CARDIAC RHYTHMS (ECG)

NAME: MELODY A. BOADO SUBJECT: MEDSURG

YEAR AND SECTION: BSN 3-B

Ventricular Fibrillation
Ventricular fibrillation (VFib) is a chaotic rhythm originating in the ventricles, resulting in no cardiac
output. Coarse VFib is noted when the amplitude (height) of the rhythm is equal to or more than 3 mm. Fine
VFib is less than 3 mm in height and signifies less electrical energy within the myocardium - less
opportunity for a successful defibrillation.

Care Management:
Immediate defibrillation is the treatment of choice for VFib, along with CPR. Early recognition, early
defibrillation, and effective chest compressions are crucial for improving survival rates. Advanced cardiac
life support (ACLS) protocols should be followed, including administration of antiarrhythmic medications
such as amiodarone or lidocaine.

Primary Source:
Pellegrino, J. L., Charlton, N. P., Carlson, J. N., Flores, G. E., Goolsby, C., Hoover, A. V., Kule, A., Magid,
D. J., Orkin, A., Singletary, E. M., Slater, T., & Swain, J. (2020). 2020 American Heart Association and
American Red Cross Focused update for First Aid. Circulation, 142(17).
https://doi.org/10.1161/cir.0000000000000900

Junctional Tachycardia
Junctional tachycardia results from enhanced automaticity, increased sympathetic activity (catecholamines)
and ischemia. Key features of this rhythm include a rate over 100/ minute, inverted or absent P waves (in
lead lI), shortened PR interval, and QRS complexes that are usually narrow. Note the inverted P wave buried
in each QRS complex displayed here in this ECG.
Care Management:
Treatment of junctional tachycardia depends on the patient's hemodynamic stability. In stable patients,
vagal maneuvers or pharmacological interventions such as adenosine or beta-blockers can be considered. In
unstable patients, synchronized cardioversion may be necessary.

Primary Source:
Walsh, E. P., Saul, J. P., Sholler, G. F., Triedman, J. K., Jonas, R. A., Mayer, J. E., & Wessel, D. (1997b).
Evaluation of a staged treatment protocol for rapid automatic junctional tachycardia after operation for
congenital heart disease. Journal of the American College of Cardiology, 29(5), 1046–1053.
https://doi.org/10.1016/s0735-1097(97)00040-5

Sinus Exit Block

Sinus exit block (sinoatrial block) results from blocked sinus impulses- impulses not getting through to
depolarize the atria. While the sinus is firing on schedule, the tissue around the SA node is not carrying the
impulse. The seriousness of this dysrhythmia is related to the frequency and duration of the blocks. Note that
each pause is equal to a multiple of previous P-P intervals.

Care Management:
The management of sinus exit block depends on the patient's symptoms and underlying cause. If the patient
is symptomatic or has a high-degree sinus exit block, a permanent pacemaker may be indicated.

Primary Source:
Shen, W., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P.,
Hamdan, M. H., Krahn, A. D., Link, M. S., Olshansky, B., Raj, S. R., Sandhu, R. K., Sorajja, D., Sun, B., &
Yancy, C. W. (2017). 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with
Syncope: A report of the American College of Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 136(5).
https://doi.org/10.1161/cir.0000000000000499
 Second Degree AV Block Type I
Second degree AV block Type I (Wenckebach or Mobitz Type I) results from a cyclical and progressive
conduction delay through the AV junction. The ECG presents with a cyclical lengthening of the PR interval
followed by a dropped QRS - a P wave not partnered with a QRS. The QRS complexes yield an irregular
rhythm. Second degree AV block Type I may be caused by enhanced vagal tone, myocardial ischemia or the
effects of drugs such as calcium-channel blockers, digitalis and beta-blockers.

Care Management:
In most cases, second-degree AV block type 1 is a benign condition and does not require specific treatment.
If the patient is symptomatic or develops higher degrees of AV block, a temporary pacemaker may be
necessary.

Primary Source:
Richley, D. (2019). Recognising and treating arrhythmias in primary care. Practice Nursing, 30(6), 270–275.
https://doi.org/10.12968/pnur.2019.30.6.270

Sinus Rhythm with Premature Ventricular Complex

Premature ventricular complexes (PVC) often represent increased ventricular automaticity or reentry
phenonomen. The presence of PVCs may be benign but can indicate irritable ventricles. PVCs arrive earlier
than expected and is usually wide (12 seconds or more). Note that the T wave often points in an opposite
direction from the QRS complex. A PVC every second complex is called ventricular bigeminy..

Care Management:
Treatment of PVCs depends on the patient's symptoms and underlying cardiac condition. If the PVCs are
infrequent and the patient is asymptomatic, no specific treatment may be required. However, if the PVCs are
frequent or associated with symptoms, further evaluation and management of the underlying cause may be
necessary.

Primary Source:
Olasveengen, T. M., De Caen, A. R., Mancini, M. E., Maconochie, I., Aickin, R., Atkins, D. L., Berg, R. A.,
Bingham, R., Brooks, S. C., Castrén, M., Chung, S. P., Considine, J., Couto, T. B., Escalante, R., Gazmuri,
R. J., Guerguerian, A., Hatanaka, T., Koster, R. W., Kudenchuk, P. J., . . . Nolan, J. P. (2017b). 2017
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations Summary. Circulation, 136(23).
https://doi.org/10.1161/cir.0000000000000541
 Accelerated Junctional
Accelerated junctional rhythm results from enhanced automaticity, increased sympathetic nervous system
activity (catecholamines) or ischemia. Key features of this rhythm include a rate between 60-100/ minute,
inverted or absent P waves (in lead I), shortened PR interval, and QRS complexes that are usually narrow.

Care Management:
The management of an accelerated junctional rhythm depends on the patient's symptoms and underlying
cause. If the patient is hemodynamically stable and asymptomatic, no specific treatment may be required.
However, if the patient is symptomatic or has underlying cardiac pathology, further evaluation and
management may be necessary, which may include addressing the underlying cause or considering
pharmacological interventions.

Primary Source:
Breslow, M. J., Evers, A. S., & Lebowitz, P. W. (1985b). Successful Treatment of Accelerated Junctional
Rhythm with Propranolol. Anesthesiology, 62(2), 180–181. https://doi.org/10.1097/00000542-198502000-
00016

Supraventricular Tachycardia
Supraventricular tachycardia is an ominous rhythm with rates often between 170-230 per minute. The
telltale sign of supraventricular tachycardia is the narrow QRS which defines its supraventricular origin and
its regular, rapid pattern. This rhythm is most likely not sinus tachycardia due to its very fast rate. For those
who are at rest, narrow QRS tachycardias over 150/ minute are most often supraventricular tachycardia.

Care Management:
The management of SVT depends on the patient's hemodynamic stability. Vagal maneuvers, such as the
Valsalva maneuver or carotid sinus massage, can be attempted initially. If vagal maneuvers fail or if the
patient is hemodynamically unstable, pharmacological interventions, such as adenosine or calcium channel
blockers, may be used. In some cases, synchronized cardioversion may be necessary.

Primary Source:
Correction to: 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular
Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines and the Heart Rhythm Society. (2016). Circulation, 134(11).
https://doi.org/10.1161/cir.0000000000000448

Junctional Rhythm
Junctional rhythm - also called junctional escape rhythm - originates from the AV junction (AV node and
Bundle of His). The expected pacemaker rate of the AV junction is 40-60/minute. In lead Il, a junctional
rhythm presents with inverted or absent P waves. Note: an absent P wave in junctional rhythm is also
associated with loss of atrial kick.

Care Management:
The management of a junctional rhythm depends on the patient's symptoms and underlying cause. If the
patient is asymptomatic and hemodynamically stable, no specific treatment may be required. However, if the
patient is symptomatic or has underlying cardiac pathology, further evaluation and management may be
necessary.

Primary Source:
Breslow, M. J., Evers, A. S., & Lebowitz, P. W. (1985b). Successful Treatment of Accelerated Junctional
Rhythm with Propranolol. Anesthesiology, 62(2), 180–181. https://doi.org/10.1097/00000542-198502000-
00016

Sinus Arrest
Sinus Arrest (a.k.a. sinus pause) occurs when the SA node fails to fire. The resulting pause is often NOT
equal to the multiple of P-P intervals seen in Sinus Exit Block. Instead, often an escape pacemaker such as
the AV junction will assume control of the heart. Again, like Sinus Exit Block, treatment is related to the
frequency and duration of the periods of sinus arrest.

Care Management:
The management of sinus arrest depends on the patient's symptoms and underlying cause. If the patient is
asymptomatic and the episodes of sinus arrest are infrequent, no specific treatment may be required.
However, if the patient is symptomatic or has underlying cardiac pathology, further evaluation and
management may be necessary, which may include considering a permanent pacemaker.

Primary Source:
Shen, W. K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B. P.,
Hamdan, M. H., Krahn, A. D., Link, M. S., Olshansky, B., Raj, S. R., Sandhu, R. K., Sorajja, D., Sun, B., &
Yancy, C. W. (2017). 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with
Syncope: Executive Summary: A report of the American College of Cardiology/American Heart Association
Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 136(5).
https://doi.org/10.1161/cir.0000000000000498

Sinus Rhythm with Premature Ventricular Complex

Premature ventricular complexes (PVC) often represent increased ventricular automaticity or reentry
phenonomen. The presence of PVCs may be benign but can indicate irritable ventricles. PVCs arrive earlier
than expected and is usually wide (12 seconds or more). Note that the T wave often points in an opposite
direction from the QRS complex. A PVC every second complex is called ventricular bigeminy..

Care Management:
Treatment of PVCs depends on the patient's symptoms and underlying cardiac condition. If the PVCs are
infrequent and the patient is asymptomatic, no specific treatment may be required. However, if the PVCs are
frequent or associated with symptoms, further evaluation and management of the underlying cause may be
necessary.

Primary Source:
Olasveengen, T. M., De Caen, A. R., Mancini, M. E., Maconochie, I., Aickin, R., Atkins, D. L., Berg, R. A.,
Bingham, R., Brooks, S. C., Castrén, M., Chung, S. P., Considine, J., Couto, T. B., Escalante, R., Gazmuri,
R. J., Guerguerian, A., Hatanaka, T., Koster, R. W., Kudenchuk, P. J., . . . Nolan, J. P. (2017b). 2017
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations Summary. Circulation, 136(23).
https://doi.org/10.1161/cir.0000000000000541
 Wandering Pacemaker
A wandering pacemaker rhythm is a supraventricular rhythm with varying locations of impulse formation
resulting in three or more different P waves. With a narrow QRS complex, the absence of a P wave qualifies
as one type of P wave. In the rhythm above, note the P waves from the sinus node, the atria and the junction.

Care Management:
The management of a wandering pacemaker depends on the patient's symptoms and underlying cause. If the
patient is asymptomatic and hemodynamically stable, no specific treatment may be required. However, if the
patient is symptomatic or has underlying cardiac pathology, further evaluation and management may be
necessary, which may include addressing the underlying cause or considering pharmacological
interventions.

Primary Source:
Lu, M., De Venecia, T., Patnaik, S., & Figueredo, V. M. (2016b). Atrial myocardial infarction: A tale of the
forgotten chamber. International Journal of Cardiology, 202, 904–909.
https://doi.org/10.1016/j.ijcard.2015.10.070

Second Degree AV Block with 2:1 Conduction

Second Degree AV Block with 2:1 conduction is a special case of second degree AV block with each
alternative P wave NOT paired with a QRS complex. The PR interval remains constant. This rhythm
requires close monitoring due to risks of: 1) low cardiac output associated with a slow heart rate; and 2) the
potential to progress to third degree AV block.

Care Management:
Second-degree AV block type 2:1 is often an indication for a permanent pacemaker, especially if the patient
is symptomatic or has underlying cardiac pathology. Close monitoring and evaluation of the patient's
symptoms, ECG findings, and underlying cardiac condition are essential in determining the appropriate
management approach.

Primary Source:
Kusumoto, F., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R.,
Goldschlager, N., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K.
R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019e). 2018
ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac
Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 140(8).
https://doi.org/10.1161/cir.0000000000000628

Paced Ventricular Rhythm

Ventricular paced rhythm (or paced ventricular rhythm) results from the electronic pacing of a ventricle.
Note the vertical spike before the QRS complex. An electronic pacemaker lead repeatedly generates a small
but sufficient current to begin depolarization of the ventricle..and the resulting QRS complex.

Care Management:
The management of a paced ventricular rhythm depends on the patient's symptoms, underlying cardiac
condition, and the type of pacemaker being used. Regular follow-up with the patient's cardiologist or
electrophysiologist is important to ensure proper functioning of the pacemaker and to address any issues or
concerns that may arise.

Primary Source:
Van Diepen, S., Katz, J. N., Albert, N. M., Henry, T. D., Jacobs, A. K., Kapur, N. K., Kilic, A., Menon, V.,
Ohman, E. M., Sweitzer, N. K., Thiele, H., Washam, J. B., & Cohen, M. G. (2017). Contemporary
Management of Cardiogenic Shock: A scientific statement from the American Heart Association.
Circulation, 136(16). https://doi.org/10.1161/cir.0000000000000525

NSR with Premature Atrial Complexes

Premature Atrial Complexes or PAC result from irritability to the atria resulting in increased automaticity of
atrial tissue. Since the atria initiate an impulse earlier than expected from the SA node, this is a premature
complex. Expect narrow QRS and flattenned, notched, peaked or biphasic P waves for the PAC.
Care Management:
Treatment of premature atrial complexes (PACs) depends on the patient's symptoms and underlying cardiac
condition. If the PACs are infrequent and the patient is asymptomatic, no specific treatment may be
required. However, if the PACs are frequent or associated with symptoms, further evaluation and
management of the underlying cause may be necessary.

Primary Source:
Olasveengen, T. M., De Caen, A. R., Mancini, M. E., Maconochie, I., Aickin, R., Atkins, D. L., Berg, R. A.,
Bingham, R., Brooks, S. C., Castrén, M., Chung, S. P., Considine, J., Couto, T. B., Escalante, R., Gazmuri,
R. J., Guerguerian, A., Hatanaka, T., Koster, R. W., Kudenchuk, P. J., . . . Nolan, J. P. (2017). 2017
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations Summary. Circulation, 136(23).
https://doi.org/10.1161/cir.0000000000000541

Atrial Flutter
Atrial flutter results from the development of a reentry circuit within the atria generating a loop that
discharges impulses at a flutter rate of 250-350 / minute. Most often the AV junction passes every second
(rate = 150, called a 2:1 response) or every fourth impulse(rate = 75, called a 4:1 response) through to the
ventricles. Atrial flutter is readily identified by the sawtooth baseline.

Care Management:
The management of atrial flutter depends on the patient's hemodynamic stability and symptoms. In stable
patients, pharmacological interventions, such as antiarrhythmic medications or rate-controlling agents, may
be considered. In unstable patients or those with compromised hemodynamics, synchronized cardioversion
may be necessary.

Primary Source:
January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T.,
Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., &
Yancy, C. W. (2019b). 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for
the Management of Patients With Atrial Fibrillation: A Report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm
Society in Collaboration With the Society of Thoracic Surgeons. Circulation, 140(2).
https://doi.org/10.1161/cir.0000000000000665
 Accelerated Junctional
Accelerated junctional rhythm results from enhanced automaticity, increased sympathetic nervous system
activity (catecholamines) or ischemia. Key features of this rhythm include a rate between 60-100/ minute,
inverted or absent P waves (in lead I), shortened PR interval, and QRS complexes that are usually narrow.

Care Management:
The management of an accelerated junctional rhythm depends on the patient's symptoms and underlying
cause. If the patient is hemodynamically stable and asymptomatic, no specific treatment may be required.
However, if the patient is symptomatic or has underlying cardiac pathology, further evaluation and
management may be necessary, which may include addressing the underlying cause or considering
pharmacological interventions.

Primary Source:
Breslow, M. J., Evers, A. S., & Lebowitz, P. W. (1985b). Successful Treatment of Accelerated Junctional
Rhythm with Propranolol. Anesthesiology, 62(2), 180–181. https://doi.org/10.1097/00000542-198502000-
00016

Second Degree AV Block Type ll

Second Degree AV Block Type ll is typically caused by an intermittent block (interrupted supraventricular
impulse) below the AV node. One or more QRS complexes are dropped with PR intervals that do not
change (fixed PR interval). This irregular rhythm requires close monitoring: 1) low cardiac output is likely
when multiple dropped QRS Complexes occur,; and 2) this rhythm can progress to complete heart block
(third degree AVB).

Care Management:
Second-degree AV block type 2 is often an indication for a permanent pacemaker, especially if the patient
is symptomatic or has underlying cardiac pathology. Close monitoring and evaluation of the patient's
symptoms, ECG findings, and underlying cardiac condition are essential in determining the appropriate
management approach.
Primary Source:
Kusumoto, F., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R.,
Goldschlager, N., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K.
R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019d). 2018
ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac
Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 140(8).
https://doi.org/10.1161/cir.0000000000000628

NSR with First Degree AV Block

First degree AV block results from a prolonged transmission of the electrical impulse through the AV
junction (AV node and the Bundle of His). The significant finding of this rhythm is a prolonged PR interval
of more than .20 seconds. The underlying rhythm should be identified and named prior to claiming a first
degree AV block. For example, this rhythm is a normal sinus rhythm WITH a first degree AV block.

Care Management:
First-degree AV block is often a benign condition and does not require specific treatment. However, if the
patient has symptoms or develops higher degrees of AV block, further evaluation and management may be
necessary, which may include considering a permanent pacemaker.

Primary Source:
Kusumoto, F., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R.,
Goldschlager, N., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K.
R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019c). 2018
ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac
Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 140(8).
https://doi.org/10.1161/cir.0000000000000628
 Regular Sinus Rhythm
Sinus rhythm - also known as regular sinus rhythm (RSR) or normal sinus rhythm (NSR) - is
the most common adult rhythm with rates between 60-100/minute. The QRS is most often
narrow with upright P waves in Lead II.

Care Management: Sinus rhythm is the normal rhythm of the heart and does not require specific treatment.
However, if the patient has symptoms or underlying cardiac pathology, further evaluation and management
may be necessary.

Primary Source:
Page, R. L., Joglar, J. A., Caldwell, M. A., Calkins, H., Conti, J. B., Deal, B. J., Estes, N. M., Field, M. E.,
Goldberger, Z. D., Hammill, S. C., Indik, J. H., Lindsay, B. D., Olshansky, B., Russo, A. M., Shen, W. K.,
Tracy, C. M., & Al‐Khatib, S. M. (2016). 2015 ACC/AHA/HRS Guideline for the Management of Adult
Patients with Supraventricular Tachycardia. Circulation, 133(14).
https://doi.org/10.1161/cir.0000000000000311

Junctional Tachycardia
Junctional tachycardia results from enhanced automaticity, increased sympathetic activity (catecholamines)
and ischemia. Key features of this rhythm include a rate over 100/minute, inverted or absent P waves (in
lead lI), shortened PR interval, and QRS complexes that are usually narrow. Note the inverted P wave buried
in each QRS complex displayed here in this ECG.

Care Management:
Treatment of junctional tachycardia depends on the patient's hemodynamic stability. In stable patients, vagal
maneuvers or pharmacological interventions such as adenosine or beta-blockers can be considered. In
unstable patients, synchronized cardioversion may be necessary.

Primary Source:
Walsh, E. P., Saul, J. P., Sholler, G. F., Triedman, J. K., Jonas, R. A., Mayer, J. E., & Wessel, D. (1997b).
Evaluation of a staged treatment protocol for rapid automatic junctional tachycardia after operation for
congenital heart disease. Journal of the American College of Cardiology, 29(5), 1046–1053.
https://doi.org/10.1016/s0735-1097(97)00040-5
 Ventricular Tachycardia
Ventricular tachycardia (VT) often resuits in hemodynamic compromise (due to minimal ventricular filling
time and the absence of atrial kick). What makes this rhythm more ominous is its tendency to transition into
ventricular fibrillation. Causes of VT include myocardial ischemia, a PVC landing on a T wave (R-on-T),
cardiac drug toxicity and electrolyte imbalance. Non-sustained VT (a group of 3 or more PVCs) is a run of
VT.

Care Management:
The management of ventricular tachycardia depends on the patient's hemodynamic stability. In stable
patients, antiarrhythmic medications such as amiodarone or lidocaine may be used. In unstable patients or
those with compromised hemodynamics, immediate synchronized cardioversion is necessary.

Primary Source:
Al‐Khatib, S. M., Stevenson, W. G., Ackerman, M. J., Bryant, W. J., Callans, D. J., Curtis, A. B., Deal, B.
J., Dickfeld, T., Field, M. E., Fonarow, G. C., Gillis, A. M., Granger, C. B., Hammill, S. C., Mark, D. B.,
Joglar, J. A., Kay, G. N., Matlock, D. D., Myerburg, R. J., & Page, R. L. (2018). 2017 AHA/ACC/HRS
Guideline for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac
Death. Circulation, 138(13). https://doi.org/10.1161/cir.0000000000000549

Third Degree AV Block

Third degree AV block (complete heart block) is often an ominous rhythm requiring close monitoring for
hemodynamic compromise, progression to ventricular standstill or asystole and other lethal dysrhythmias.
Significant characteristics of this rhythm are: 1) lonely P waves - P wave without an accompanied QRS
complex; and 2) chaotic PR intervals. A narrow QRS denotes a higher junctional block while a wide QRS
points more towards a sub-nodal block high in the bundle branches.

Care Management:
Third-degree AV block is often an indication for a permanent pacemaker, especially if the patient is
symptomatic or has underlying cardiac pathology. Close monitoring and evaluation of the patient's
symptoms, ECG findings, and underlying cardiac condition are essential in determining the appropriate
management approach.

Primary Source:
Kusumoto, F., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R.,
Goldschlager, N., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K.
R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019b). 2018
ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac
Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 140(8).
https://doi.org/10.1161/cir.0000000000000628

Sinus Bradycardia
Sinus Bradycardia with rates greater than 50/minute may be well tolerated by healthy adults. Athletes may
routinely be in sinus bradycardia due to an optimal cardiac stroke volume that requires less HR to yield
acceptable cardiac output. Sinus bradycardia may also be produced with Vagal stimulation or due to Sick
Sinus Syndrome. Expect a narrow
QRS with upright P waves in Lead ll.

Care Management:
Sinus bradycardia is often a benign condition and does not require specific treatment if the patient is
asymptomatic and hemodynamically stable. However, if the patient is symptomatic or has underlying
cardiac pathology, further evaluation and management may be necessary, which may include addressing the
underlying cause or considering a temporary or permanent pacemaker.

Primary Source:
Kusumoto, F., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R.,
Goldschlager, N., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K.
R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019). 2018
ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac
Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 140(8).
https://doi.org/10.1161/cir.0000000000000628
 Regular Sinus Rhythm
Sinus rhythm - also known as regular sinus rhythm (RSR) or normal sinus rhythm (NSR) - is the most
common adult rhythm with rates between 60-100/minute. The QRS is most often narrow with upright P
waves in Lead II.

Care Management:
Sinus rhythm is the normal rhythm of the heart and does not require specific treatment. However, if the
patient has symptoms or underlying cardiac pathology, further evaluation and management may be
necessary.

Primary Source:
Page, R. L., Joglar, J. A., Caldwell, M. A., Calkins, H., Conti, J. B., Deal, B. J., Estes, N. M., Field, M. E.,
Goldberger, Z. D., Hammill, S. C., Indik, J. H., Lindsay, B. D., Olshansky, B., Russo, A. M., Shen, W. K.,
Tracy, C. M., & Al‐Khatib, S. M. (2016). 2015 ACC/AHA/HRS Guideline for the Management of Adult
Patients with Supraventricular Tachycardia. Circulation, 133(14).
https://doi.org/10.1161/cir.0000000000000311