Wandering Atrial pacemaker

                                       Wandering Atrial pacemaker


Wandering atrial Pacemaker is an arrhythmia consider the normal variant EKG in normal heart and wealthy person and differ from sinus arrhythmia .

the mechanism of the  arrhythmia is believed to fluctuation of vagal tone that result in arrhythmia .
In this case the sino-atrial (SA) pacemaker transfer to other latent pacemaker in atrial (other site of SA pacemaker) and move to AV junction and than move back to SA and these circle is continue to maintain that rhythm . This variable pacemaker site changes believe the result of vagal tone fluctuation and in consequence these different pacemakers produce different formes of P wave, variable PR interval and Irregular of RR interval  .  
Wandering Atrial pacemaker is called when the heart rate is less than 100 beats per minute .

 When it over 100 beates per minute than we call Multifocal Atrial Tachycardia (clickhere to see it)  ( Arrhythmia that has many P waves morphology and irregularly irregular RR Interval ) that frequently confuse with Atrial fibrillation(afib) .

Please don't confuse frome irregularly irregular to irregular regular rhythm
        In irregularly irregular rhythm we have 3 majors arrhythmia that we have to consider rapidly
                1. Atrial fibrillation (clickhere to see it)
                2. Atrial flutter with variable conduction ( variable conduction of AV node ) (clickhere to see)
                3. Mutifocal Atrial Tachycardia ( MAT)
      In irregular regular rhythm we have
                1. second degree AV block
                2. premature beat (click here to see PAC)


All the conduction abnormality will discus respectively .

Now skip all that thing we go to Wandering atrial pacemaker
  the criteria for WAP are
     Rate < 100 beats per minute
     Rhythm irregularly irregular
     At lease 3 different P wave forme
     PR interval variable  

Other case of WAP

                                                             

Atrial Flutter

                                                          Atrial Flutter


Atrial Flutter is a supra ventricular tachycardia , it mean that narrow complex QRS tachycardia like other supra ventricular tachycardia except aberrant conduction  withe wide complex .

This arrhythmia cause by a circuit reentrant around the tricuspide valve in the right atrium.
Like other SVT the re-entrant circuit is initiated   by premature atrial beat  cause some part of the circuit in refractory state and other can conduce the electrical impulse, so this part conduce  to the refractory area that just recovery, so it form the cycle of conduction and this conduction turn over and over to make the circuit  of re-entrant ,this circuit conduce the fast rate of electrical signal so it cause fast atrial activity that we see on surface ECG rapid atrial activity (many many P wave).

This figure show you the re entrant of Atrial flutter locate at the right atrial compare to Atrial fibrillation that is chaos electrical activity in  both atriums. and also show the direction of the re entrant that counterclockwise direction,that will show P wave invert in DII DII AVF and up right in V1,  that we called typical flutter. In contrast if the direction ogf the circuit is clockwise we call atypical flutter result in  P wave positive in DII DIII AVF and negative in V1.

Here EKG show the typical and atypical flutter

The most common rate of atrial flutter with atrial rate around 300 per minute and the conduction throw the AV node with 2:1 ratio result in ventricular rate about 150 beats per minute . Like that the ventricular rate depend on AV node conduction it can 2:1,3:1or 4:1 or can be greater with 1:1 conduction that cause very fast ventricular rate.

The typical and atypical flutter can occur in same patient

Voila the atrial flutter criteria 

     1 . rate : Atrial rate 250-350 bpm, Ventricular rate variable (depend on AV conduction )

     2 .Rhythm : Atrial regular      , Ventricular variable (depend on AV conduction )

     3 .P wave : Flutter wave ''saw toothed appearance''

     4 .PR interval : Variable

     5 .QRS         : Narrow , wide if F wave buried in QRS 

Here some EKG of Atrial flutter 

The ECG
 C, D  show Atrial flutter with atrial rate about 300 per minute with variable conduction result in                irregularly irregular RR interval
A : show the constant conduction of AV node 2:1 ration and regular of RR interval.
B : show the irregular regular conduction 

This EKG show atrial flutter with 2:1 conduction, and flutter with 1:1 ratio conduction result in very fast of ventricular rate

Another cases  Please try to interpretation all  EKG below

How to diagnosis multifocal atrial tachycardia or MAT

                           How to diagnosis multifocal atrial tachycardia or MAT


Multifocal atrial tachycardia is an irregularly irregular rhythm that is frequently associated with severe respiratory disease like decompensated  COPD , severe asthma , severe pulmonary infection.............

The irregularly irregular rhythm have 3 major dysrhythmia
      1. Atrial fibrillation
     2. Multifocal atrial tachycardia
     3. Atrial flutter with variable AV conduction
So when we see irregularly irregular rhythm we think to 3 diagnosis above , to day i will show you the EKG of Multifocal atrial tachycardia.
The pattern of this arrhythmia is
       1. Irregularly irregular RR interval 
       2. P wave precede each QRS complex
       3. at leas 3 morphorlogies of P wave ( multifocale origin of P wave )
      4. Heart rate > 100 per minute 


Here the EKG of MAT

                        

We see heart rate >100 , Irregularly irregular with differences P waves precede each QRS

Another case of MAT with exacerbation of COPD(chronic obstructive pulmonary disease)

    We apply the same criteria like above

Another EKG

How to diagnose atrial fibrillation on ECG paper

                    How to diagnose atrial fibrillation on ECG paper


Hi everyone to day i happy to show you how to diagnosis atrial fibrillation on ECG paper , and i wish that after you read this article you really can diagnosis atrial fibrillation easily just take a look on record strip .


Atrial fibrillation is the most arrhythmia that we meet every day and all departments in hospital so we have to familiar and can diagnose it. This arrhythmia is very commonly in patient with dilated atrium , so all pathology that cause enlargement of atrium is the major cause of atrial fibrillation(afib).


Atrial fibrillation can define as :

Irregularly irrregular ventricular  rhythm and low amplitude baseline oscillation (fibrillatory or f wave)

This is the very useful definition and can help to diagnosis.


here is an ECG of atrial fibrillation

You see there is irregular and irregular of RR interval is the key point to diagnosis of afib and you can't find the P wave but we can see the baseline oscillation.



So take home point to diagnose atrial fibrillation , you have to find

        1. irregular and irregular of RR interval

        2.  baseline oscillation


Another ECG for atrial fibrillation

Yes atrial fibrillation criteria

   1. irregular and irregular of RR interval    

 2.  baseline oscillation

Now you can try another EKG to diagnose afib