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ECG Mastery Improving Your ECG Interpretation Skills
ECG Mastery Improving Your ECG Interpretation Skills
ECG Mastery Improving Your ECG Interpretation Skills
Chapter 4
Atrial Arrhythmias
• The pacemaker site transfers from the sinoatrial (SA) node to other latent pacemaker sites in the atria and the
atrioventricular (AV) junction and then moves back to the SA node.
Clinical Tip:
Wandering atrial pacemaker may occur in normal hearts as a result of fluctuations in vagal tone. It may also be
seen in patients with heart disease or chronic obstructive pulmonary disease (COPD).
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• This form of wandering atrial pacemaker is associated with a ventricular response of greater than 100 bpm.
• Multifocal atrial tachycardia may be confused with atrial fibrillation; however, multifocal atrial tachycardia has a
visible P wave.
Clinical Tip:
Multifocal atrial tachycardia is commonly seen in patients with chronic obstructive pulmonary disease but may
also occur in acute myocardial infarction.
• A single contraction occurs earlier than the next expected sinus contraction.
• After the premature atrial contraction (PAC), sinus rhythm usually resumes.
Rate: Depends on rate of underlying rhythm Rhythm: Irregular whenever a PAC occurs
P Waves: Present; in the PAC, may PR Interval: Varies in the PAC; QRS: Normal (0.06–0.10 sec)
have a different shape otherwise normal (0.12–0.20 sec)
Clinical Tip:
In patients with heart disease, frequent PACs may precede paroxysmal supraventricular tachycardia, atrial
fibrillation, or atrial flutter.
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ATRIAL TACHYCARDIA ■
• A rapid atrial rate overrides the SA node and becomes the dominant pacemaker.
• Some ST wave and T wave abnormalities may be present.
SUPRAVENTRICULAR TACHYCARDIA ■
• Supraventricular tachycardia has such a fast rate that the P waves may not be seen. They are frequently buried
in the T waves.
Clinical Tip:
Supraventricular tachycardia may be related to caffeine intake, nicotine, stress, or anxiety in healthy adults.
Clinical Tip:
Some patients may experience angina, hypotension, lightheadedness, palpitations, and intense anxiety.
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• Paroxysmal supraventricular tachycardia is a rapid rhythm that starts and stops suddenly.
• For accurate interpretation, the beginning or end of the paroxysmal supraventricular tachycardia must be seen.
• Paroxysmal supraventricular tachycardia is sometimes called paroxysmal atrial tachycardia.
Clinical Tip:
The patient may feel palpitations, dizziness, lightheadedness, or anxiety.
ATRIAL FLUTTER ■
• The AV node conducts impulses to the ventricles at a 2:1, 3:1, 4:1, or greater ratio (rarely 1:1).
• The degree of AV block may be consistent or variable.
Rate: Atrial: 250–350 bpm; ventricular: variable. Rhythm: Atrial: regular; ventricular: variable
P Waves: Flutter waves have a PR Interval: None, not QRS: Usually normal (0.06–
saw-toothed appearance; some may measurable 0.10 sec), but may appear widened
not be visible, being buried in QRS if flutter waves are buried in the
QRS
ATRIAL FIBRILLATION ■
• Rapid, erratic electrical discharge comes from multiple atrial ectopic foci.
• No organized atrial depolarization are detectable.
WOLFF-PARKINSON-WHITE SYNDROME ■
• In Wolff-Parkinson-White Syndrome, an accessory conduction pathway is present between the atria and the
ventricles. Electrical impulses may be rapidly conducted to the ventricles.
• These rapid impulses create a slurring of the initial portion of the QRS; the slurred effect is called a delta wave.
Rate: Depends on rate of underlying rhythm Rhythm: Regular unless associated with atrial
fibrillation
P Waves: Normal (upright and PR Interval: Short (less than QRS: Wide (greater than 0.10 sec);
uniform) unless atrial fibrillation is 0.12 sec) delta wave present
present
Clinical Tip:
Wolff-Parkinson-White Syndrome is associated with narrow-complex tachycardias, including atrial flutter and
atrial fibrillation.
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It is important to distinguish the variables with each arrhythmia to properly identify the ECG. The summary
of identifying ECG features for atrial arrhythmias is presented in TABLE 4-1.
For instructions on analyzing the ECG strips, please see the guidelines given at the end of Chapter 2.
ECG 4•1
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•2
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•3
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•4
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•5
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•6
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•7
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•8
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•9
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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Take the ECG challenge! The following ECG strips build on what you learned from Chapter 3: Sinoatrial Node
Arrhythmias and Chapter 4: Atrial Arrhythmias.
ECG 4•10
H i n t : Notice the P waves are normal but encroach on the preceding T waves.
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•11
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•12
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•13
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•14
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•15
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•16
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•17
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•18
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•19
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•20
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•21
H i n t : Use the Precise Heart Rate Calculation: 1,500/39 = 38.46 rounded to 38. Or, 38 bpm.
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•22
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•23
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•24
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•25
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•26
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•27
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•28
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
ECG 4•29
H i n t : Remember sinus arrhythmia has an irregular rhythm that varies with respiration.
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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ECG 4•30
Rate: Rhythm:
P Waves: PR Interval: QRS:
Interpretation:
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