Basic ECG II

Basic ECG
Cardiac Rhythm Disorders
Prof.Otomar Kittnar,MD,PhD.
physiology.lf1.cuni.cz
Arrhythmia
Arrhythmia, also known as cardiac arrhythmia or heart arrhythmia, is a
group of conditions in which the heartbeat is irregular, too fast, or too
slow. Arrhythmias are due to problems with the electrical conduction
system of the heart. Some arrhythmias can be found on the healthy heart
(premature beats etc.), nevertheless mostly arrhythmias are symptoms of
many different cardiac pathologies.
ECG is a crucial method for the diagnosis of arrhythmias.
Physiological ECG curve
Physiological ECG curve
PQ ST segments
T
ECG
Q S
PQ QT intervals
QRS
time
In order to identify arrhythmias the following parameters have to be

evaluated: intervals and amplitudes and configurations of ECG waves
on one cardiac cycle, and the rhythm on the whole recording (heart rate,
regularity, origin).
Physiological ECG recording
The characteristic indicators of a normality of the ECG recording:

• The regularity of the rhythm (differences of RR intervals ≤ 10%).
• The origin of all cardiac cycles in the SA node (sinus rhythm).
• The heart rate in a range 60-100 beats/minute.
• Every P wave followed by physiological PQ segment and QRS complex.
• Physiological shape and duration of QRS complexes (80-100 ms).
• ST segment in isoelectric line.
• T wave oriented identically with QRS complex.
• Physiological duration of the QT interval (approx. 250-500 ms).
• Physiological position of the electric heart axis (−30° - +110°).
Sinus arrhythmias
Sinus arrhythmias are rhythm disorders arising in the SA node (P wave

has physiological shape and PQ interval has physiological duration).
Basic types of sinus arrhythmias:
• Sinus bradycardia
• Sinus tachycardia
• Respiratory sinus arrhythmia
• Non-respiratory sinus arrhythmia
• Sick sinus syndrome
Sinus bradycardia
Physiological recording, normal heart rate (73 beats/min in this case).
Sinus bradycardia, the rhythm arising in the SA node, heart rate is slow and
sustained (49 beats/min in this case).
Sinus bradycardia can be physiological (e.g. during sleep or in athletes).
Sinus tachycardia
Physiological recording, normal heart rate (73 beats/min in this case).
Sinus tachycardia, the rhythm arising in the SA node, heart rate is fast and
sustained (150 beats/min in this case).
Sinus tachycardia can be physiological (e.g. during exercise).
Respiratory sinus arrhythmia
Physiological recording, regular rhythm.
Respiratory sinus arrhythmia is heart rate variability in synchrony with

respiration, by which the RR interval on an ECG is shortened during inspiration
and prolonged during expiration. It is a physiologic phenomenon in young
people reflecting respiratory-circulatory interactions.
Non-respiratory sinus arrhythmia: heart rate variability not in synchrony with

respiration.
Sick sinus syndrome
Sick sinus syndrome has multiple manifestations on electrocardiogram,
including sinus bradycardia, sinus arrest, sinoatrial block, and in most cases
alternating patterns of bradycardia and tachycardia (bradycardia-
tachycardia syndrome).
Supraventricular arrhythmias
Supraventricular arrhythmias are rhythm disorders arising in atrial

myocardium incl. AV node (P wave has not physiological shape and
PQ interval has usually shorter duration, QRS complex is normal as
the depolarisation wave spreads to the ventricles in the normal way).
Basic types of the supraventricular arrhythmias:

• Premature supraventricular beats (extrasystoles)
• Supraventricular tachycardia
• Atrial fibrillation
• Atrial flutter
Rhythms arising in the AV node are called (junctional or nodal).

Supraventricular premature beat
(extrasystole)
Supraventricular premature beat
(extrasystole)
Premature beat appears earlier, P has abnormal shape, QRS complex is

normal. After the compensatory pause next beat is late. Summation of both RR
intervals corresponds to summation of two physiological RR intervals.
Nodal rhythm
Heart rate is decreased, P waves are missing, QRS complexes are normal.
Supraventricular bigeminy
Supraventricular bigeminy is a rhythm disorder when each

physiological beat is followed by an supraventricular beat arising from
the atrial myocardium (P wave is abnormal, PQ interval is shorter).
Supraventricular tachycardia
Heart rate is above 100 beats/min. P waves are abnormal (or missed), QRS
complexes are normal.
Atrial fibrillation
Atrial fibrillation (upper curve): P waves (called usually „f“ waves) with the rate
300-600/min. QRS complexes are normal shaped. AV node blocks spreading of
high atrial rates to the ventricles, only occasionally some depolarization passes,
so QRS complexes have irregular rhythm.
Normal rhythm (down curve): Physiological P waves, regular rhythm.

Atrial fibrillation
Atrial flutter
P waves can be seen at the rate 250-350/min, giving a „saw-tooth“ appearance.
There are 2 to 5 P waves per QRS complex and ventricular activation is perfectly
regular, so atrial flutter can be in ratios 2:1, 3:1, 4:1 or 5:1.
Atrial flutter 2:1
Ventricular arrhythmias
Ventricular arrhythmias are rhythm disorders arising in the ventricular

myocardium. QRS complexes are wide with unusual shape and they
are followed by an abnormal T wave.
Basic types of the ventricular arrhythmias:

• Ventricular premature beats (extrasystoles)
• Ventricular tachykardia
• Ventricular flutter
• Ventricular fibrillation
• Ventricular arrest
Ventricular premature beat
P wave is missing.
Premature QRS complex is wide
(more than 100 ms), it has
usually high amplitude and
unusual shape.
T wave is abnormal and it is
usually inverted.
Ventricular premature beats
Ventricular premature beats
ventricular bigeminy
Ventricular tachycardia
No P waves, repeated ventricular premature beats (at least 3 repeated) with

the heart rate 140-220/min. QRS complexes slightly irregular and vary slightly
in shape.
Ventricular tachycardia
No P waves, only repeated ventricular premature beats.

Ventricular flutter
Ventricular flutter is relatively rare, it is as serious as ventricular fibrillation.

Heart rate 180-240/min.
Ventricular fibrillation
When the ventricular muscle fibers contract independently no QRS complex can
be identified and the ECG is totally disorganized.
Ventricular arrest
Ventricular tachycardia turns into cardiac arrest. Only P waves can be seen.

Basic ECG II

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Basic ECG

Cardiac Rhythm Disorders

In order to identify arrhythmias the following parameters have to be

The characteristic indicators of a normality of the ECG recording:

Sinus arrhythmias are rhythm disorders arising in the SA node (P wave

Physiological recording, normal heart rate (73 beats/min in this case).

Sinus bradycardia can be physiological (e.g. during sleep or in athletes).

Physiological recording, normal heart rate (73 beats/min in this case).

Sinus tachycardia can be physiological (e.g. during exercise).

Physiological recording, regular rhythm.

Respiratory sinus arrhythmia is heart rate variability in synchrony with

Non-respiratory sinus arrhythmia: heart rate variability not in synchrony with

Supraventricular arrhythmias are rhythm disorders arising in atrial

Basic types of the supraventricular arrhythmias:

Rhythms arising in the AV node are called (junctional or nodal).

Premature beat appears earlier, P has abnormal shape, QRS complex is

Supraventricular bigeminy is a rhythm disorder when each

Normal rhythm (down curve): Physiological P waves, regular rhythm.

Ventricular arrhythmias are rhythm disorders arising in the ventricular

Basic types of the ventricular arrhythmias:

No P waves, repeated ventricular premature beats (at least 3 repeated) with

No P waves, only repeated ventricular premature beats.

Ventricular flutter is relatively rare, it is as serious as ventricular fibrillation.

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