Sinus Node Rhythms and Arrhythmias

«Basics

Step 2: Heart Rate»

Author(s)	J.S.S.G. de Jong
Moderator	I.A.C. van der Bilt
Supervisor
some notes about authorship

Normal heart rhythm: sinus rhythm

The conduction system handles the spreading of an electrical signal through the heart. The normal sinus rhythm begins in the sinus node and goes via the AV node to the His bundle where it splits via the right and left bundle branch.

During normal sinus rhythm, every atrial contraction (P-wave) is followed by a ventricular contraction (QRS complex).

Normal sinus rhythm with a positive P-wave in I, II and AVF, and a biphasic P-wave in V1.

The normal heart rhythm is sinus rhythm. That means that the rhythm has its origin in the sinus node, the heart's fastest physiological impulse generator. The sinus node (SA) is located in the upper part of the wall of the right atrium. When the sinus node generates an electrical impulse, first the cells of the right atrium depolarise, then the cells of the left atrium, the AV (atrioventricular) node follows and at last the ventricles are stimulated via the His bundle.

With this knowledge it is quite simple to recognise normal sinus rhythm on the ECG.

Criteria for normal sinus rhythm (see also Basics)

• A P wave morphology P wave (atrial contraction) precedes every QRS complex
• The rhythm is regular, but varies slightly while breathing
• The frequency ranges between 60 and 100 beats per minute
• The P waves maximum height is 2.5 mm in II and/or III
• The P wave is positive in I and II, and biphasic in V1

These last two definitions will be discussed in the topic P wave morphology. Heart rhythms which are not sinus rhythm are arrhythmias.

Interpretation of the heart rhythm

A good stepwise approach to interprete the heart rhythm is to follow these steps:

• Cherchez le P, French for find the P waves.
  • Do you see P waves? Leads II and V1 are often most suitable to find P waves.
  • What is the rate of the P waves?
  • What is the P wave morphology?
• What is the relationship between P waves and QRS complexes?
  • Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? In short: is there a 1:1 relation between P waves and QRS complexes?
  • What is the PR interval and does it change?
• What is the ventricular heart rate?
• What is the QRS morphology?
• What is the clinical setting?

Sinus arrhythmias

Some variants of sinusrhythm exist:

• Asystole
• Sinustachycardia (>100 beats per minute)
• Sinusbradycardia (<60 beats per minute)
• Sinus arrest or pause
• Sino-atrial exit block
• Sick Sinus Syndrome

If the heart rate exceeds 100 bpm, the tachcyardia flow chart should be followed.

Examples

An example of normal sinus rhythm.

Another example of normal sinus rhythm.