EKG #9

Premature Ventricular Contractions (PVCs)

 Premature Ventricular Contraction: when the ventricles contract earlier than normal in
the cardiac cycle d/t an abnormal contraction signal (depolarization) originating from
somewhere in the ventricles rather than coming from the pacemaker cells
 Normal conduction:
o SA node sends an electrical signal that propagates out through the walls of the
heart  contracts both upper chambers  that signal moves to the AV node 
the signal is delayed for a split second  the signal then goes down in the
ventricles  it moves down the Bundle of HIS and into the L/R bundle branches
 into each ventricle’s Purkinje fibers  causing them to contract as well
o So in a healthy heart: the upper chambers contract first  then shortly after the
lower chambers contract
o EKG:

 P-wave: atrial depolarization (contraction)

 If the first is downwards (or negative) it’s called a Q-wave (this
can be remembered by remembering the letter Q has a downward
tail)
 If the next deflection is upward (or positive) it’s called the R-wave
 If the first wave after the P-wave is upwards you skip the Q and
call it an R-wave
 Any downward deflection after the R-wave is called the S-wave
 QRS Complex: ventricular contraction
 Normally lasts <100 milliseconds (2.5 little boxes)
 Usually made up of three smaller waves (deflections)
 T-wave: ventricular repolarization (relaxation)
 PR segment: corresponds to the pause in the AV node
 ST segment: the interval b/t ventricular depolarization and repolarization
 TP segment: represents the heart’s quiet time when the cells are finished
repolarizing and are ready for another signal
 PVCs show up on the ECG as wide QRS complexes
  In addition to the pacemaker cells in the SA node  cells in the AV node,
Bundle of HIS, and the Purkinje fibers all have the ability to generate an
electrical potential (these are known as Latent Pacemakers)
 Latent Pacemakers have slower depolarization rates which is the
rate at which they fire off electrical signals  they get slower as
you move further down
 SA node’s depolarization rate is the fastest  each time the SA
node fires it resets all the slower ones
 If the SA node stopped altogether then the AV node would take
over at its slightly slower pace
 If you were to have a ventricular ectopic focus somewhere in the
ventricles (a cell or area of tissue that sends off an early
depolarization wave before even the SA node gets to fire) this is
what leads to a premature ventricular contraction (PVC)

 Causes:
o One cause of a Latent Pacemaker Cell or Cardiac Muscle Cell depolarizing early
is it gets enhanced automatically which might result from irritating stressors like
electrolyte imbalances, drugs (ex. Cocaine or meth), ischemic damage (ex. MI), or
anything that increases sympathetic activity (ex. Anxiety)
o Ectopic beats can also have “triggered activity” where cells depolarize early
 While the exact mechanism is unclear in this case it might be due to an ion
channel dysfunction that leads to an unexpected change in the membrane
potential during or right after repolarization
 Early-Afterdepolarization: when a cell depolarization happens during
ventricular repolarization

 Delayed-Afterdepolarization: when a cell depolarization happens after

repolarization is finished

 Reentrant Loop: a depolarization wave encounters tissue that doesn’t

depolarize (ex. Scar tissue from an MI) and as a result the wave starts
going around and around that tissue
  A reentrant loop basically starts sending out depolarization waves
to the rest of the heart tissue each time the wave goes around
 If the ectopic focus originates in the right ventricle, the wave will
depolarize the right ventricle first and then the left ventricle  produces a
QRS complex that looks like a left bundle branch block
 If the ectopic focus originates in the left ventricle, the wave will
depolarizing the left ventricle first and then the right ventricle, which
produces a QRS complex that looks like a right bundle branch block
 Lead V1 on an EKG measures a depolarization wave that moves towards
the right ventricle:
 When an ectopic focus originates in the left ventricle, and moves
towards the right ventricle, the V1 lead shows a large positive
complex, with a dominating R wave

 When an ectopic focus originates in the right ventricle, and then

moves towards the left ventricle, the V1 lead shows a large
negative complex, with a dominating S wave

 Regardless of the originating ventricle, a PVC often has an

abnormal T wave since the timing and direction of repolarization
will be abnormal as well

 Compensatory Pause: having a normal sinus complex w/ a P-wave that is 2x the

normal sinus interval after a PVC

o What ends up happening is there is this big, long pause between ventricular
contractions which is greater than the sinus interval and longer time b/t
contractions means more ventricular filling which means the heart contracts with
greater strength which can be felt as a palpation
 Noncompensatory Pause: having a normal sinus complex landing <2x the normal sinus
interval
o This is how you can tell if the PVC depolarized the atrium or not

 A ventricular ectopic focus can fire at different points in the cardiac cycle:
o It might happen during a P-wave which can get completely lost in the QRS
complex

o The ectopic beat could happen during the PR segment and because the ectopic
depolarization happens relatively slowly it will combine with the normal
depolarization wave coming down the ventricular conduction system resulting in
a ventricular fusion beat

o These can appear lots of different ways depending on where the two
depolarization waves meet each other:
 R-on-T Phenomenon: Early-Afterdepolarizations start during the ST
segment or even during the T-wave

 Sometimes PVCs can keep happening rather than being isolated events
 Ex. Ventricular Bigeminy is when a PVC consistently comes
after each normal cardiac cycle
  Ex. Ventricular Trigeminy is when a PVC comes after every
two normal cardiac cycles

 You might have multiple ectopic foci PVCs producing different appearing
QRS complexes on a single rhythm strip

 Symptoms:
o Most people w/ PVCs do not notice them
o Lightheadedness d/t less blood getting delivered to the brain
o Triggering of ventricular tachycardia or fibrillation (rare)

 Diagnosis:
o Based on the EKG
o Holter monitor

 Treatment:
o Typically, don’t need treatment
o If caused by a medication or use of a substance  stopping will resolve the issue
o Can be treated w/:
 Beta Blockers
 CCB
o Radiofrequency Ablation (if ectopic focus)

Ventricular Tachycardia (VT)

 PVCs are single beats originating from the ventricles and any time there are more than 3
beats like this in a row it is defined as ventricular tachycardia
 V-tach can cause the heart rate to get above 100 bpm which can be extremely dangerous
and lead to sudden cardiac death
 o Most pts w/ V-tach experience heart rates as high as 250 bpm and 250 bpm means
the heart is beating over 4x per second  when the chambers are pumping that
fast, they don’t have enough time to even fill w/ blood  so the heart is pumping
out tablespoons of blood to the body and brain which is not enough

 Symptoms:
o Chest Pain
o Fainting
o Dizziness
o ShOB
o Sudden Death

 Two ways an electrical signal can start in a ventricle:

o The signal’s focal
 Focal V-tach: a specific area of the ventricle has abnormal automaticity
 Automaticity Rate: the frequency at which a cell sends out a
signal
o The signal’s reentrant
 Cardiomyocytes (heart muscle cells) can be stressed which might change a
couple of their properties including how fast they relay or conduct the
signal to the next cell as well as how long their refractory period (the
period right after conducting a signal where the cells can’t conduct another
signal) is

 Causes:
o Certain medications
o Illicit drugs (meth or cocaine)
o Electrolyte imbalances
o Ischemia to the ventricular muscle

 Diagnosis:
o EKG
 When they all look the same it is called monomorphic (just has one
morphology or one form)

 Sometimes can be polymorphic (the shape changes from beat to beat

because the signal’s originating from different points in the ventricles) 
 might happen when multiple areas of pacemaker cells become irritated and
develop increased automaticity rates

 Treatment:
o Cardioversion (drug or electrical)
 Drug: involves a drug treatment that aims to lower the heart rate back to a
normal rhythm
 Electrical: uses an electrical pulse of energy delivered to the heart that is
synchronized w/ the fast rate to be delivered on the R-wave which is the
peak of the QRS complex  this is done to try and avoid delivering it
during a vulnerable period on the T-wave in which the electrical
cardioversion could induce V-fib
o Radiofrequency Catheter Ablation: radiofrequency waves are used to heat up
and destroy the tissue that’s causing the irregular heartbeat which can essentially
cure certain tachycardias
o Surgically implanted ICD (small device capable of delivering electrical
cardioversion)

 Strips: