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ECG Rhythm Interpretation
Module III
Normal Sinus Rhythm
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Course Objectives
• To recognize the normal rhythm of the
heart - “Normal Sinus Rhythm.”
• To recognize the 13 most common
rhythm disturbances.
• To recognize an acute myocardial
infarction on a 12-lead ECG.
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Learning Modules
• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
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Normal Sinus Rhythm (NSR)
• Etiology: the electrical impulse is formed
in the SA node and conducted normally.
• This is the normal rhythm of the heart;
other rhythms that do not conduct via
the typical pathway are called
arrhythmias.
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NSR Parameters
•Rate 60 - 100 bpm
•Regularity regular
•P waves normal
•PR interval 0.12 - 0.20 s
•QRS duration 0.04 - 0.12 s
Any deviation from above is sinus
tachycardia, sinus bradycardia or an
arrhythmia
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Arrhythmia Formation
Arrhythmias can arise from problems in
the:
• Sinus node
• Atrial cells
• AV junction
• Ventricular cells
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SA Node Problems
The SA Node can:
• fire too slow Sinus Bradycardia
• fire too fast Sinus Tachycardia
Sinus Tachycardia may be an appropriate
response to stress.
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Atrial Cell Problems
Atrial cells can:
• fire occasionally Premature Atrial
from a focus Contractions (PACs)
• fire continuously Atrial Flutter
due to a looping
re-entrant circuit
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Premature Atrial Contractions
(PACs)
• Early contraction that originate from a
foccal point in the arterial instead of SA
node
• This is cause arterial to contract early
• The rhythm above shows normal sinus
beats followed by PACs, after PACs you
can see a pause
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Premature Beats
• Premature Atrial Contractions
(PACs)
• Premature Ventricular Contractions
(PVCs)
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Rhythm #3
• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2/7 different contour
• PR interval? 0.14 s (except 2/7)
• QRS duration? 0.08 s
Interpretation? NSR with Premature Atrial
Contractions
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Premature Atrial Contractions
• Deviation from NSR
– These ectopic beats originate in the
atria (but not in the SA node),
therefore the contour of the P wave,
the PR interval, and the timing are
different than a normally generated
pulse from the SA node
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Premature Atrial Contractions
• Etiology: Excitation of an atrial cell
forms an impulse that is then conducted
normally through the AV node and
ventricles.
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Teaching Moment
• When an impulse originates anywhere in
the atria (SA node, atrial cells, AV node,
Bundle of His) and then is conducted
normally through the ventricles, the QRS
will be narrow (0.04 - 0.12 s).
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• PACs present early P waves that look
different from the uniform P waves on the
underlying rhythm
• after the PAC you can see a pause
• Conducted PACs; if the early P waves
followed by a QRS complex, it indicates
that the electrical signals reaches and
deplorized ventricles
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• Non-conducted PACs; if no QRS complex
follows the premature P waves, it means
that impulse did not reach the ventricles,
which could be due to blockage of the
signal.
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PAC Characteristic
Irregular rhythm due to PACs
Early P waves that have different shape or size
compered to underlying rhythm
PAC may or may not have QRS after it
PR interval varies due to the PAC
QRS complex is normal ( < 0.12 sec) but early
with the PAC may be missing
QT interval can be normal
T waves varies due to alteration in the ventricular
Repolarization after the PAC
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WHAT CAUSES PACs?
• Arterial enlargement
• Tobacco use
• Regular use of stimulants caffeine
• Inflammation of atrial tissue
• Abnormal electrolytes ( low K and Mag)
• Lots of stress
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Treatment
• Beta lockers and calcium channel
blockers
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Educate the patient
• Smoking cessation
• Limiting alcohol
• Staying hydrated
• Avoiding caffeine
• Managing stress
• Healthy deit
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Teaching Moment
• A re-entrant
pathway occurs
when an impulse
loops and results
in self-
perpetuating
impulse
formation.
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Ventricular Cell Problems
Ventricular cells can:
• fire occasionally Premature Ventricular
from 1 or more foci Contractions (PVCs)
• fire continuously Ventricular Fibrillation
from multiple foci
• fire continuously Ventricular Tachycardia
due to a looping re-
entrant circuit
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Premature Ventricular Contractions
(PVCs)
• Premature Ventricular Contractions (PVCs)
are early contractions that originate in the
ventricles,
• Its usually because of ventricular irritability
• The early contraction occurs suddenly and
interrupts the normal electrical conduction
system
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Rhythm #4
• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
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PVCs
• Deviation from NSR
– Ectopic beats originate in the ventricles
resulting in wide and bizarre QRS
complexes.
– When there are more than 1 premature
beats and look alike, they are called
“uniform”. When they look different, they are
called “multiform”.
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PVCs
• Etiology: One or more ventricular cells
are depolarizing and the impulses are
abnormally conducting through the
ventricles.
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Teaching Moment
• When an impulse originates in a
ventricle, conduction through the
ventricles will be inefficient and the
QRS will be wide and bizarre.
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Ventricular Conduction
Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
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Characteristic
1. Wide and bizarre QRS complex (>0.12
sec) at the PVC site; normal QRS
elsewhere
2. Compensatory pause follows PVCs as
the heart resets for the next beat
3. Irregular rhythm due to PVCs
disturpting the normal heart beat
rhythm
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Continue,,,,
4) Missing P Waves where PVC occurs,
normal P waves else where
5) PR interval and QT interval cant be
measured during PVCs but should be normal
else where
6) Inverted T waves after PVC CA BE
SOMETIMES NOTED, normal T waves else
where.
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Beware
1. Premature beats that occur with the t wave. Increases the risk
of v-tach or v- fib, specially patients with heart disease. ( R to
T phenomenon )
2. Variability in appearance; multiform PVCs (not the same
looking) the PVC is coming fro various sites
3. Consecutive PVCs (occurs in pairs or runs) three or more
PVCs in a row is called a run of v-tach
4. Sequences of beats; bigeminy or trigeminy
Bigeminy; beat -PVCs beat -PVCs ( every other beat
Trigeminy; beat-beat-PVCs beat- beat-PVCs (every third beat)
•
Causes of PVCs
1. Prolapsed mitral valve
2. Risk caffeine, stress, nicotine
3. Electrolytes low k and mag
4. Myocardial irritability; heart trauma/ disease
5. Anemia
6. Thyroid; hyperthyroidism
7. Underlying heart condition; MI, CAD, Heart failure
8. Rhythm disorder; A-fib BBB
9. Elevated blood pressure
TREATMENT
Symptomatic treatment
addressing the underlying heart conditions
Medications such as anti arrhythmics; beta
blockers, or calcium channel blockers to reduce
PVC frequency
Cardiac ablation to eliminate source
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