wandering atrial pacemaker regular or irregular

Ectopic Supraventricular Arrhythmias

Various rhythms result from supraventricular foci (usually in the atria). Diagnosis is by electrocardiography. Many are asymptomatic and require no treatment.

(See also Overview of Arrhythmias .)

Ectopic supraventricular rhythms include

Atrial premature beats

Atrial tachycardia, multifocal atrial tachycardia, nonparoxysmal junctional tachycardia, wandering atrial pacemaker.

Atrial premature beats (APB), or premature atrial contractions (PAC), are common episodic impulses. They may occur in normal hearts with or without precipitating factors (eg, coffee, tea, alcohol, pseudoephedrine ) or may be a sign of a cardiopulmonary disorder. They are common in patients with chronic obstructive pulmonary disease (COPD). They occasionally cause palpitations.

Diagnosis is by electrocardiography (ECG—see figure Atrial premature beat ).

Atrial premature beat (APB)

Image courtesy of L. Brent Mitchell, MD.

APBs may be normally, aberrantly, or not conducted and are usually followed by a noncompensatory pause. Aberrantly conducted APBs (usually with right bundle branch block morphology) must be distinguished from premature beats of ventricular origin.

Atrial escape beats are ectopic atrial beats that emerge after long sinus pauses or sinus arrest. They may be single or multiple; escape beats from a single focus may produce a continuous rhythm (called ectopic atrial rhythm). Heart rate is typically slower, P wave morphology is typically different, and PR interval is slightly shorter than in sinus rhythm.

Atrial tachycardia is a regular rhythm caused by the consistent, rapid atrial activation from a single atrial focus. Heart rate is usually 150 to 200 beats/minute; however, with a very rapid atrial rate, nodal dysfunction, and/or digitalis toxicity, atrioventricular (AV) block may be present, and ventricular rate may be slower. Mechanisms include enhanced atrial automaticity and intra-atrial reentry.

Atrial tachycardia is the least common form (5%) of paroxysmal supraventricular tachycardia and usually occurs in patients with a structural heart disorder. Other causes include atrial irritation (eg, pericarditis

Symptoms are those of other tachycardias (eg, light-headedness, dizziness, palpitations, and rarely syncope).

Diagnosis is by electrocardiography (ECG); P waves, which differ in morphology from normal sinus P waves, precede QRS complexes but may be hidden within the preceding T wave (see figure True atrial tachycardia ).

True atrial tachycardia

Vagal maneuvers may be used to slow the heart rate, allowing visualization of P waves when they are hidden, but these maneuvers do not usually terminate the arrhythmia (demonstrating that the AV node is not an obligate part of the arrhythmia circuit).

Treatment involves managing causes and slowing ventricular response rate using a beta-blocker or calcium channel blocker. An episode may be terminated by direct current cardioversion . Pharmacologic approaches to termination and prevention of atrial tachycardia include antiarrhythmic drugs in class Ia, Ic, or III. If these noninvasive measures are ineffective, alternatives include overdrive pacing and ablation .

Multifocal atrial tachycardia (chaotic atrial tachycardia) is an irregularly irregular rhythm caused by the random discharge of multiple ectopic atrial foci. By definition, heart rate is > 100 beats/minute. On ECG, P-wave morphology differs from beat to beat, and there are ≥ 3 distinct P-wave morphologies. The presence of P waves distinguishes multifocal atrial tachycardia from atrial fibrillation . Except for the rate, features are the same as those of wandering atrial pacemaker. Symptoms, when they occur, are those of rapid tachycardia. Multifocal atrial tachycardia can be due to an underlying pulmonary disorder such as chronic obstructive pulmonary disease coronary artery disease , and electrolyte abnormalities such as hypokalemia . Treatment is directed at the underlying disorder.

Nonparoxysmal junctional tachycardia is caused by abnormal automaticity in the AV node or adjacent tissue, which typically follows open heart surgery, acute inferior myocardial infarction, myocarditis, or digitalis toxicity. Heart rate is 60 to 120 beats/minute; thus, symptoms are usually absent. ECG shows regular, normal-appearing QRS complexes without identifiable P waves or with retrograde P waves (inverted in the inferior leads) that occur shortly before ( < 0.1 second) or after the QRS complex. The rhythm is distinguished from paroxysmal supraventricular tachycardia by the lower heart rate and gradual onset and offset. Treatment is directed at causes.

Wandering atrial pacemaker (multifocal atrial rhythm) is an irregularly irregular rhythm caused by the random discharge of multiple ectopic atrial foci. By definition, heart rate is ≤ 100 beats/minute. Except for the rate, features are the same as those of multifocal atrial tachycardia. Treatment is directed at causes.

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Wandering Atrial Pacemaker EKG Interpretation with Rhythm Strip

Ekg features, wandering atrial pacemaker ekg interpretation example.

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Key features, clinical presentation, diagnostic evaluation, ongoing management.

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ESSENTIALS OF DIAGNOSIS

Progressive cyclic variation in P-wave morphology

Heart rate 60–100 bpm

Variation of P-wave morphology, P-P interval, and P-R interval

GENERAL CONSIDERATIONS

This rhythm is benign

This rhythm and multifocal atrial tachycardia are similar except for heart rate

The other possible explanation is that there is significant respiratory sinus arrhythmia, with uncovering of latent foci of pacemaker activity

Usually, it is associated with underlying lung disease

In the elderly, it may be a manifestation of sick sinus syndrome

In the young and athletic heart, it may represent enhanced vagal tone

SYMPTOMS AND SIGNS

Usually causes no symptoms and is incidentally discovered

Occasional patient may feel skipped beats

PHYSICAL EXAM FINDINGS

Variable S 1

DIFFERENTIAL DIAGNOSIS

Multifocal atrial tachycardia (heart rate > 100 bpm)

Frequent premature atrial complexes and atrial bigeminy

LABORATORY TESTS

None specific

ELECTROCARDIOGRAPHY

ECG to document rhythm

CARDIOLOGY REFERRAL

Not required

MEDICATIONS

No specific treatment

Monitor and treat the underlying cause, such as sick sinus syndrome or lung disease

DIET AND ACTIVITY

No restrictions

General healthy lifestyle

Once a year if sinus node abnormality is suspected; otherwise when symptoms arise

COMPLICATIONS

May progress to sick sinus syndrome

This condition by itself is benign

PRACTICE GUIDELINES

Indications for pacemaker:

– If part of sick sinus syndrome

– If associated with documented symptomatic bradycardia

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• Wandering atrial pacemaker
• 2 Clinical Features
• 3.1 Palpitations
• 4.2 Diagnosis
• 5 Management
• 6 Disposition
• 8 External Links
• 9 References
• Three or more ectopic foci within the atrial myocardium serve as the pacemaker
• Rate is less than 100bpm (in contrast to MAT )
• Is irregularly irregular therefore sometimes confused with atrial fibrillation and sinus arrhythmia
• Intrinsic cardiac or pulmonary disease
• Metabolic derangements
• Drug toxicity (including Digoxin )

Clinical Features

• Often seen in the extremes of age and in athletes
• Rarely causes symptoms

Differential Diagnosis

Palpitations.

• Narrow-complex tachycardias
• Wide-complex tachycardias
• Second Degree AV Block Type I (Wenckeback)
• Second Degree AV Block Type II
• Third Degree AV Block
• Premature atrial contraction
• Premature junctional contraction
• Premature ventricular contraction
• Sick sinus syndrome
• Acute coronary syndrome
• Cardiomyopathy
• Congenital heart disease
• Congestive heart failure (CHF)
• Mitral valve prolapse
• Pacemaker complication
• Pericarditis
• Myocarditis
• Valvular disease
• Panic attack
• Somatic Symptom Disorder
• Drugs of abuse (e.g. cocaine )
• Medications (e.g. digoxin , theophylline )
• Thyroid storm
• Pulmonary embolism
• Dehydration
• Pheochromocytoma

• ECG should show three distinct P wave morphologies with a ventricular rate <100bpm
• Rarely requires treatment

Disposition

• Outpatient management
• Multifocal atrial tachycardia
• Dysrhythmia

External Links

• Richard Cunningham
• fardis tavangary
• Ross Donaldson
• Privacy policy
• Disclaimers

Multifocal Atrial Tachycardia (MAT)

• Ed Burns and Robert Buttner
• Jun 4, 2021

Multifocal Atrial Tachycardia (MAT) Overview

• A rapid, irregular atrial rhythm arising from multiple ectopic foci within the atria.
• Most commonly seen in patients with severe COPD  or congestive heart failure.
• It is typically a transitional rhythm between frequent premature atrial complexes (PACs) and atrial flutter / fibrillation.

AKA “Chaotic atrial tachycardia”

Electrocardiographic Features

• Heart rate > 100 bpm (usually 100-150 bpm; may be as high as 250 bpm).
• Irregularly irregular rhythm with varying PP, PR and RR intervals.
• At least 3 distinct P-wave morphologies in the same lead.
• Isoelectric baseline between P-waves (i.e. no flutter waves).
• Absence of a single dominant atrial pacemaker (i.e. not just sinus rhythm with frequent PACs).
• Some P waves may be nonconducted; others may be aberrantly conducted to the ventricles.

There may be additional electrocardiographic features suggestive of COPD.

Clinical Relevance

• Usually occurs in seriously ill elderly patients with respiratory failure (e.g. exacerbation of COPD / CHF).
• Tends to resolve following treatment of the underlying disorder.
• The development of MAT during an acute illness is a poor prognostic sign, associated with a 60% in-hospital mortality and mean survival of just over a year. Death occurs due to the underlying illness; not the arrhythmia itself.

Arises due to a combination of factors that are present in hospitalised patients with acute-on-chronic respiratory failure:

• Right atrial dilatation (from cor pulmonale )
• Increased sympathetic drive
• Hypoxia and hypercarbia
• Beta-agonists
• Theophylline
• Electrolyte abnormalities: Hypokalaemia and hypomagnesaemia  (e.g. secondary to diuretics / beta-agonists)

The net result is increased atrial automaticity.

ECG Examples

Multifocal atrial tachycardia:

• Rapid irregular rhythm > 100 bpm.
• At least 3 distinctive P-wave morphologies (arrows).

MAT with additional features of COPD :

• Rapid, irregular rhythm with multiple P-wave morphologies (best seen in the rhythm strip).
• Right axis deviation, dominant R wave in V1 and deep S wave in V6 suggest right ventricular hypertrophy due to cor pulmonale. 

Related Topics

• The ECG in COPD
• Right atrial enlargement (P pulmonale)
• Right ventricular hypertrophy

Advanced Reading

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course : Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop . Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog .
• Zimmerman FH. ECG Core Curriculum . 2023
• Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations , 2022
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine . 1e, 2020
• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care . 2e, 2019
• Hampton J, Adlam D. The ECG Made Practical 7e, 2019
• Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG . 2015
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest

ECG LIBRARY

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

Robert Buttner

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library . Twitter: @rob_buttner

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Atrial Rhythms Module

Atrial dysrhythmias.

Thomas E. O'Brien AS CCT CRAT RMA

Learning Objectives

At the conclusion of this training module the reader will be able to:

• Recall and apply the 5-steps of heart rhythm interpretation
• Recognize the difference between regular and irregular rhythms
• Recall the normal range for PR interval and QRS complex
• Recognize the features and qualifying criteria for the following complexes and rhythms:
• Premature Atrial Complexes
• Wandering Atrial Pacemaker Rhythm

Multifocal Atrial Tachycardia

• Atrial Flutter
• Atrial Fibrillation

Authors and Reviewers

• EKG heart rhythm modules: Thomas O'Brien
• Medical review: Dr. Jonathan Keroes, MD
• Medical review: Dr. Pedro Azevedo, MD, Cardiology
• Last Update: 11/8/2021
• Electrocardiography for Healthcare Professionals, 6th Edition Kathryn Booth and Thomas O'Brien ISBN10: 1265013470, ISBN13: 9781265013479 McGraw Hill, 2023
• Rapid Interpretation of EKG's, Sixth Edition Dale Dublin Cover Publishing Company
• EKG Reference Guide EKG.Academy
• 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs Aaron Reed Create Space Independent Publishing
• The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG Jonathan Keroes, David Lieberman Publisher: Lippincott Williams & Wilkin) ISBN-10: 0781784425; ISBN-13: 978-0781784429
• ECG Reference Guide PracticalClinicalSkills.com

Lesson #1: Rhythm Analysis Method 312

The five steps of rhythm analysis will be followed when analyzing any rhythm strip.

• Analyze each step in the following order.

Rhythm Regularity

• P wave morphology
• P R interval or PRi
• QRS complex duration and morphology
• Carefully measure from the tip of one R wave to the next, from the beginning to the end of the tracing.
• A rhythm is considered “regular or constant” when the distance apart is either the same or varies by 1 ½ small boxes or less from one R wave to the next R wave.

Heart Rate Regular (Constant) Rhythms

• The heart rate determination technique used will be the 1500 technique.
• Starting at the beginning of the tracing through the end, measure from one R wave to the next R wave (ventricular assessment), then P wave to P wave (atrial assessment), then count the number of small boxes between each and divide that number into 1500. This technique will give you the most accurate heart rate when analyzing regular heart rhythms. You may include ½ of a small box i.e. 1500/37.5 = 40 bpm (don’t forget to round up or down if a portion of a beat is included in the answer).

Step 2 (Cont)

Heart rate - irregular rhythms.

• If the rhythm varies by two small boxes or more, the rhythm is considered “irregular”.
• The heart rate determination technique used for irregular rhythms will be the “six-second technique”.
• Simply count the number of cardiac complexes in six seconds and multiply by ten.

P wave Morphology (shape)

• Lead II is most commonly referenced in cardiac monitoring
• In this training module, lead two will specifically be referenced unless otherwise specified.
• The P wave in lead II in a normal heart is typically rounded and upright in appearance.
• Changes in shape must be reported. This can be an indicator that the locus of stimulation is changing or the pathway taken is changing.
• P waves may come in a variety of morphologies i.e. rounded and upright, peaked, flattened, notched, biphasic(pictured), inverted and even buried or absent!
• Remember to describe the shape. This can be very important to the physician when diagnosing the patient.

PR interval (PRi)

• Measurement of the PR interval reflects the amount of time from the beginning of atrial depolarization to the beginning of ventricular depolarization.
• Plainly stated, this measurement is from the beginning of the P wave to the beginning of the QRS complex.
• The normal range for PR interval is: 0.12 – 0.20 seconds (3 to 5 small boxes)
• It is important that you measure each PR interval on the rhythm strip.
• Some tracings do not have the same PRi measurement from one cardiac complex to the next. Sometimes there is a prolonging pattern, sometimes not.
• If the PR intervals are variable, report them as variable, but note if a pattern is present or not.

QRS complex

• QRS represents ventricular depolarization.
• It is very important to analyze each QRS complex on the tracing and report the duration measurement and describe the shape (including any changes in shape).
• As discussed in step 3, when referring to P waves, remember changes in the shape of the waveform can indicate the locus of stimulation has changed or a different conduction pathway was followed. It is no different when analyzing the QRS complex. The difference is that in step 3, we were looking at atrial activity. Now we are looking at ventricular activity.
• Measure from the beginning to the end of ventricular depolarization.
• The normal duration of the QRS complex is: 0.06 – 0.10 second

Lesson #2: Interpretation 312

Introduction.

• The previous slides presented the five-steps of rhythm analysis. These five steps must be followed regardless of how simple of complex the tracing is you are reviewing.
• The information gathered in these steps are telling a story.
• The title of that story is the interpretation.

Atrial Dysrhythmias Types

The dysrhythmias in this category occur as a result of problems in the atria. These atrial dysrhythmias primarily affect the P wave. We will be discussing the following complexes and rhythms:

• Premature Atrial Complexes (PAC’s)
• Wandering Atrial Pacemaker

Lesson #3: Premature Atrial Complex

Intro to pacs.

• PACs can occur for a number of different reasons i.e., diet, fatigue, stress, disease, ischemia to name a few.
• Premature complexes frequently occur in bradycardic rhythms, but may occur almost any time.
• PACs occur when an early electrical impulse occurs from a location in the atria other than the SA node.

Intro to PACs 2

• This early impulse causes an early cardiac complex which disrupts the underlying rhythm.
• The locus of stimulation being different, results in a change in the morphology of the P wave.
• PACs can occur occasionally or frequently.
• PACs ECG can be observed with or without a pattern
• The P wave with PAC's will always be upright

EKG Analysis

Notice the following: the R to R interval is irregular, the fifth complex is early and the P wave on the early complex is a different shape.

EKG Practice Strip

Analyze this tracing using the five steps of rhythm analysis.

• Rhythm: Irregular
• P wave: Upright & uniform (except early complexes - biphasic)
• PR interval: 0.16 second
• Interpretation: Sinus Bradycardia with PACs

Lesson #4: Wandering Atrial Pacemaker

Description.

• Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring.
• Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering.
• These changes in the locus of stimulation affect the morphology of the P waves.
• In Wandering Atrial Pacemaker ECG, you must observe at least three different shaped P waves. No other changes in the tracing may be observed. The rhythm may or may not be regular.
• The PR interval is often affected, but does not have to be.
• The bottom line, is you must observe at least three different shaped P waves.

Practice Strip

• P wave: Changing Shapes (3 or more)
• PR interval: Variable
• Interpretation: Wandering Atrial Pacemaker

Lesson #5: Multifocal Atrial Tachycardia

• Multifocal Atrial Tachycardia is just a faster version of Wandering Atrial Pacemaker. The criteria is the same as Wandering Atrial Pacemaker with the only difference being the heart rate exceeds 100 bpm.
• These changes in the locus of stimulation within the atria affect the morphology of the P waves.
• Remember, you must observe at least three different shaped P waves.
• Due to the presence of irregular R to R intervals coupled with the changing P wave morphology, some people have confused this rhythm with Atrial Fibrillation.

Lesson #6: Atrial Flutter

• Atrial Flutter (sometimes called a flutter) occurs when there is an obstruction within the atrial electrical conduction system.
• Due to this impediment a series of rapid depolarizations occur.
• These depolarizations may occur two, three, four or more times per QRS complex.
• The AV node functions like a “gatekeeper” blocking the extra impulses until the ventricular conduction system is able to accept the impulse.
• The impulse that is accepted will cause the QRS complex to occur.
• Each atrial flutter ECG wave represents atrial depolarization. This will be noted next to the P wave step in rhythm analysis. Instead of P waves, this tracing has “F” waves. No P waves mean there is no PR interval measurement.
• When the tracing is interpreted, the ratio of F waves to each QRS complex will be documented along with the rhythm i.e. Atrial Flutter 4:1 (indicates 4 “F” waves to each QRS complex). Not all Atrial Flutter rhythm strips will have a regular rhythm. In that case just document and report your observations.
• Compare your answers with the answers on the next slide.

Practice Strip Answers

• Rhythm: Regular
• Rate: Ventricles - 80, Atria - 320
• P wave: "F" waves
• PR interval: absent
• Interpretation: Atrial Flutter 4:1

Lesson #7: Atrial Fibrillation

• Atrial Fibrillation (afeb) occurs when multiple electrical impulses occur within the atria. This chaotic electrical activity results in a chaotic wave form between the QRS complexes. P waves are absent. They are replaced by lower case "f" waves. No P waves means there is no PR interval measurement.
• This rapid electrical activity overwhelms the AV node causing impulses to enter the ventricular conduction system at irregular points. This results in irregular R to R intervals.
• Not all fibrillatory waves are created equal. The "f" waves can be coarse (majority measure 3 mm or more) or can be fine (majority of waveforms measure less than 3 mm) to almost absent. Regardless always report your observations. Many times when a patient has "new onset" Atrial Fibrillation the patient will report with a heart rate of 160 bpm or more.
• When a patient experiences A-fib, the atria are not contracting as they normally would. They are just quivering. This absence of contraction of the atria can result in a loss of cardiac output anywhere from 15 - 30% due to the absence of "atrial kick". This is why the heart rate is so high. The body is trying to maintain homeostasis.
• It will be impossible to determine the atrial rate. You will only be able to analyze and report the ventricular rate.
• Atrial Fibrillation with a ventricular response in excess of 100 bpm is commonly referred to as Atrial Fibrillation with “rapid ventricular response” or "uncontrolled A-fib".
• Rate: Ventricles - 90, Atria - Unable to determine (UTD)
• P wave: "f" waves
• Interpretation: Atrial Fibrillation

Lesson #8: Quiz Test Questions 312

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Wandering Pacemaker

When several pacemakers are competing, p-waves with different origins and thus configurations occur. The rhythm is slightly different from beat to beat.

note If the heart rate increases to above 100bpm, it is called Multifocal Atrial Tachycardia . Possible causes are hypoxia, COPD and medication such as digoxin.

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