Lesson on Arrhythmia

BIMC, 17 February 2004

Charles Hoo, M.D.
Rhythms:
 Sinus rhythm
 Atrial rhythm
 Junctional rhythm
 Ventricular rhythm ( Idioventricular
rhythm )
 Premature beat ( extrasystole )
 Blocks
About ECG :
Sinus rhythm
 Normal sinus rhythm
 Sinus tachycardia
 Sinus bradycardia
 Sinus arrhythmia
 Sinus arrest
 Sinus block
Sinus rhythm
Criteria :
 P wave : normal, each P always followed by
QRS and T ( 1:1 )
 PR interval : normal ( 0,12 - 0,20 s )
 QRS wave : normal ( 0,06 – 0,12 s )
Sinus rhythm

Normal sinus rhythm

…plus ….
 Rhythm : regular ( RR interval constant )
 Frequency : 60-100x/min
Sinus rhythm

Sinus tachycardia
…plus ….
 Rhythm : regular ( RR interval constant )
 Frequency : >100-150x/min
Sinus rhythm

Sinus bradycardia
…plus ….
 Rhythm : regular ( RR interval constant )
 Frequency : < 60x/min
Sinus rhythm

Sinus arrhythmia
… plus ….
 Rhythm : irregular ( RR interval not constant )
 To differentiate between normal variant and sinus arrhythmia, use this rule:
if the longest minus shortest of RR interval in 1 minute > 0,12 s  sinus
arrhythmia.
 Frequency : usually 60-100x/min
Sinus rhythm

Sinus arrest
…plus ….
 Rhythm : regular ( RR interval constant )
 There are one or more episodes of nil P, QRS, and T

 Ratio of RR’ to RR is not complete number

 Frequency : usually < 60x/min

Sinus rhythm

Sinus block
…plus ….
 Rhythm : regular ( RR interval constant )
 There are one or more episodes of nil P, QRS, and T

 Ratio of RR’ to RR is a complete number

 Frequency : usually < 60x/min

Junctional rhythm

Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : 40-60x/min ( if 60-100x/min, called : accelerated junctional
rhythm )
 P wave : negative, occur before or after QRS or not seen
 PR interval : shortened ( < 0,12 s ) or not seen
 QRS wave : normal ( 0,06 – 0,12 s )
Junctional tachycardia

Included in Supraventricular tachycardia ( SVT )

Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : > 100x/min, usually 150-250x/min
 P wave : negative, occur before or after QRS or not seen
 PR interval : shortened ( < 0,12 s ) or not seen
 QRS wave : normal ( 0,06 – 0,12 s )
Atrial rhythm
Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : 40-60x/min
 P wave : normal, each P always followed by QRS and T (
1:1 )
 PR interval : shortened ( < 0,12 s )
 QRS wave : normal ( 0,06 – 0,12 s )
Atrial tachycardia

Included in Supraventricular tachycardia ( SVT )

Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : > 100x/min, usually 150-250x/min
 P wave : normal or not seen
 PR interval : shortened ( < 0,12 s ) or not seen
 QRS wave : normal ( 0,06 – 0,12 s )
Atrial flutter

Criteria :
 Rhythm : usually regular ( RR interval constant )
 Frequency : variable - slow ventricular response ( < 60x/min )
- normal ventricular response ( 60-100x/min )
- rapid ventricular response ( >100x/min )
 P wave : saw teeth pattern which P waves occur in regular pattern and have a good ratio
( e.g., P : QRS = 2:1, 3:1, 4:1 )
 PR interval : cannot be evaluated
 QRS wave : normal ( 0,06 – 0,12 s )
Atrial fibrillation

Criteria :
 Rhythm : irregular ( RR interval not constant )
 Frequency : variable and irregular - slow ventricular response ( < 60x/min )
- normal ventricular response ( 60-100x/min )
- rapid ventricular response ( >100x/min )
 P wave : cannot be identified
 PR interval : cannot be evaluated
 QRS wave : normal ( 0,06 – 0,12 s )
Ventricular rhythm
( Idioventricular rhythm )

Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : 20-40x/min
 P wave : not seen
 PR interval : none
 QRS wave : prolonged ( > 0,12 s )
Ventricular tachycardia

Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : > 100x/min
 P wave : not seen
 PR interval : none
 QRS wave : prolonged ( > 0,12 s )
Ventricular fibrillation

Criteria :
 Rhythm : irregular
 Frequency : cannot be evaluated
 P wave : none
 PR interval : none
 QRS wave : uncounted, irregular, wavy
Ventricular fibrillation
There are 2 kinds of Ventricular fibrillation :
 Coarse VF

 Fine VF ( should be DD : Asystole )

Premature beat
( extrasystole )
Premature beat ( extrasystole )
 Mention first the base rhythm then name the
type of premature rhythm
 Occurs paroxysmally
 The RR interval after premature beat always
longer than RR of base rhythm (compensatory
phase)
Premature atrial beat
( Atrial extrasystole )

Criteria :
 Rhythm : irregular, because of the occurrence of premature
complexes
 Frequency : depend on base rhythm’s frequency
 P wave : abnormal, depend on the origin of impuls
 PR interval : normal or shortened ( < 0,12 s )
 QRS wave : normal ( 0,06 – 0,12 s )
Premature junctional beat
( Junctional extrasystole )

Criteria :
 Rhythm : irregular, because of the occurrence of premature
complexes
 Frequency : depend on base rhythm’s frequency
 P wave : abnormal, depend on the origin of impuls
 PR interval : shortened ( < 0,12 s ) or none
 QRS wave : normal ( 0,06 – 0,12 s )
Premature ventricular beat
( Ventricular extrasystole )

Criteria :
 Rhythm : irregular, because of the occurrence of premature
complexes
 Frequency : depend on base rhythm’s frequency
 P wave : none
 PR interval : none
 QRS wave : prolonged ( > 0,12 s )
Premature ventricular beat
( Ventricular extrasystole )
Life threatening Premature ventricular beats :
 Occur more than 6x/min

 Bigemini ( normal : premature = 1:1 )

 Multifocal ( more than one type pattern )

 Salvo/consecutive ( 2 or 3 beats; note : if 4 or more

beats, is called as Ventricular tachycardia )

 R on T

Life threatening because can become ventricular

tachycardia.
Life threatening Premature Ventricular beats
Bigemini
Life threatening Premature Ventricular beats
Multifocal
Life threatening Premature Ventricular beats
Salvo / consecutive
Life threatening Premature Ventricular beats
R on T
Blocks in heart rhythm
Sinoatrial block ( SA Block ) /
Sinus block

There are one or more episodes of nil P, QRS, and T

Ratio of RR’ to RR is a complete number
DD : AV block – grade II type Mobitz 2
Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : usually <60x/min
 P wave : normal, each P always followed by QRS and T ( 1:1 )
 PR interval : normal ( 0,12 - 0,20 s )
 QRS wave : normal ( 0,06 – 0,12 s )
Atrioventricular block ( AV block )
Grade I

Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : usually 60-100x/min
 P wave : normal, each P always followed by QRS and T ( 1:1 )
 PR interval : prolonged ( > 0,20 s )
 QRS wave : normal ( 0,06 – 0,12 s )
Atrioventricular block ( AV block )
Grade II - type Mobitz 1 ( Wenchebach )

Criteria :
 Rhythm : irregular
 Frequency : 60-100x/min or < 60x/min
 P wave : normal, but there is one P that not followed by QRS in a cycle
( e.g., 3:2, 4:3, 5:4 )
 PR interval : prolonged ( > 0,20 s ) gradually unto there is a P that not followed by
QRS, then the cycle repeated
 QRS wave : normal ( 0,06 – 0,12 s )
Atrioventricular block ( AV block )
Grade II - type Mobitz 2

Criteria :
 Rhythm : irregular
 Frequency : usually < 60x/min
 P wave : normal, but there are one or more Ps that not followed by QRS in a cycle
( e.g., 2:1, 3:1, 4:1 )
 PR interval : normal ( 0,12 - 0,20 s ) or prolonged constantly then the block occurs
 QRS wave : normal ( 0,06 – 0,12 s )
Atrioventricular block ( AV block )
Grade III

DD : Junctional ryhthm
Ventricular rhythm
Criteria :
 Rhythm : regular ( RR interval constant )
 Frequency : usually < 60x/min
 P wave : normal, but the P and QRS stand independently, thus the P waves sometimes
followed by QRS, sometimes not
 PR interval : variable or none
 QRS wave : normal ( 0,06 – 0,12 s ) or prolonged
….thank you