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Arrhythmias and ECG Interpretation

Arrhythmias and ECG interpretation can be summarized as follows: 1. Arrhythmias are abnormalities of the cardiac rhythm or rate that are classified based on their origin and appearance on ECGs. 2. Common arrhythmias include sinus tachycardia, sinus bradycardia, supraventricular tachycardia, atrial flutter, ventricular tachycardia, atrial fibrillation, heart block, and premature beats. 3. ECG patterns of arrhythmias provide clues to their origin and type, such as the presence, shape, and timing of P waves compared to QRS complexes.

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Hassan Adel Alojaimi
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49 views48 pages

Arrhythmias and ECG Interpretation

Arrhythmias and ECG interpretation can be summarized as follows: 1. Arrhythmias are abnormalities of the cardiac rhythm or rate that are classified based on their origin and appearance on ECGs. 2. Common arrhythmias include sinus tachycardia, sinus bradycardia, supraventricular tachycardia, atrial flutter, ventricular tachycardia, atrial fibrillation, heart block, and premature beats. 3. ECG patterns of arrhythmias provide clues to their origin and type, such as the presence, shape, and timing of P waves compared to QRS complexes.

Uploaded by

Hassan Adel Alojaimi
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Arrhythmias and ECG

interpretation
 Definition of arrhythmia :

Abnormality of the cardiac rhythm or rate.


 Clinical classification:
Sinus rhythm disturbances:
1. Sinus tachycardia.
2. Sinus bradycardia.
3. Sinus arrhythmia.

Pathological Tachy-arrhythmias:
1. Supraventricular tachycardia (SVT).
2. Atrial Flutter.
3. Ventricular tachycardia (VT).
4. Atrial Fibrillation (AF).
Pathological Brady-arrhythmias:
1. Nodal(junctional)rhythm.
2. Heart block
3. Sick sinus syndrome.

Others:
1. Premature beats (Extrasystole).
2. Pre-excitation syndrome.
SINUS TACHYCARDIA:

 Definition:
The SAN discharges at rapid rate > 100/min.

 ECG:
o QRS:
• Rhythm: regular.
• Rate: 100-180/min
• Duration: normal.
o P wave:
• Normal
SINUS BRADYCARDIA:

 Definition:
The SAN discharges at slow rate < 60 /min.

 ECG:
o QRS:
• Rhythm: regular.
• Rate: 50-60 /min , (or less).
• Duration: normal.
o P wave:
• Normal
SUPRAVENTRICULAR TACHYCARDIA:

 Definition:
It is an tachy-arrhythmia originating from above the ventricle.

 Types:
1. Atrial tachycardia: Arrhythmia originate from the Atria.
2. Nodal tachycardia: Arrhythmia originate from the AVN.
 ECG:
o QRS:
• Rhythm: regular.
• Rate: 120-250 /min.
• Duration: normal.
o P wave:
In Atrial tachycardia: deformed.
In Nodal tachycardia: absent or inverted.
Nodal tachycardia
“Absent p”
Nodal tachycardia
“Inverted p”

“Before QRS” “After QRS”


Atrial Flutter:

 Definition:
 A tachycardia in which the atria discharge at regular rapid rate 240-440 /min.

 A physiological block occurs in the AVN (2:1 or 3:1 or 4:1).

 Therefore only ½ , or 1/3 or ¼ of the atrial impulses will pass to the ventricles.

 The block may be:


o Fixed ( e.g 2:1) or
o Variable ( e.g changing from: 2:1 to 3:1 to 4:1 …….)
 Types:
1. Type I (common, typical ):
the atrial rate is 240-340/min (approximately 300/min).
1. Type II (rare):
the atrial rate is 340-440/min (approximately 400/min).
 ECG:
o QRS:
• Rhythm: regular (fixed block) , irregular (variable block).
• Rate: 150 or 100 or 75 /min(according to AV block).
• Duration: normal.
o P wave:
• Replaced by : multiple “Flutter waves” at a rate 240-340/min
• Typically : “ Saw-tooth appearance”.
VENTRICULAR TACHYCARDIA:

 Definition:
It is an arrhythmia originating from the ventricle that presents with:
o Three or more successive ventricular premature beats.
o Rapid regular tachycardia at a rate of: 120-250/min.

Since there is no retrograde conduction in the AVN , there will be AV dissociation:


o The ventricles will be controlled by the ventricular focus :(VR 120-250/min).
o The atria will be controlled by the SAN : (AR :60-100/min).

 Types:
1. Sustained: persists > 30 sec. or causes hemodynamic instability.
2. Non-sustained: persists < 30 sec. with no hemodynamic instability .
 ECG:
o QRS:
• Rhythm: regular.
• Rate: 120-150/min.
• Duration: wide .
o P wave: (may not appear)
Normal in rate (60-100/min) &shape.
Comes before, after or is hidden by the QRS (AV dissociation).
Special types of VT:

 Torsade de pointes:
QRS complexes change continuously and rapidly and irregularly from an upright to an
inverted position (twisting of points).

 Accelerated Idio-Ventricular Rythm:


An ectopic ventricular pacemaker discharges at a rate: 60-120/min and controls the
ventricles only resulting in a slow VT.
Torsade de pointes
ATRIAL FIBRILLATION:

 Definition:

o A form of tachycardia in which the atria discharge at a rate: 400-600/min.

o An irregular block occurs in the AVN , allowing only some impulses to pass to the
ventricle in an irregular manner.

o The ventricular beats will be:


Rhythm: markedly irregular.
Rate: 100-160/min
Force: variable.
Causes of slow AF:
1)Drugs : Digitalis or B-Blocker.
2)Lone AF: Idiopathic( primary ) , more
common in old age .
3)Associated heart block.
 ECG:
o QRS:
• Rhythm: markedly irregular.
• Rate: 100-160/min.
• Duration: normal .
o P wave: “Absent p”
Replaced by : fibrillation waves (irregular vibrations).
PREMATURE BEATS (EXTRASYSTOLES):

 Definition:

o They are ectopic cardiac impulses occurring before the expected sinus impulse
causing premature beats.

o When the normal sinus impulse arises, heart will not respond “refractory period”.

o These ectopic cardiac impulses may arise :


Supraventricular (from the Atria or AVN)
Ventricular (from the Ventricles).
 ECG:

o QRS:
• Rhythm: irregular (Occasional irregularity) but sinus.

• The premature beat comes early and is followed by a compensatory


pause:
1. Supraventricular:
-Atrial beats: deformed P-wave followed by a normal QRS.
-Nodal beats: absent or inverted P-wave , a normal QRS.

1. Ventricular:
-Ventricular beats: absent P-wave , wide QRS.
Atrial extrasystole:
Nodal extrasystole:
Ventricular extrasystole:
NODAL(JUNCTIONAL) RHYTHM:

 Definition:
o AVN initiated electrical activity of the heart.
o The impulses spread up and down to activate the atria and the ventricles
simultaneously.

 There are 2 possibilities:

1-Nodal tachycardia:
Abnormal automaticity in the AVN overtakes the normal SAN.
2- Nodal rhythm:
An escape rhythm in which the AVN becomes the pace-maker of the heart
discharging at a rate of 40-60/min, In cases of:

Severe bradycardia: when the SAN discharges at a rate slower than the intrinsic
AVN pacemaker.
Heart block: conduction problem between the SAN and the AVN .
 ECG:
o QRS:
• Rhythm: regular.
• Rate: 40-60/min
• Duration: normal.
o P wave:
• Absent or inverted.
 HEART BLOCK:

 Definition:

o A disease in the Electrical system of the heart.

o Impairment of impulse conduction at any of the following sites:


1. SAN (Sinoatrial block): Between the SAN and the atria.
2. AVN (AV block) : Between the atria and the venrticles.
3. Bundle branch (BBB): Along the bundle branches.
 Types ( Degrees) of AV block:

1. First degree: delayed conduction of ALL impulses.

2. Second degree: no conduction of some impulses.

3. Third degree: no conduction of ALL impulses.


First degree:
-ALL p waves are followed by a QRS complex.
-ECG : PR :prolonged > 0.2 sec (>5small squares) , fixed.
Second degree(Incomplete HB):
Some p waves are not followed by a QRS complex.
There are 2 types:

1. Mobitz Type I: (Wenckebach phenomenon) (Block is in AVN)


- Progressive prolongation of the AV conduction time until conduction fails completely and an
atrial impulse is blocked.

2. Mobitz Type II : (Block is below AVN : Infra-Hiss)


-Every 2,3 or 4 atrial impulses , the AVN transmits only one impulse to the ventricles .
- The block will be 2:1 , or3:1 , or 4:1 .
- The block may be :
• Fixed ( e.g 2:1).
• Variable ( e.g changing from : 2:1 to 3:1 to 4:1 ……)
- Mobitz Type I:
- ECG:
- PR : progressive prolongation until a QRS is dropped .
- Until a p wave not followed by a QRS complex.
- Then , the PR returns to its normal duration and the sequence is
repeated.
2. Mobitz Type II :
- ECG:
o QRS:
• Rhythm: regular (Fixed block) , irregular (variable block).
• Rate: slow , e.g 30-50/min (according to AV block).
• Duration: normal.
o P wave:
• Normal rate.
• 2, 3 or 4 p waves occur before each QRS .
• The block may be : fixed or variable.
Third degree(complete HB):

• No conduction of All impulses from the atria to the ventricles.


• How do the ventricles work???
• They will be controlled by Idioventricular pacemaker.
No relation between p wave and QRS complexes (AV dissociation).
- ECG:
o QRS:
• Rhythm: regular.
• Rate: 30-40/min.
• Duration: wide.
o P wave:
• Normal in rate (60-100/min) and shape.
• Comes before , after or is hidden by the QRS .
Acute Myocardial infarction:
ECG:
 Hyperacute T wave is the earliest sign.
 Inverted T wave = ischaemia.
 Pathological Q wave= infarction.
 Elevated convex ST segment (injury pattern ) = recent infarction.
 According to ST segment elevation , there are 2 types of MI:

1.STEMI : Confirmed by cardiac markers (enzymes).


2.NSTEMI: Diagnosed by cadiac markers (enzymes).
((A normal ECG does not rule out acute myocardial infarction.))

 According to Q waves, there are 2 types of MI:


1. Q wave MI : “Transmural MI”
Usually associated with STEMI.
2. non Q wave MI : ”subendocardial MI”
Usually associated with NSTEMI.
 According to affected leads , there are many sites of MI:

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