EKG: Sinus rhythm

• Implies origin is from the SA node

• P wave for every QRS complex
• P wave upright in leads I, II, III
 Normal Sinus Rhythm

• Rate: 60 to 100 bpm

• Rhythm: Regular, sinus
• Intervals: normal
 Sinus Bradycardia

• Rate: <60 bpm

• Rhythm:regular, sinus
• Intervals: normal
 Sinus Tachycardia

• Rate: > 100 bpm

• Rhythm: regular, sinus
• Intervals: normal
 Sinus Arrhythmia
• Impulse is initiated by the SA node
– P waves all identical
• Consistent and normal PR intervals
• IRREGULAR R to R intervals
• Common in children and young adults
• Varies with inspiration
 Sinus Arrest
• SA node fails to initiate an impulse
• NO PQRST complex
• Causes:
– Hypoxia
– Ischemia/infarction
– Myocarditis
– Increased vagal tone
– Drugs (digitalis, salicylates)
Sinus Arrest
 First Degree AV Block
• Fixed, prolonged PR interval >200 ms
• Population
– Highly conditioned athletes
– History of MI, myocarditis
– Medication induced
• Ca channel blockers, Beta-blockers, digitalis
First Degree AV Block
Second Degree AV Blocks
• Some P waves fail to conduct to ventricles
and generate a QRS complex

• Mobitz I (Wenckebach)
– Progressive prolongation of PRI resulting in a
dropped QRS
– Delay at the AV node (72%) or HIS -Purkinje
system (28%)

• Mobitz II
– Sudden unexpected blocked P waves
– No variation in PRI
– “randomly” dropped beats
Second Degree AV Blocks
 The AV Blocks
• Third Degree Block
– AV dissociation
– Escape beat
• AV nodal – rate normal
– Narrow complex
• Junctional – rate 40-60’s
– Narrow complex
• Ventricular – rate 30-40’s
– Wide complex, bizarre shape
 Third Degree AV Block
• Complete Heart Block
• Complete absence of AV conduction
• Block is at level of AV node, HIS bundle or
bundle branch-Purkinje system
• QRS duration depends on site of block
 Wide QRS = Bundle Branch Block
• Left (LBBB)
• Right (RBBB)
• Left Anterior Fascicular Block (LAFB)
• Left Posterior Fascicular Block (LPFB)
 PRE-MATURE CONTRACTIONS
OR EXTRA SYSTOLE
Extra systole means pre-mature excitation
and contraction of entire heart or some of
its portions.
Depending on their origin
1. Atrial extra systole.
2. AV junctional extra systole.
3. Ventricular extra systole.
Premature Atrial Contractions

– P wave is from ectopic focus

• Different morphology
– Normal QRS
– Occur early in the cycle (premature)
– have a compensatory pause
– Can occur in healthy individuals or secondary
to CHF, ischemia, COPD
 ATRIAL EXTRA SYSTOLE
• Results in deformation of P wave during
extra systole.
• From superior portion of atria P wave is
positive and deformed.
• From middle portion of atria P wave is
biphasic or flattened P wave.
• From inferior atrial extra systole excitation
propagates through the atria retrogradely
this leads to negative P wave.
PACs
 AV JUNCTIONAL EXTRA
SYSTOLE

• Excitation and AV junction transmits

impulses retrogradely so QRS- T wave
normal.
• Mising P wave, or P wave is superimpose
on to QRS-T complex.
A.V nodal premature contraction
 Ventricular Extra systole
• From intra ventricular
conducting system or
from ventricular
myocardium.
• QRS complex is
widened.
• QRS complex is 0.12
seconds or more.
 PAROXYSMAL TACHYCHARDIA
• Paroxysmal means that the heart rate
becomes rapid in paroxysms, with
paroxysm beginning suddenly and
lasting for a few seconds or minutes then
paroxysm ends suddenly
1. Atrial paroxysmal tachychardia.
2. AV paroxysmal tachychardia.
3. Ventricular paroxysmal tachychardia.
Ventricular fibrillation