![]() ![]() The patient did not require external pacing and was admitted for placement of a permanent pacemaker. Shortly after this ECG was obtained, the monitor showed multiple 3- to 4-second pauses. Labs were unremarkable for any significant abnormalities. Overall, these findings suggest sinus node dysfunction, also called sick sinus syndrome. The 7th beat is a wide complex premature beat with no preceding P-wave, and may be a PVC (arising from a ventricular focus) or an Ashman beat (an aberrantly conducted beat arising from a supraventricular focus). Image 3. Junctional bradycardia continues for 2 beats, followed by a sinus beat, then the rhythm returns to AF. The 6th QRS complex is a junctional beat with a retrograde P-wave preceding the QRS with a PR interval <120 ms (best seen in inferior leads). The 5th QRS complex is a sinus beat - narrow complex and preceded by a P-wave with a normal PR interval. Retrograde P-waves in these leads will usually be inverted (ie, upright, as they are typically inverted in normal sinus rhythm). ![]() Atrial fibrillation is more common than atrial flutter. There are likely retrograde P-waves after the QRS complexes in beats 1-4, best seen in V1 and aVR as upright deflections immediately following the QRS. But in AFib, the heartbeat is often more irregular and chaotic. Image 2. The rhythm changes to a junctional bradycardia at ~33 bpm. Vagal maneuvers or adenosine will slow ventricular rate but not atrial rate Ventricular rate is a fraction of atrial rate (2:1 → 150 bpm, 3:1 → 100 bpm) in the absence of a variable blockĬonsider AFlutter when ventricular rate is consistently around 150 bpm The treatments for AFib and atrial flutter are similar. A person with atrial fibrillation also may have a related heart rhythm problem called atrial flutter. Irregular RR interval when AV conduction is present (ie, in the absence of a 3rd degree AV block)Ītrial rate is 250-350 bpm and typically fixed over time Treatment for atrial fibrillation may include medicines, therapy to shock the heart back to a regular rhythm and procedures to block faulty heart signals. Stereotypical “sawtooth pattern” of F-waves best seen in the inferior leadsĪbsence of distinct repeating P-waves with atrial depolarization rate typically >300 bpm Presence of f-waves of varying morphology, duration, and timingĬaused by a re-entrant circuit initiated in the right atrium Irregularly irregular rhythm with absence of any organized atrial activity AFib is typically described as “coarse” when the majority of f-waves are easily seen and have an amplitude ≥3-5 mm. However, AFlutter will demonstrate consistent F-wave morphology, duration, and timing with the absence of an isoelectric baseline in lead II. It was initially mistaken for atrial flutter (AFlutter) with variable block because the large amplitude f-waves (fibrillatory waves) look like F-waves (flutter waves) and appear regular at ~300 bpm. Image 1. The initial rhythm is coarse atrial fibrillation (AFib) with an average ventricular rate ~60 bpm.
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