Bradyarrhythmias occur when the heart rate is <60 beats per minute (bpm); can be physiologic, such as in young individuals and in well-trained athletes, or pathologic and symptomatic. Typically, symptoms occur when the heart rate is <40 beats per minute.
|Location of Disease ||Name of Disorder ||ECG Findings |
|SA nodal disease ||Sinus pause ||Transient absence of sinus P wave |
|AV nodal disease ||First-degree AV block ||Prolonged PR interval (>200 ms) |
| ||Mobitz Type I second-degree AV block (Wenckebach phenomenon) ||PR interval prolongs until a nonconducted P wave is seen; (Figure 9-1) |
| ||Third-degree (complete) block with narrow escape rhythm ||P's and QRS's are dissociated; QRS complexes are narrow (Figure 9-2) |
|Infranodal disease ||Mobitz Type II second-degree AV block ||PR interval constant and see intermittent nonconducted P waves |
| ||Third-degree (complete) block with wide escape rhythm ||P's and QRS's are dissociated; QRS complexes are wide |
Mobitz Type I second-degree AV block, also known as Wenckebach phenomenon.
Complete heart block with a narrow escape.
In the setting of a reversible cause, the only treatment indicated is to avoid the inciting cause.
Indications for permanent pacing include evidence of infranodal disease or symptomatic bradycardia at any level (SA node, AV node, or infranodal) that is spontaneous or secondary to the need for advancement of medical therapy (β-blocker, calcium channel blocker, etc); symptoms include dizziness, fatigue, syncope, poor exercise tolerance, and so on.
Tachyarrhythmias occur when the heart rate is >100 beats per minute and are divided into narrow QRS complex and wide QRS complex tachyarrhythmias.
This can be further divided into supraventricular tachyarrhythmias (SVT), atrial fibrillation (AF), and atrial flutter.
|Supraventricular Tachycardia ||ECG Findings |
|Sinus tachycardia ||Sinus P waves at a rate >100 bpm |
|AVNRT ||Narrow-complex tachycardia with no obvious P waves; short RP interval (Figure 9-3) |
|ORT ||Narrow-complex tachycardia; P waves often not visible, but if visible, then mid-RP interval |
|Atrial tachycardia ||Narrow-complex tachycardia with long RP interval |
|PJRT ||Narrow-complex tachycardia with long RP interval |
The figure demonstrates the relationship of the intervals that can be used to distinguish the different SVTs.
It is often difficult to diagnose the type of SVT based solely on surface ECG findings. Most often, electrophysiology (EP) study is required for definitive diagnosis. However, evaluating the RP interval (...