition is commonly associated with the phases of

• The periods of faster heart rate occur towards the end of

• The mechanism is mediated by reflex stimulation of the vagus

• Sinus arrhythmia is characterized by normal P- QRS – T

• Sinus arrhythmia can be accentuated by vagotonic procedures

• It can be abolished by vagolytic procedures, namely exercise

• Respiratory sinus arrhythmia is a normal physiological

• It may cause considerably irregular pulse in childhood

• Sinus Tachycardia in the absence of a complicating conduction

• It varies with emotion, respiration & exercise

• Vagotonic procedures, e.g. carotid sinus compression, result

• It is normal physiological response to exercise & emotion

• If it persist at rest is usually an expression of some underlying

(Failure to develop sinus tachycardia with exercise or fever may

• Ventricular rate is usually < 60 bpm

• It is commonly associated with respiratory sinus arrhythmia

• Sinus bradycardia occurs as a normal phenomenon in athletes

• It is physiological response during sleep

• A common presentation in patients administering with beta

• In the presence of structural nodal disease of the SA node

 If SA node fails or defaults, the AV node takes over the control

• The rhythm produced by AV node pacemaker is called

 In case AV node fails to conduct sinus beats the control of

 Supraventricular rhythm: An abnormal rhythm that originates

L9 - ECG Rate & Rhythm

L9 - ECG Rate & Rhythm