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Garcia, Cholson Banjo E. Conduction disturbance Originate from: ◦ sinus node ◦ AV node ◦ bundle branch Sinoatrial Block Atrioventricular Block Bundle Branch Block Fascicular Block Impaired conduction from the SA node to the atria No depolarization of the atria Absence of PQRST complex Etiology Increased vagal tone Inferior wall MI Age related degeneration Drugs (digoxin, beta blockers, ccb, class IAantiarrythmic) ◦ Hyperkalemia ◦ myocarditis ◦ ◦ ◦ ◦ RR interval: irregular (creating a pause, atria is blocked so it never depolarized PP interval surrounding the pause is commonly multiple of the previous PP interval 1st degree AV block 2nd degree AV block, Type 1 (Mobitz or Wenkebach) 2nd degree AV block, Type 2 (Mobitz II) 3rd degree AV block (CHB) Prolonged conduction between the atria and the ventricles Partial block within the AV node Prolongation of the PR interval and preservation of the underlying rhythm • Etiology – Drugs – Increased vagal tone – Hyperkalemia – MI (inferior wall) – Myocarditis – Degeneration of conducting pathways assoc. with aging – Idiopathic cause PR interval: > 0.20 seconds Length of PR interval is constant P wave is followed by a QRS complex Mobitz type I or Wenckebach Intermittent conduction between the atria and ventricle Found with the AV node • Etiology – Digitalis – Escessive vagal tone – MI (inferior wall) – Ischemic heart disease – Myocarditis – Normal variant Progressive lengthening of the PR interval until a QRS complex is dropped; P wave appears on time, but no QRS follows RR interval: irregular owing to drop beats causing the QRS complex to appear clustered together (narrow) “Grouped Beating” PP: constant Mobitz type II Intermittent and sudden loss of conduction between atria and the ventricles Found below the bundle of his Can proceed to complete heart block Ventricular rate tends to be slower and cardiac output diminishes • Etiology – Acute Myocardial Infarction (anterior wall) – Drugs (digitalis, beta blocker, ccb) – Degeneration of electrical conduction system (assoc. with aging) PR interval: constant or fixed QRS: wider than normal because of associated conduction block in ventricles Conduction ratio varies (1:1, 2:1; 3:1) PP: regular RR: irregular Complete heart block Complete absence of conduction between atria and ventricles • Etiology – Drug toxicity (digoxin, beta blocker, ccb) – Excessive vagal tone – Acute MI – Age-related Degeneration of electrical conduction system – Myocarditis – Endocarditis – Cardiac Surgery – Congenital origin Atrial and ventricular rates are different No relationship between P waves and the QRS complex P waves appear but no QRS PP and RR interval: constant Look for 3 ECG patterns 1. Look for the RR interval. Regular or irregular? 2. Look at the P wave. Is there one or more P wave for every QRS 3. Look at the PR interval. Stay the same or change? If REGULAR (1st degree or 3rd degree) ◦ Only 1 P wave for every QRS ◦ PR interval stay the same 1st degree ◦ more than 1 P wave ◦ PR interval changes 3rd degree IRREGULAR ( 2nd degree) ◦ PR interval change: 2nd degree AV block, TYPE I ◦ PR interval stay the same: 2nd degree AV Block, TYPE II Defect in the intraventricular conduction Supravetricular impulse: from the unblocked branch depolarizes one ventricle Blocked branch: impluse spread slowly through the ventricular muscle resulting in abnormal depolarization Hallmark: abnormal wide QRS complex • Conduction Delay in the right bundle branch Etiology – RVH – Right ventricular strain – ASD – Wolf parkinson -white – Coronary artery disease – Myocarditis – Cardiac contusion – Idiopathic cause QRS complex: 0.12 or more in width QRS is wide and positive assumes in lead V1 rSR: leads V1 and V2 Wide or Deep I, avL V5 and V6 Down slopping of ST segment V1 and V2 • Etiology – LVH – Cardiomyopathy – HPN – Wolf parkinson -white – Coronary artery disease – Myocarditis QRS complex: 0.12 or more in width QRS is negative V1 and V2 rSR (rabbit ear) in I, avL, V5, V6 Wide or deep S V1 and V2 Down slopping of ST segment I, avL, V5, V6 Right Bundle Branch Block Left Bundle Branch Block QRS wide and predominantly positive V1 rSR in lead V1 QRS wide and predominantly negative V1 rSR in lead V6 Deep S in lead V6 Deep S in lead V1 Late intrinsicoid deflection in lead V1 Late intrinsicoid deflection in lead V6 Hemiblocks Disturbed conduction in either the anterior or posterior division, or fasicle, of the left bundle branch Delay in the conduction through the anterior fascicle of the LBB Anterior fascicle long thin and has a single blood supply, making it vulnerable to block • Etiology – Coronary artery disease – MI – Congenital Heart disease – Cardiac surgery – Aging process – Normal variant QRS: prolonged (0.08-0.11) Left axis deviation QRS axis (-45 and -90) Small q wave and a tall R wave in lead I and avL Small r wave and deep S wave in lead II, III and avF Delay in the conduction through the posterior fascicle of the LBB Posterior: short, thick and has double blood supply Appearance implies large amount of Myocardial injury has occurred • Etiology – Coronary artery disease – MI – Congenital Heart disease – Cardiac surgery QRS: prolonged (0.08-0.11) Right axis deviation QRS axis (+90 and +180) Small q wave and a tall R wave in lead II, III and avF Small r wave and deep S wave in lead I and avL LAFB LAD qR in lead I LPFB RAD qR in lead III rS in lead III rS in lead I