7/12/2015

ECG tutorial: Ventricular arrhythmias

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

ECGtutorial:Ventriculararrhythmias
Author
JordanMPrutkin,MD,
MHS,FHRS

SectionEditor
AryLGoldberger,MD

DeputyEditor
GordonMSaperia,MD,
FACC

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2015.|Thistopiclastupdated:Nov25,2013.
INTRODUCTIONVentriculararrhythmiasarewidecomplexrhythmsthatmayberegularorirregular.
Thesemaybenormalrate,bradycardic,ortachycardic,andmayoccurassinglebeatsorsustained.Some
ventriculararrhythmiasmaybepresentassuddencardiacarrest.
PREMATUREVENTRICULARCONTRACTIONSPrematureventricularcontractions(PVCs),ventricular
prematurebeats(VPBs),ventricularprematurecomplexes(VPCs),prematureventricularbeats(PVBs),or
ventricularextrasystoles(VES)areearlyoccurring,widenedQRScomplexesthathaveadistinct
morphology(resemblingneitheratypicalleftnorrightbundlebranchblock)thatismarkedlydifferentfrom
thesinusQRScomplex.UnifocalPVCsallhaveasinglemorphology.MultipledifferentQRSmorphologies
aretermedmultiformPVCs.
Ingeneral,thereisnoPwaveidentifiedbeforeaprematureQRScomplex.However,theremaybeanormal
sinusPwavepresentifthePVCisverylateinthissituation,thereisalongcouplinginterval(fromtheprior
QRScomplex),thePwaveisnotconducted,andthePRintervalisshorterthanthenativesinusbeat.
TheQRScomplexofaPVCiswidened,oftennotched,andwithaQRSdurationusually>0.16seconds
(waveform1).Itwillhaveamorphologythatresemblesarightorleftbundlebranchblockdependingupon
thelocationoforigin,butitsmorphologyisgenerallynotthesameasatypicalbundlebranchblock.Itis
assumedthatthePVCoriginatesintheleftventriclewhenithasapositivedeflectionortallRwaveinV1
(rightbundlebranchblockconfiguration),whileanegativecomplexwithadeepSwaveinV1(resemblinga
leftbundlebranchblockmorphology)originatesintherightventricle.Otherfindingsonthe
electrocardiogram(ECG)includemarkedrepolarizationabnormalities,manifestedasSTsegmentandT
waveabnormalities.Retrogradeactivationoftheatriumisvariablypresentitdependsuponthelocationof
theprematurebeat,thetimenecessaryforimpulseconductiontotheatrioventricular(AV)node,thecoupling
intervaltothepriorsinusbeat,andtheabilityofthenodetoconductretrogradetotheatrium.Whenpresent,
thereisaretrogradePwave,usuallyseenwithinorslightlybeforetheTwave.Theintervalfromthe
previousPwavetotheretrogradePwaveis,however,shorterthantheunderlyingsinusPPinterval,
reflectingtheprematureactivationoftheatrium.
TherecanbemanysinusnoderesponsestoaPVC.Mostcommonly,afullcompensatorypausefollowsthe
PVCthus,thePPintervalbetweentheQRScomplexesbeforeandaftertheprematurebeatistwicethePP
intervalbetweentwosuccessivesinusbeats.ThepauseisduetoretrogradeAVnodalpenetrationofthe
PVC,whichcausestheAVnodetoberefractorytothenextontimesinusimpulse,whichisblocked.The
subsequentsinusimpulsedoesconductthroughtheAVnodetostimulatetheventricle.Inthissituation,a
normalappearingPwavemaybeseen,oftenburiedintheSTsegmentorTwaveofthePVC,withnoQRS
followingit.OthercasesmayhaveretrogradeactivationoftheatriumwithaninvertedPwaveintheinferior
leadsandresultantdelayofsinusnodeimpulsegeneration.Inthissituation,thePPintervalbetweenthe
QRScomplexbeforeandafterthePVCislessthantwosinusbeats.
Onoccasion,thePVCmaybeinterpolated.ItoccursbetweentwonormalsinusQRScomplexes,andthe
PPintervalbetweentheQRScomplexpriortoandaftertheprematurebeatisthesameastheunderlying
sinusPPinterval,duetolackofretrogradepenetrationintotheAVnode(waveform2).Iftheventricular
myocardiumisnolongerrefractoryfromthePVC,itiscapableofagainbeingstimulatedfromthenextsinus
beat.TherealsomaybeconcealedretrogradeconductionofthePVCintotheAVnode,renderingitpartially
refractoryandleadingtoalongerPRintervalofthefirstsinusbeatfollowingtheprematurecomplex.

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

1/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

VentricularbigeminyVentricularbigeminyispresentwhenaprematureventricularcomplexfollows
eachsinusbeat(waveform3).Ventricularbigeminymaybecomeselfperpetuating,asituationknownasthe
ruleofbigeminy.ThisoccursbecausethelongcyclelengthafterthepriorPVCtendstoprecipitatethenext
PVCafterasinusbeat.Thepresenceofventricularbigeminyindicatesarepeatingpatternbuthasnoother
clinicalimplications.
VentriculartrigeminyVentriculartrigeminyispresentwhentwosinusbeatsarefollowedbythe
ventricularprematurebeat.Thus,everythirdbeatisaventricularprematurebeat(waveform4).
VentricularcoupletsVentricularcoupletsaredefinedastwoPVCsinarow(waveform5).Thereisoften
acompensatorypauseafterthesecondprematurebeat.Thetwoprematurebeatsmayhaveanidentical
morphology(unifocalcouplet),ortheirmorphologymaydiffer(multifocalcouplet).TheRRintervalbetween
thetwosuccessivePVCsvarieswidely.
VENTRICULARESCAPECOMPLEXESORRHYTHMAnescapeventricularbeatorrhythmoccurs
whenthereisfailureofthesinusandatrioventricular(AV)nodetogenerateanimpulse.Thereisanabsence
ofPwaveactivity,associatedwithawidenedQRScomplexthatresemblesaprematureventricular
contraction(PVC)andoccursafterapauseofvariableduration(butalwaysgreaterthanthenormalsinus
RRinterval).Persistenceofthisactivityleadstomultiplesuccessiveventricularcomplexes,representingan
escapeventricularrhythmwitharatethatisslowerthanthenormalsinusrhythm.Incasesofcompleteor
thirddegreeheartblockinwhichthereissinusnodeactivitybutfailureofconductionthroughtheAVnode,
therearePwavesdissociatedfromtheventricularcomplexeswitharatefasterthantheventricularrate(AV
dissociation)(waveform6).
VENTRICULARPARASYSTOLEVentricularparasystolerepresentsanindependentectopicventricular
rhythmthathasnorelationshiptothesinusrhythm.Itappearsontheelectrocardiogram(ECG)asunifocal
prematureventricularcontractions(PVCs)withavariablecouplingcycle(theintervalbetweenthepriorsinus
beatandtheprematurebeatvaries)(waveform7).TheintervalbetweentwosuccessivePVCsisalways
constantorsomeintegeroftheunderlyingrateoftheectopicfocus.
Ventricularparasystoleistheresultofanectopicfocuswithintheventricularmyocardiumorventricular
conductionsystem,whichmanifestsspontaneousautomaticityandhasaratethatisslowerthanthe
underlyingsinusrate.Thisfocusisnotdepressedoroverdrivenbythenormalventricularconduction
becauseofentranceblockintotheareaoftheectopicfocusitisprotectedfromsuppression.However,the
ectopicfocusmayormaynotactivatetheventricularmyocardiumandthereforeresultinaPVC,depending
ontheabilityoftherestoftheventricularmyocardiumtobestimulated,whichinturnisdeterminedbyits
stateifrefractoriness.Thus,theremayalsobeintermittentexitblockfromthisfocus,andthePVCdoesnot
appearattheexpectedtime,butlaterPVCsarepresentattheunderlyingrateoftheparasystolicfocus.
VENTRICULARTACHYCARDIAVentriculartachycardia(VT)isdefinedasthreeormoresuccessive
ventricularcomplexesatarategreaterthan100beatsperminute.NonsustainedVTisaseriesofatleast
threeconsecutiveventricularbeatsthathaveadurationoflessthan30secondsordonotrequire
emergencyinterventionsustainedVTlastsformorethan30secondsorrequiresterminationearlybecause
ofhemodynamicimpairment.Therhythmisusuallyregular,althoughtheremaybeslightirregularityofthe
RRintervals.(See"NonsustainedVTintheabsenceofapparentstructuralheartdisease"and"Sustained
monomorphicventriculartachycardia:Diagnosisandevaluation".)
ThemorphologyoftheQRScomplexduringVTisusuallydifferentwhencomparedtothesinusbeat.(See
"ApproachtothediagnosisofwideQRScomplextachycardias".)
Additionally,itdoesnotresembleeitheratypicalleftorrightbundlebranchblock,asventricularactivationis
notviathenormalHisPurkinjeconductionsystem,butisthroughdirectventricularmyocardialactivation.
TheQRSaxismaybedeviatedtotheleftortotheright.ThewidthoftheQRScomplexisgenerally>0.16
secwheninaleftbundlebranchblockpatternand>0.14secwheninarightbundlebranchblockpattern.
Otherusefulfeaturesofventriculartachycardiainclude:
Atrioventricular(AV)dissociation,whichisthehallmarkofventriculartachycardia.Subtledifferencesin
STTwavemorphologyrepresentingpossiblysuperimposedPwavesshouldbeassessed.
http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

2/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Presenceoffusionorcapturebeats.
AbsenceofanRScomplexinalloftheprecordialleads.
LongestRtoSinterval>100msinanyprecordiallead.
ConcordanceoftheQRScomplexacrosstheprecordialleads(eg,RwavesorSwavesonlyinleads
V1V6).However,thismaybeseeninanysituationinwhichthereisdirectmyocardialactivation,
includingWolffParkinsonWhitepatternorapacedcomplex.Negativeconcordanceislessuseful,as
thismaybeseenwithaleftbundlebranchblock.
AmonophasicRr'patterninlead1(termedrabbitears)withatallerleftear.Thisisoftenassociated
withanrSorQScomplexmorphologyinleadsV5V6.
Anindeterminateaxis(between90and180).However,thismaybeseeninanysituationinwhich
thereisdirectmyocardialactivationincludingapacedrhythm(especiallybiventricularpacing)orWolff
ParkinsonWhitepattern.
InleadII,timefrombeginningoftheQRStofirstchangeofpolarity50ms,regardlessofwhetherthe
QRSchangeispositiveornegative.
InleadaVR,aninitialRwave,widthoftherorqwave>40ms,and/ornotchonthedescendinglimbof
apredominantlynegativeQRS.
TheVTismonomorphicwhenalloftheQRScomplexesofanepisodeareidentical(waveform8).However,
monomorphicVToftendisplayssubtlechangesoftheQRScomplexeswithregardtomorphologyandwidth
asaresultofvariablechangesintheelectrophysiologicpropertiesoftheventricularmyocardium.
WhentheQRScomplexeswithineachepisodedisplaychangingmorphologies,oftenwithgrosslyirregular
RRintervals,theVTiscalledpolymorphic(waveform9).(See"Catecholaminergicpolymorphicventricular
tachycardiaandotherpolymorphicventriculartachycardiaswithanormalQTinterval".)Thedifferencesin
QRSmorphologyresultfromchangesinthedirection(vector)ofmyocardialactivationduetomarked
heterogeneityoftheelectrophysiologiccharacteristicsoftheventricularmyocardium.Therateisusually
between100and330beatsperminute.IfthepolymorphicVTisassociatedwithabaselineQRScomplex
thathasanormalQTinterval,themostcommonetiologyisischemia.IfthepolymorphicVTisassociated
withaQRScomplexonthebaselineelectrocardiogram(ECG)thathasQTprolongation,thenthe
polymorphicVTistermedtorsadesdespointes.TheQTprolongationmaybeacquired,duetomedications
thatprolongtheQTinterval(see"AcquiredlongQTsyndrome")orcongenital,theresultofachannelopathy
(see"ClinicalfeaturesofcongenitallongQTsyndrome").
ThepresenceofAVdissociationisaveryimportantfindingandisusuallydiagnosticofVT.(See"Approach
tothediagnosisofwideQRScomplextachycardias".)However,itisnotalwayspresent,orifpresentmay
notbeeasilyrecognized,especiallywhentheventricularrateisveryrapid(theRRcyclelengthisshort).The
Pwavesarenotdistinctiveinthesecases,butmayaltertheQRScomplexesorbesuperimposeduponthe
STandTwaves,causingirregularchangesintheirmorphology.
AVdissociationoccursasaresultofretrogradeVAconductionthatenters,butblocks,withintheAVnode
(concealedconduction).Theretrogradeconcealedconductionintothenodecausesthenodetobe
refractorytoantegradestimulation,therebyblockingconductionfromtheatriumtotheventricle.Ifthe
tachycardiadoesnotleadtoAVblock,fusionorcapturebeatsmaybepresent,asdescribedbelow.Insome
casesofVT,thereisretrogradeconductionthroughtheAVnodeandretrogradeactivationoftheatria.
Theremaybeavariabledegreeofretrogradeblock(2:1,3:1,orevenWenckebach)onoccasion,theremay
be1:1retrogradeactivationoftheatriumandthereforenoAVdissociationwithafixedRPinterval.
Dissociationismoreobviouswhenthetachycardiarateisrelativelyslow.ThePwavesoccurataslower
ratethantheQRScomplexes,andthereisnorelationshipbetweenthem.
OtherfeaturesofAVdissociationinclude:
Fusionbeats,whichoccurwithaQRScomplexthathasfeaturesresemblingboththesinusQRSand
thatoftheVT.Theseresultfromsimultaneousactivationoftheventriclesfromtheventricularfocusas
http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

3/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

wellasviaasinusbeattravellingdownthenormalAVnodalHisPurkinjepathway.
CaptureorDresslerbeats,whichareintermittentlycapturedQRScomplexesthatareidenticaltosinus
complexes.TheyareprecededbyaPwave,indicatingthatthereisintermittentcaptureofthe
ventriclesbythesinusnodeviathenormalAVnodalHisPurkinjepathway(waveform10).However,
theoccurrenceofintermittentcaptureoftheventriclefromabovedoesnotaltertheVToraffectits
focusoforigin.
RepetitivemonomorphicventriculartachycardiaRepetitivemonomorphicVToccursinthosewithno
structuralheartdisease.(See"Monomorphicventriculartachycardiaintheabsenceofapparentstructural
heartdisease".)
Itmostfrequentlyoriginatesfromtherightventricularoutflowtract(RVOT)justinferiortothepulmonary
valve,butlessfrequentlymayoccurintheleftventricularoutflowtract,sinusesofValsalva,orotherareasof
theheart.RVOTVThastheECGappearanceofaleftbundlebranchblockpatternwithaninferiorlydirected
axis.Ingeneral,thesehaveabenignprognosis.
VentricularflutterVentricularflutterisamonomorphicVTthatoccursataveryrapidrate,usuallyaround
300beatsperminute(figure1).OftennodistinctiveTwavesarediscernible.Thereisnoisoelectricinterval
betweenQRScomplexes.Pwavesorevidenceofatrialactivityareabsentsincetheventricularrateisrapid.
TorsadesdepointesTorsadesdepointesisarapidanddistinctformofpolymorphicVTassociatedwith
abaselineprolongedQTinterval.Itmeans"twistingofpoints,"anamethatreferstothecontinuously
changingaxisofpolymorphicQRSmorphologiesthatareobservedduringeachepisode(waveform11AB).
Thetypicalformisinitiatedbybradycardiaorispausedependent,withashortlongshortcouplinginterval,
ie,aPVC(shortRRinterval),acompensatorypause(longRRinterval),andsecondPVC(shortRRinterval)
(waveform11B).(See"ClinicalfeaturesofcongenitallongQTsyndrome".)IfthebaselineQTcintervalis
normal,therhythmisreferredtoaspolymorphicVTandnottorsadesdepointes.
ACCELERATEDIDIOVENTRICULARRHYTHMAnacceleratedidioventricularrhythm(AIVR)isa
repetitiveventricularrhythmoccurringataratebetween60and100beatsperminute(waveform12).Itmay
betheresultofanacceleratedventricularfocusthatgeneratesanimpulsefasterthanthesinusnodeand
thereforeassumescontrol.Theremayormaynotbeatrioventricular(AV)dissociationifdissociationis
present,theatrialrateisslowerthantheventricularrateandthePPintervalsarelongerthantheRR
intervals.Ontheotherhand,iftheidioventricularrhythmrepresentsanescaperhythm(generallytheresult
ofthirddegreeAVnodalblock),thePwavesaredissociatedfromtheQRSimpulsesandtheatrialrateis
fasterthantheventricularrate.Inthesettingofacuteischemia,AIVRmaybeamarkerofspontaneousor
inducedreperfusion.(See"Thirddegree(complete)atrioventricularblock".)
VENTRICULARFIBRILLATIONVentricularfibrillationisidentifiedbythecompleteabsenceofproperly
formedQRScomplexesandnoobviousPwaves(waveform13).Thereisnouniformactivationofthe
ventricularmyocardiumandtheQRScomplexeshavemarkedlydifferentmorphology,axis,andamplitude.
Therateisirregularandusuallygreaterthan300beatsperminute.Whenthefibrillationisrecentonset,the
amplitudeisusuallyhigh,butastimepasses,thefibrillatorywavesbecomefinerandmayresemble
asystole.Ventricularfibrillationleadspromptlytocardiacarrest.
SUMMARY
Prematureventricularcontractions(PVCs)areearlyoccurringbeatswithwidenedQRScomplexesthat
haveadistinctmorphologythatismarkedlydifferentfromthesinusQRScomplex(waveform1).Other
characteristicsincludemarkedrepolarizationabnormalitiesandnoconductedPwaveidentifiedbefore
aprematureQRScomplex.
Ventriculartachycardia(VT)isdefinedasthreeormoresuccessiveventricularcomplexes(waveform
8).NonsustainedVTisaseriesofatleastthreerepetitiveventricularbeatsthathaveadurationofless
than30secondsordonotrequireemergencytherapysustainedVTlastsformorethan30secondsor
isterminatedearlierbecauseofhemodynamicimpairment.IfthereisonebasicmorphologyoftheQRS
complexes,itistermedmonomorphicVT.IftheQRScomplexmorphologyischanging,especially
http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

4/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

withachangeinaxis,theVTistermedpolymorphic.PolymorphicVTassociatedwithabaselinelong
QTciscalledtorsadesdepointes.
Anacceleratedidioventricularrhythm(AIVR)isarepetitiveventricularrhythmoccurringatarate
between60and100beatsperminute(waveform12).
VentricularfibrillationisidentifiedbythecompleteabsenceofproperlyformedQRScomplexesandno
obviousPwaves(waveform13).Thisleadstosuddencardiacarrest.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
Topic2119Version5.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

5/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

GRAPHICS
Singleleadelectrocardiogram(ECG)showinga
ventricularprematurebeat(VPB)

Thefourthbeatisaventricularprematurebeat(VPB).Ithasawide,
bizarremorphology,withaduration>0.16seconds.
Graphic57511Version3.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

6/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showingan
interpolatedventricularprematurebeat(VPB)

Thethirdbeatisaventricularprematurebeat(VPB).Itiscalledan
interpolatedVPBsinceitdoesnotaltertheunderlyingsinusRRinterval.
Graphic72768Version3.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

7/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Electrocardiogram(ECG)showingventricularbigeminy

Aventricularprematurebeat(VPB)followseachsinusbeat,andthecoupling
intervalbetweentheVPBandtheprevioussinusQRScomplexisconstant(fixed
couplinginterval).Theresultingpatternisreferredtoasventricularbigeminy.
Graphic51529Version3.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

8/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showingventricular
trigeminy

Everythirdbeatisaventricularprematurebeat(VPB).Thecouplinginterval
betweentheVPBandtheprevioussinusQRScomplexisconstant(fixed
couplinginterval).Theresultingpatternisreferredtoasventriculartrigeminy.
Graphic64181Version3.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_res

9/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Ventricularcouplet

Twoventricularprematurebeats(VPBs)occurfollowingthreenormalQRS
complexes.ThisisaunifocalcoupletsincebothVPBshavethesame
morphology.
Graphic63258Version2.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

10/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Completeheartblock:Sinusrhythmwithslowjunctional
oridioventricularescaperhythym

MultiplesuccessiveQRScomplexesappearthatareofventricularoriginand
occurataratewhichisslowerthantheunderlyingsinusrhythm.Thepresence
ofPwavesthatoccurindependentoftheQRScomplexesisevidenceof
atrioventriculardissociation.
Graphic54024Version4.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

11/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Electrocardiogram(ECG)showingventricular
parasystole

Unifocalparasystolicventricularprematurebeats(VPBs)occuratarate
whichisslowerthantheunderlyingsinusrhythmandmanifestdifferent
couplingintervals(ie,thedistancebetweentheVPBandthepriorQRS
complex).Theectopicfocusdoesnotalwaysactivatetheventricular
myocardium(andthereforedoesnotprodueaVPBandtheECG)sinceit
mayarriveatatimewhentheventricleisrefractoryduetoactivation
fromthenormalconductionpathway.However,theintervalbetweentwo
successiveVPBsisalwayssomeintegeroftheunderlyingrateofthe
ectopicfocus(theinterectopicintervalshaveacommondenominator)
sincetheectopicfocusisundisturbedandcontinuestofireatitsown
intrinsicrate.
Graphic70928Version4.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

12/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showing
monomorphicventriculartachycardia

Threeormoresuccessiveventricularbeatsaredefinedasventricular
tachycardia(VT).ThisVTismonomorphicsincealloftheQRScomplexes
haveanidenticalappearance.AlthoughthePwavesarenotdistinct,theycan
beseenalteringtheQRScomplexandSTTwavesinanirregularfashion,
indicatingtheabsenceofarelationshipbetweenthePwavesandtheQRS
complexes,ie,AVdissociationispresent.
Graphic63176Version5.0

Normalrhythmstrip

NormalrhythmstripinleadII.ThePRintervalis0.15secandthe
QRSdurationis0.08sec.BoththePandTwavesareupright.
CourtesyofMortonFArnsdorf,MD.
Graphic59022Version3.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

13/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showing
polymorphicventriculartachycardia(VT)

TheQRScomplexesinpolymorphicVThavemarkedlydiffering
morphologiesduetochangesinthedirection(vector)ofmyocardial
activation.
Graphic80829Version4.0

Normalrhythmstrip

NormalrhythmstripinleadII.ThePRintervalis0.15secandthe
QRSdurationis0.08sec.BoththePandTwavesareupright.
CourtesyofMortonFArnsdorf,MD.
Graphic59022Version3.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

14/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Fusionbeats

Therhythmstripinapatientwithsustainedventriculartachycardiashowsa
fusionbeatandacapturebeat.Thefusionbeatoccurswhenasupraventricular
impulse(followingthefirstPwave)causesventricularactivation,whichfuses
withthecomplexoriginatingintheventricle,producingahybridcomplex.The
complexfollowingthesecondPwavehastheappearanceofanormalQRS
complexandisknownasacapturebeat.
Graphic72600Version4.0

Normalrhythmstrip

NormalrhythmstripinleadII.ThePRintervalis0.15secandthe
QRSdurationis0.08sec.BoththePandTwavesareupright.
CourtesyofMortonFArnsdorf,MD.
Graphic59022Version3.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

15/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Ventricularflutter

Arapidventriculartachycardia,withratesusuallyover240beatsper
minute,ischaracteristicofventricularflutter,withpredominantly
monomorphicQRScomplexes,andanabsenceofatrialactivity(P
waves).
Graphic65800Version1.0

Sinusrhythm

ThenormalPwaveinsinusrhythmisslightlynotchedsinceactivation
oftherightatriumprecedesthatoftheleftatrium.ThePwaveis
uprightinapositivedirectioninleadsIandII.APwavewitha
uniformmorphologyprecedeseachQRScomplex.Therateisbetween
60and100beatsperminuteandthecyclelengthisuniformbetween
sequentialPwavesandQRScomplexes.Inaddition,thePwave
morphologyandPRintervalsareidenticalfrombeattobeat.
Graphic69872Version2.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

16/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showing
torsadesdepointes

Thisisanatypical,rapid,andbizarreformofventriculartachycardia
thatischaracterizedbyacontinuouslychangingaxisofpolymorphic
QRSmorphologies.
Graphic53891Version4.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

17/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showing
torsadesdepointes

Theelectrocardiographicrhythmstripshowstorsadesdepointes,a
polymorphicventriculartachycardiaassociatedwithQTprolongation.
Thereisashort,preinitiatingRRintervalduetoaventricularcouplet,
whichisfollowedbyalong,initiatingcycleresultingfromthe
compensatorypauseafterthecouplet.
Graphic73827Version4.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

18/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showingaccelerated
idioventricularrhythm

Anacceleratedventricularrhythmoccursinthiscaseatarateof70beats/minute.
ThePwavesaredissociatedfromtheQRScomplexesandoccuratratewhichis
slowerthantheRRinterval.
Graphic52385Version4.0

Normalrhythmstrip

NormalrhythmstripinleadII.ThePRintervalis0.15secandthe
QRSdurationis0.08sec.BoththePandTwavesareupright.
CourtesyofMortonFArnsdorf,MD.
Graphic59022Version3.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

19/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Singleleadelectrocardiogram(ECG)showing
ventricularfibrillation

ThereisacompleteabsenceofproperlyformedQRScomplexesandno
obviousPwaves.Arecentonset(eg,withinminutes)ofthearrhythmiais
suggestedbythecoarsemorphologyofthefibrillatorywaves.
Graphic80454Version4.0

Normalrhythmstrip

NormalrhythmstripinleadII.ThePRintervalis0.15secandthe
QRSdurationis0.08sec.BoththePandTwavesareupright.
CourtesyofMortonFArnsdorf,MD.
Graphic59022Version3.0

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

20/21

7/12/2015

ECG tutorial: Ventricular arrhythmias

Disclosures
Disclosures:JordanMPrutkin,MD,MHS,FHRSGrant/Research/ClinicalTrialSupport:Boston
Scientific[Heartblock(PacemakersandICDs)]St.JudeMedical[Suddendeath(Pacemakersand
ICDs)].AryLGoldberger,MDNothingtodisclose.GordonMSaperia,MD,FACCNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmust
conformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ecg-tutorial-ventricular-arrhythmias?topicKey=CARD%2F2119&elapsedTimeMs=0&source=search_re

21/21