ECG

REMEMBER THE ‘BIX RULE’ WHILE INTERPRETING SVT

DR. D.P. KHAITAN
MD(MEDICINE) FCGP(IND) FIAMS(MEDICINE) FICP FICCMD

Introduction Some ECGs illustrating the Bix rule

Always think over 'Bix rule' while
encountering a rhythm with SVT.
A basic concept of atrial flutter and
atrial tachycardia
OUTLINE
ECG 1 midway P' in between two QRS
complexes and the next P lurking through the
next QRS
(on the subsequent ECG atrial flutter with
variable degree of AV conduction).
ECG 2 P' in between two QRS complexes and

Bix rule - know the breaking point of with intermittent short run of atrial flutter with
rhythm pattern on ECG while varying degree of AV block on the same ECG
interpreting SVT
ECG 3 Atrial tachycardia (long RP interval)
A methodical approach to Bix rule
Suspect any SVT around about 150/min Concluding remark
to be atrial flutter/atrial tachycardia with
2:1 AV conduction, unless and until
disapproved References
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REMEMBER THE 'BIX RULE' WHILE INTERPRETING SVT

A Narrative Review  DR. D.P. KHAITAN
MD (MEDICINE) FCGP (IND) FIAMS (MEDICINE) FICP FICCMD
BSTRACT

The science and art of cardiac arrhythmias lie in identifying the 'breaking out of rhythm
pattern' wherein one is most likely to find the solution. Every cardiac arrhythmia is having
some particular characteristic of identification which keeps it separate and distinct from other
arrhythmias. As per Marriott's epigrammatic - 'dig the break' – a process to seek and focus
on any interruption in the rhythm regularity , if with atrial activity (eg. one P without its
accompanying QRS complex) , it is most likely supraventricular in origin.
Bix rule is a phenomenon description to know the point of 'Breaking out of Rhythm Pattern'
in SVT.
 One P wave is halfway between the two QRS complexes and the next P is lurking
through or hidden within the next QRS complex
 The decremental conduction across AV Node does not usually tolerate
supraventricular increment beyond a limit – the comfortable ventricular zone is 150
bpm , so is due to 2:1 AV conduction –one P is blocked to pass through without
inscribing its fellow QRS.
Dr. Harold Bix with ''encyclopedic knowledge of arrhythmia'' had put this rule before the
world to recognize this pattern

1. Introduction (Keypoints)
o In this article , the implementation of 'Bix rule' is detailed - it is very useful while
interpreting SVT in certain specific situations. A correct diagnosis is very much essential
in managing the case. This popular 'Bix rule' was coined by a Viennese cardiologist
Dr. Harold Bix who had an encyclopaedic knowledge of arrhythmia. The recognition
point of 'Breaking out of Rhythm Pattern' is the fundamental in identifying the
cardiac arrhythmia.
o Let us review the Bix rule - If one is dealing with supraventriular tachycardia (almost at
the rate of 150 bpm) in which a visible P wave is situated midway between two ventricular
complexes , there will be a probability that one more P wave is lurking through or hidden
within the following QRS complex. This rule is mainly helpful in identifying atrial flutter
with 2:1 AV conduction but also helpful with atrial tachycardia with 2:1 conduction.

o The Bix rule is the very example of 'dig the break' - a definite plan paving a path to reach
to the diagnosis in certain cases of SVT with confidence.. This rule imparts a learning -
both the science and art how to think over the analysis of SVT , almost running at the rate
of 150 bpm.
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o If one thinks over and over almost every time while encountering a rhythm of SVT and
adopts the ‘Bix rule’ as a habit to pickup the P wave situated midway in between two
ventricular complexes and to search out the next P through the next QRS complex – one
may become a rockstar in picking up atrial flutter / atrial tachycardia with 2:1
AV conduction , otherwise this is being missed.

2. A basic concept of Atrial flutter and Atrial tachycarida

This become essential to review the basic concept with the differences in between atrial
flutter and atrial tachycardia to understand the electrocardiographic implication of Bix rule

ATRIAL FLUTTER ATRIAL TACHYCARDIA

1. Mechanism MACRO-REENTRY of an
electrical impulse through a
circular pathway , usually
within the right atrium
2. Rate 250-350/min , usually around
300
3. Morphology Saw-tooth appearance without
having intervening isoelectric
line
ENHANCED AUTOMATICITY
in the pacemaking cells within the
atria (others mechanisms -
triggered or micro-rentry)
100-250/min - slower than that of
atrial flutter (sometimes may go
upto 300/min)
Non-sinus P wave with intervening
isoelectric line

4. Degeneration into Flutter wave may degenerate Not so

atrial fibrillation into Fibrillation
5. Rhythm regularity Regular but may be irregular Usually regular (focal AT with
with variable AV conduction variable block may be associated
or if associated with atrial with digoxin toxicity)
fibrillation (atrial flutter -
fibrillation)
6. Vagal manoeuvres  Slowing of AVN conduction and induction of intermittent AV
(carotid massage) block , atrial electrical activity can thus be unmasked , revealing P
/ adenosine may waves with more clarity (atrial flutter , focal AT).
unmask the atrial
activity (P wave
may be visible )

NB :
 Atrial flutter :  Atrial tachycardia
 Saw-tooth appearance without  Non-sinus P’ wave with intervening
intervening isoelectric line isoelectric line
 Rate 250-350/min , usually around  Rate 100-150/min – slower than that of
300 atrial flutter (sometimes may go upto
300/min)
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3. Bix rule - know the breaking point of rhythm pattern while

interpreting SVT
The decremental conduction across AV Node does not usually tolerate supraventricular
increment beyond a limit – the comfortable ventricular zone is 150 bpm, so is due to
2:1 AV conduction.
To see in details , the following points under rectangular box should be kept in mind :

'Foundation of Bix rule'.

 Atrial flutter waves occur at about 250-350 bpm , usually around 300. These flutter
waves , especially of newer onset are conducted with 2:1 through AV node resulting
in ventricular rate 125-175 bpm, on average around 150.
 Waves of atrial tachycardia with somewhat higher rate (300 bpm) might also be
conducted with 2:1 pattern through AV node.
 SVT with 2:1 AV conduction , the first P' may be visible midway between two
ventricular complexes while the next one is probably lurking through or hidden within
the next QRS complex .

With 2:1 conduction one atrial beat is allowed to

Bix Rule pass through AV Node in a sequential way
P-QRS-T, but the next activated non-conducted
QRS --P'-- QRS atrial beat is just coincidentally coming at a time
(P') of QRS so it is lurking through or hidden within
(NB : With such higher rate , the first P may
ascend up through T-wave – at times it may
appear as the tip of the T-wave.)
 Seek the P’ midway in between two
QRS
 The next P’ would be lurking
through / hidden within next QRS

P wave midway
in between two
QRS – here
 Hide-and-seek play imposed on T

Since flutter waves tend to be somewhat

wide and rarely fall perfectly inside a
narrow QRS complex , one can still find
imprints of buried wave as a slight notch or
slur at the base of accompanying QRS
complex confirming the atrial activity Lurking P as a slight slur

hidden therein.

Atrial tachycardia with long RP interval as 2:1

Fig. 1.1 AV conduction : AT wave not so wide falls
P midway in between two QRS complex
perfectly inside QRS
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4. A methodical approach to Bix rule

The following steps should be undertaken in succession (My pneumonic ‘S’):

Suspicion Suspect any supraventricular tachycardia around about 150/min to be

atrial flutter/atrial tachycardia with 2:1 AV conduction, unless and until disapproved.

Scrutinise every lead 12 lead surface ECG should be thoroughly scrutinised to observe
the following chages :
 Find out P' in midway between two QRS
 Hide and seek play
Search out the hidden P' as peeping through the accompanying QRS.
 A slight notch or slurring through the base of QRS
 Is there any visible transient short spell of atrial flutter anywhere on ECG ?

Slow the ventricular rate carotid massage/adenosine to see the artial activity with clarity
(One should rule out atrial fibrillation which may appear at times alike atrial Flutter but these
are irregular and not all alike (disorganised) - the pattern of atrial fibrillation is irregularly
irregular).
Set long rhythm Strip II A transient short spell of atrial flutter might be visible on its
longway of rhythm strip II , it would be easier to visualise atrial flutter with more clarity.
Spot Atrial tachycardia In atrial tachycardia one can see a distinct P' wave of abnormal
morphology (non-sinus) but not alike atrial flutter appearance.

See the alternate diagnosis With the rate of round about 150 bpm with a P' wave either
behind QRS or just after the T wave may at times compels the clinician to think over the
alternate diagnosis due to the mirage effect as if P’ is situated midway.
.Two important alternate diagnosis must be excluded :
AVNRT : Short RP tachycardia (less than 50% of RR interval) ; appearing as P-wave after
QRS complex or pseudo S in inferior leads with r' in V1/aVR or even P wave may not be
visible (buried within QRS).
AVRT(orthodromic) : Long RP tachycardia (sometimes P’ wave might be seen just after T
wave – known as long RP interval with more than 50% of RR interval) , + associated with
more prominent ST/T changes over inferior/precordial leads , + electrical alternans : one may
see the evidence of WPW pattern on basal ECG or after its conversion with DC shock.

 Short RP may also be expressed as less than

50% of RR interval
 Long RP may also be expressed as more than
50% of RR interval

Fig. 1.2
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5. Some ECGs illustating the Bix rule

ECG Ventriuclar rate = 150/min with midway P' in between two QRS complexes.
On the subsequent ECG (B) atrial flutter with variable degree of AV conduction.
(1)

Source : CME INDIA on 06.11.2020 by Dr. Gupta Sir, Jamuna Nagar

History : A known case of HCM presented 1.5 years back with AF ; reverted back , now
taking tablet Prolomet XL 25mg and tablet Cordarone 200mg daily.
Today again presented with Palpitation with the ECG findings as below :
Ventricular rate 150 bpm with midway P' in between two QRS complex, clearly seen
over V1 ( situated as a sharp P over T) and lurking P' seen peeping as a tiny wavelet
through the base of the next QRS complex (see also V5)

Inj. AMIODARONE Bolus IV 150 given and the subsequent ECG is given below :

Atrial flutter with variable degree of

AV conduction

Atrial Flutter with variable degree of AV conduction.

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ECG Narrow complex tachycardia (150/min) with mid P' between two QRS
(2) complexes and with intermittent short run of atrial flutter with variable
degree of AV conduction over precordial leads in the same ECG , more
obvious over rhythm lead II

Bix Rule
QRS --P'-- QRS + Intermittent spells of atrial flutter with
(P') variable degree of AV conduction
(NB : at times a long rhythm strip II becomes
essential to visualize the intermittent spells of
Fig. 1.3 atrial flutter with more clarity)

(Source : Global Heart Rhytm Forum by Dr. Ameya udyavar on May 18 , 2020)
Source: Global Heart Rhythm Forum by Dr. Ameya Udyavar on 18.05.2020 (also
discussed the same by Dr. Chan Kit Jacky on 28.05.2020 on the same forum)

ECG findings :
 Heart rate = 150/min , midway P' (best seen in inferior leads II, III and aVF
with prominent negativity) with somewhat sinuous pattern : Bix rule
applicable.
 Simultaneous appearance of intermittent short spells of atrial flutter with
variable degree of AV conduction in the same ECG (V1 to V6 , also in
lead II).
Other associated findings (QRS axis = about -1200 with high left anterior
hemiblock with ? RBBB)
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ECG Atrial tachycardia (long RP interval)

(3)

Source : Global Heart Rhythm Forum on 08.12.2019 put by Dr. N.K. Singh , an eminent
consultant physician from India

ECG findings :
Heart rate = 150 bpm , midway P' obvious over V1 with long RP interval (other
findings - low voltage in limb leads , occasional interpolated ventricular
premature beat over precordial leads)
Well - argued in a lucid way by Dr. Prof. Narendra Kumar , eminent cardiologist -
Atrial tachycardia (long RP interval)

Concluded by the opinion of Dr. Yash Lokhanwala , eminent cardiologist :

Atrial tachycardia with IVCD of LBBB type .

(V1 is the most useful lead in view of uncertainty , also excellent lead for
characterising atrial activity)
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6. Concluding remark

If one thinks over and over almost every time while encountering a rhythm of SVT and
adopts the ‘Bix rule’ as a habit to pickup the P wave situated midway in between two
ventricular complexes and to search out the next P through the next QRS complex – one may
become a rockstar in picking up atrial flutter / atrial tachycardia with 2:1 AV conduction ,
otherwise this is being missed.
Practising makes a man perfect. And one feels that regular practicing is the starting point of
the practical implication of whatever knowledge one possesses. The appreciation of 'Bix rule'
opens a door while interpreting SVT.

7. References
1. 10 tips to never miss atrial flutter with 2:1 conduction , Dawn B. Altman, RN, EMT-
P.
https://www.ems1.com/medical-monitoring/articles/10-tips-to-never-miss-atrial-
flutter-with-21-conduction-OfLh1uxFYefd1iO9/

2. The Bix rule - Heart & Lung - The Journal of Cardiopulmonary and Acute care- by
George Nikolic , MBBS, FRACP, FACC, 2008
https://www.heartandlung.org/article/S0147-9563(07)00216-6/fulltext

3. The Bix Rule - ECG Rhythms

https://www.us.elsevierhealth.com/heart-lung-0147-9563.html
4. Diagnosing Supraventricular Tachycardia when Physical Examination Trumps the
Electrocardiogram , Author - James E. Ip, MD; Bruce B. Lerman, MD - AHA
Journals
https://www.ahajournals.org/doi/10.1161/CIRCEP.115.003082

5. The 12 Rhythms of Christmas : Atrial Flutter , Source - ems12lead.com