5 Easy Steps to Always Follow When Analyzing Rhythms

When analyzing any type of heart rhythm I recommend following the 5 steps below. If you answer
each of these questions and apply it to the “hallmarks” of all the rhythms, you should not have any
problem identifying rhythms. This is because every dysrhythmia has a certain “hallmark” that sets
it apart from the other rhythms.

1. Are p-waves present? If so, how many p-waves are present in 6 seconds? (when you
count the p-waves you are calculating the atrial rate) Normal atrial rates are 60-100 beats
per minute.
2. Are the p-waves regular? This is where you will measure the distance between each p-
wave with calipers or a sheet of paper.
3. Are the r-waves regular? Again, you will use calipers or a sheet of paper to measure the
distance between each r-wave to see if they are regular.
4. How many r-waves are present in 6 seconds? This is how to calculate the ventricular rate.
You do this the same way you measured the atrial rate. A normal ventricular rate of 60-100
bpm.
5. If there are p-waves, what is the measurement of the PR-interval? What is the width of
the QRS complex? Note: You cannot measure a PR interval with a-fib or a-flutter because
there are no p-waves present.
Difference Between Atrial Fibrillation and Atrial Flutter
Now, let’s talk about the difference between the two rhythms. But first, let’s look at a normal
rhythm.

In Normal Sinus Rhythm (NSR), you will always have the following:

1. P-waves will be present with atrial rate of 60-100 bpms (meaning there will be 6-10 p-waves
present in 6 seconds)
2. P-waves will be regular
3. R-waves will be regular
4. There will be 6-10 QRS complexes in 6 seconds to equal a ventricular rate of 60-100 bpms
5. PR interval will be measurable and be a length of 0.12-0.20 seconds. And QRS complex will
measure less than 0.12 seconds.
In atrial fibrillation, you will always have the following:
 1. No p-waves will be present. The little humps you are seeing are called f-waves (fibrillary
waves). Therefore, you cannot count the atrial rate.
2. P-waves are not present so you can’t measure if the p-waves are regular.
3. R-waves will be irregular because of the random fibrillary waves quivering at various times.
4. Typically there are 6-10 r-waves in a-fib in 6 seconds, BUT if the patient is having what is
called a-fib with RVR (rapid ventricular response) you can have many r-waves varying from
11-200. On the heart monitor you would see a fluctuating heart rate of 110-200 when the a-
fib is not controlled.
5. PR interval is not measurable because you don’t have p-waves and the QRS complex is
usually less than 0.12 seconds.
In atrial flutter, you will always have the following:

1. No p-waves will be present BUT a wave of f-wave called SAW-TOOTH WAVES. This will
NEVER be present in a-fib. This is a big difference in how you tell if the rhythm is a-flutter or
a-fib.
2. P-waves are not present so you can’t measure if the p-waves are regular.
3. R-waves tend to be regular BUT the can be irregular depending on the quivering of the
atrium. You can see in the example I provided that this r-waves are irregular.
4. Typically there are 6-10 r-waves in a-flutter in 6 seconds, BUT if the patient is having what is
called rapid a-flutter, you can have many r-waves varying from 11-200. On the heart monitor
you would see a fluctuating heart rate of 110-200 when the a-flutter is not controlled.
5. PR interval is not measurable because you don’t have p-waves and the QRS complex is
usually less than 0.12 seconds.
Conclusion
The major difference between a-fib and a-flutter are the saw-tooth waves in a-flutter and that in a-
fib the r-waves are always irregular. The r-waves in a-flutter can be regular or irregular.