complexes cannot be defined since P waves cannot

be identified.
Ventricular tachycardia is present with three or more
beats of ventricular origin in a row. Ventricular
tachycardia is usually regular but it can be irregular.
The QRS complexes are wide. P waves are sometimes
identifiable but they bear no relationship to the
QRS complexes.
It can be difficult to distinguish ventricular
tachycardia from supraventricular tachycardia with
aberrant conduction. When in doubt assume the rhythm
is ventricular tachycardia.
1. VENTRICULAR FIBRILATION

Disorganised electrical signals cause the ventricles to quiver instead of contract in a rhythmic
fashion. A patient will be unconscious as blood is not pumped to the brain. Immediate
treatment by defibrillation is indicated. This condition may occur during or after a
myocardial infarct
1. What is the rate and is it regular?
The heart rate is very rapid and the rhythm is not
regular.
2. Is the QRS wide or narrow?
The QRS complex is absent.
3. Are P waves present and upright?
P waves are absent.
4. How are the P waves related to the QRS complex?
There are no P waves or QRS complexes so there is no
relationship between them.
In ventricular fibrillation areas of the ventricles are
depolarizing and repolarizing in a completely disorganized
fashion. All pumping function of the ventricles is lost.

The electrocardiogram may show voltage fluctuations.

The amplitude of these waves is described by the terms
"coarse" and "fine"
2. TORSADE DE POINTES

This is a form of polymorphic VT that occurs when the SR shown on an ECG has a
prolonged QT interval. The ECG exhibits a continuously changing axis (hence, "turning of
points" which can look like ventricular fibrillation (VF). The prolonged QT interval can be
caused by: antiarrhythmic agents, hypokalemia, hypomagnesemia, bradycardia
However, in very rare cases it may be congenital (Jervell and LangeNielsen syndrome or
RomanoWard syndrome).
1. What is the rate and is it regular?
The heart rate is fast and the rhythm is regular.
2. Is the QRS wide or narrow?
The QRS complex is wide and the direction of polarity
is changing.
3. Are P waves present and upright?
P waves are not apparent.
4. How are the P waves related to the QRS complex?
The relationship between the P waves and QRS complexes
is not defined since the P waves are not identifiable.
Torsades de Pointes is a variant form of ventricular
tachycardia in which the polarity periodically changes
from positive to negative. The name means twisting of the
points.
The rhythm is usually regular but it can be irregular.
The QRS complexes are wide. P waves are sometimes
identifiable but they bear no relationship to the QRS
complexes.
It is important to distinguish Torsade de Pointes from
ventricular tachycardia since the treatment is different.
Torsades de Pointes is associated with a long QT interval.

Agents such as quinidine and procainamide can prolong the

QT interval and worsen the arrhythmia. Overdrive pacing
and magnesium are the treatments of choice for Torsade de
Pointes.
3. IDIOVENTRICULAR

In idioventricular rhythm the rate is 30-45 bpm. The QRS complexes are wide (> 0.12 sec,
often > 0.16 sec) because the ventricular signal is transmitted by cell-to-cell conduction
between cardiomyocytes and not by the conduction system.
Accelerated idioventricuar rhythm is a rapid form (60-120 bpm) of idioventricular rhythm
associated with reperfusion during myocardial infarction.
1. What is the rate and is it regular?
The heart rate is slow and the rhythm is regular.
2. Is the QRS wide or narrow?
The QRS complex is wide.
3. Are P waves present and upright?
P waves are not apparent.
4. How are the P waves related to the QRS complex?
The relationship between the P waves and QRS
complexes cannot be defined since P waves cannot
be identified.
Accelerated idioventricular rhythm arises from
the regular firing of a ventricular site. The rate
is typically 40 to 99 beats per minute with wide and
bizarre complexes.

4. PREMATURE ATRIAL CONTRACTION

Premature atrial contraction (PAC): The atria fires an early impulse which causes the heart to
beat earlier causing irregularity in the heart rhythm.
1. What is the rate and is it regular?
The heart rate is normal, but the rhythm is not
regular. There are early beats.
2. Is the QRS wide or narrow?
The QRS complex of the early beat is usually narrow, but
it can be wide if there is abnormal conduction.
3. Are P waves present and upright?
The early beats have upright P waves.
4. How are the P waves related to the QRS complex?
There is a 1-to-1 relationship between the P waves and
QRS complexes of the early beats. The PR interval may
be normal, longer or slightly shorter in the early
beats.
Premature atrial complexes are early beats that arise in
the atria. An upright P wave precedes the QRS although
the P wave may be hidden by the previous T wave.
Regularity is determined from inspection of the R-R
intervals. A regular rhythm has constant R-R interval.
Slight irregularities may not be apparent especially with
high heart rate.
Irregularities can be caused by:
1. Periodic speeding and slowing with respiration
as in sinus arrhythmia
2. Premature beat - a beat earlier than expected
3. Pause - prolonged R-R interval
4. Irregularly irregular or chaotic
The QRS is usually narrow and similar to the normal
sinus beats. The QRS complex can be wide if there is
aberrant conduction, however, a premature beat with
a wide QRS should be considered a PVC unless a P
wave is obvious.
It is important to distinguish PACs with aberrant

conduction from PVCs since PVCs may be potentially

dangerous and supraventricular beats are usually benign.
When in doubt assume the beat is a premature ventricular
contraction.
5. PREMATURE JUNCTIONAL CONTRACTION

PJCs may occur in both healthy and diseased hearts. If they are occasional, they
are insignificant. If they are frequent, junctional tachycardia may result. Treatment is
usually not required.
1. What is the rate and is it regular?
The heart rate is normal, but the rhythm is not regular.
There are early beats.
2. Is the QRS wide or narrow?
The QRS complex is narrow.
3. Are P waves present and upright?
P waves are absent or negative in the early beats.
4. How are the P waves related to the QRS complex?
The early beats have no P waves or a fixed, 1-to-1
relationship between the P waves and QRS complexes.
An inverted P wave comes before the QRS in high
junctional and after the QRS in low junctional.
Premature junctional complexes are early beats that
arise in the AV node. If the impulse arises high in the
junction, an inverted P wave precedes the QRS. The
P wave is inverted since the impulse is conducted
retrograde through the atria.
If the impulse arises in the middle of the junction, the
P wave is not present. It is either buried in the QRS or
the impulse was not conducted to the atria.
If the impulse arises low in the junction, the impulse
takes a long time to pass through the node and retrograde
through the atria. The P wave is inverted and follows the
QRS complex.

6. PREMATURE VENTRICULAR CONTRACTION

The ventricles fire an early impulse which causes the heart to beat earlier causing irregularity
in the heart rhythm
1. What is the rate and is it regular?
The heart rate is normal, but the rhythm is not regular.
There are early beats.
2. Is the QRS wide or narrow?
The QRS complexes of the early beats are wide.
3. Are P waves present and upright?
P waves are absent in the early beats.
4. How are the P waves related to the QRS complex?
The early beats have no P waves so there is no
relationship to the QRS.
Premature ventricular complexes are early beats that
arise in the ventricle. They are conducted through the
ventricle and have a wide, often bizarre QRS complex.
It is important to distinguish PVCs from supraventricular beats with aberrant conduction since PVCs
may be potentially dangerous and supraventricular beats
are usually benign. When in doubt assume the beat is a
premature ventricular contraction.
7. AV BLOCK 1ST DEGREE

1st Degree AV block is caused by a conduction delay through the AV node but all electrical
signals reach the ventricles. This rarely causes any problems by itself and often trained
athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s in length,
or 3-5 small squares on the ECG.
This is where there is a prolonged PR interval of >200 milliseconds (5 small squares; see No
specific therapy is required and the prognosis is excellent. However, it can be a marker for an
underlying problem such as myocarditis, MI, degenerative disease, or, most commonly, a
drug effect (eg, tricyclic antidepressants).
1. What is the rate and is it regular?
The heart rate is slow to normal and the rhythm is
regular.
2. Is the QRS wide or narrow?
The QRS complex is narrow.
3. Are P waves present and upright?
The P waves are upright.
4. How are the P waves related to the QRS complex?
There is a fixed, 1-to-1 relationship between the P
waves and QRS complexes, but the PR interval is
prolonged.
Every P wave causes a QRS complex in first degree AV
block. The PR interval is fixed, but it is greater than

0.2 seconds.
8. AV BLOCK 2ND DEGREE TYPE 1

Type I occurs when there is a repeated pattern of progressive prolongation of the PR interval,
which eventually results in the failure of conduction of one atrial beat. The cause is usually
benign, but it can be a marker for the same underlying cardiac problems as first-degree AV
block. In most cases, treatment is unnecessary. Routine prophylactic permanent pacing is not
recommended unless the patient is symptomatic with presyncope, recurrent syncope, or
bradycardia that exacerbates congestive heart failure or angina.
1. What is the rate and is it regular?
The heart rate is slow to normal. The rhythm is not
regular since some QRS complexes are missing.
2. Is the QRS wide or narrow?
The QRS complex is narrow.
3. Are P waves present and upright?
The P waves are upright.
4. How are the P waves related to the QRS complex?
There are more P waves than QRS complexes. The PR
interval progressively lengthens until a QRS complex
is dropped. The shortest PR interval follows the
dropped beat.

Second degree type I AV block is also known as Mobitz

Type I or Wenkebach. The conduction block occurs in the
AV node. The PR interval progressively lengthens until the
impulse is not conducted to the ventricles.
Second degree type I AV block is most commonly
associated with right coronary artery occlusion with
inferior wall infarctions. This block generally has a
good prognosis.
9. AV BLOCK 2ND DEGREE TYPE II

In type II, most beats are conducted with a constant PR interval, but occasionally atrial
depolarization is not followed by ventricular depolarization Type II is pathological and
indicates disease of the conduction system distal to the AV node. It can frequently lead to
complete AV block, causing StokesAdams attacks. Therefore, temporary and then
permanent pacing (DDD) is indicated in most patients, even those who initially present
without symptoms.
1. What is the rate and is it regular?
The heart rate is slow to normal and the rhythm is not
regular. QRS complexes are missing.
2. Is the QRS wide or narrow?
The QRS complex is usually wide.
3. Are P waves present and upright?

The P waves are upright.

4. How are the P waves related to the QRS complex?
There are more P waves than QRS complexes. The PR
interval is fixed and usually has normal duration.
Second degree type II AV block is also known as Mobitz
Type II. The conduction block is infranodal. The PR
interval is fixed duration until the impulse is not
conducted to the ventricles.
Second degree type II AV block is most commonly
associated with anterior wall infarctions. This block
has a propensity to progress to third degree AV block.
10.

AV BLOCK 3RD DEGREE

With complete heart block, there is complete dissociation of the P waves and QRS complexes
The ventricular escape complexes are usually wide and occur at around 3040 bpm. There is
a significant risk of asystole and thus permanent pacing (DDD) is indicated, regardless of
symptoms. Acquired AV block is most commonly due to ischemic heart disease or drug
toxicity (in particular -blockers, digitalis, and calcium-channel blockers).
1. What is the rate and is it regular?
The heart rate is slow to normal and the rhythm is

regular.
2. Is the QRS wide or narrow?
The QRS complex is wide.
3. Are P waves present and upright?
The P waves are upright.
4. How are the P waves related to the QRS complex?
There are usually more P waves than QRS complexes.
There is usually atrial and ventricular regularity,
but they are independent of each other. P waves march
through QRS complexes.
Third degree AV block is complete heart block. The
atria beat at their rate while the ventricular rate is
determined by a junctional or ventricular pacemaker.
P waves "march through" or are unrelated to QRS
complexes.

11.

ASYSTOLE

Looking at the ECG you'll see that:

Rhythm - Flat
Rate - 0 Beats per minute
QRS Duration - None
P Wave - None
Carry out CPR!!

12.

MYOCARD INFARK

Looking at the ECG you'll see that:

Rhythm Regular
Rate - 80 Beats per minute
QRS Duration - Normal
P Wave - Normal
S-T Element does not go isoelectric which indicates infarction
13. SUPRAVENTRICULAR TACHYCARDIA

A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not
under direct control from the SA node. SVT can occur in all age groups
Looking at the ECG you'll see that:
Rhythm - Regular
Rate - 140-220 beats per minute
QRS Duration - Usually normal
P Wave - Often buried in preceding T wave
P-R Interval - Depends on site of supraventricular pacemaker Impulses stimulating the heart
are not being generated by the sinus node, but instead are coming from a collection of tissue
around and involving the atrioventricular (AV) node
14. ATRIOVENTRICULAR BLOCK

Atrioventricular block (AVB): the sinus node may be generating heart beats causing the atria
to contract at a normal rate, however not every electrical impulse coming from the atria is
being passed down to the ventricles by the atrioventricular node due to a block in conduction.
There are various types of AV block depending upon the mechanism of block. Second degree
AV block is when the impulse from the atria is blocked every certain number of beats.
While in complete AV block non of the atrial impulses pass through the atrioventricular node
and the ventricles generate their own rhythm.
15. BUNDLE BRANCK BLOCK

A problem in the bundle of His presents in an identical fashion to a combined block of both
bundles, ie, complete heart block. However, a more common occurrence is an isolated left or
right bundle branch block. These are usually distinct from any problem with AV conduction
(ie, they usually coexist with normal sinus rhythm [SR]). The patterns of the ECG are
characteristic, but highly variable; the hallmark is a wide QRS complex.
Electrocardiogram patterns of left bundle branch block and right bundle branch block.
In left bundle branch block (LBBB), the pattern is best detected in V6 where there is an "M"
pattern, while in V1 there is a "W" pattern (see
In right bundle branch block (RBBB), the pattern is best detected in V1 where there is an
RSR complex, while in V6 there is a QRS complex (see
In fact, both LBBB and RBBB are found in the "normal" population. New LBBB is cause for
concern, and if it can clearly be related to an acute episode of chest pain then it probably
indicates MI. Both RBBB and LBBB probably indicate increased risk for cardiovascular
disease; however, neither on its own is an indication for pacing

16.

ST segment depression

ST segment depression can be caused by ischemia, digitalis, rapid heart rate, and temperature
or electrolyte abnormality. It can also be a reflected or reciprocal ST elevation (showing an
inverted view of whats happening at another place in the heart). The shape of the ST
segment, and whether the abnormality is localized to leads looking at one area of the heart,
often allows the cause of ST depression to be diagnosed. ST segment depression is
considered significant if the ST segment is at least one box below baseline, as measured two
boxes after the end of the QRS. As with infarction, the location of the ischemia is reflected in
the leads in which the ST depression occurs.
Causes of ST Depression:
1. Ischemia
2. Hypothermia
3. Hypokalemia
4. Tachycardia
5. Subendocardial infarct
6. Reciprocal ST elevation
7. Ventricular Hypertrophy
8. Bundle branch block
9. Digitalis
http://www.tveatch.org/ekgs/ekg85.html&usg.

1. NORMAL SINUS RHYTHM

2. SINUS TACHYCARDIA

3. SINUS BRADICARDIA

4. ATRIAL TACHYCARDIA

5. ATRIAL FIBRILATION

6. ATRIAL FLUTTER

7. JUNCTIONAL RHYTHM

8. VENTRICULAR TACHYCARDIA

9. VENTRICULAR FIBRILATION

10.

TORSADE DE POINTES

11.

IDIOVENTRICULAR

12.

PREMATURE ATRIAL CONTRACTION

13.

PREMATURE JUNCTIONAL CONTRACTION

14.

PREMATURE VENTRICULAR CONTRACTION

15.

AV BLOCK 1ST DEGREE

16.

AV BLOCK 2ND DEGREE TYPE 1

17.

AV BLOCK 2ND DEGREE TYPE II

18.

AV BLOCK 3RD DEGREE

19.

ASYSTOLE

20.

MYOCARD INFARK

21. SUPRAVENTRICULAR TACHYCARDIA

22. ATRIOVENTRICULAR BLOCK

23. BUNDLE BRANCK BLOCK