Chapter 6

ATRIAL DYSRHYTHMIAS

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 Learning Outcomes
6.1 Summarize the similarities and differences between atrial
dysrhythmias.
6.2 Analyze premature atrial complexes and their effect on the
patient, including basic patient care and treatment.
6.3 Analyze wandering atrial pacemaker and its effect on the
patient, including basic patient care and treatment.
6.4 Analyze multifocal atrial tachycardia and its effect on the
patient, including basic patient care and treatment.
6.5 Analyze atrial flutter and its effect on the patient, including
basic patient care and treatment.
6.6 Analyze atrial fibrillation and its effect on the patient,
including basic patient care and treatment.
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 Learning Outcome 6.1
Introduction to Atrial Dysrhythmias
Key Terms
Ectopic impulse

Neurological

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 Introduction to Atrial Dysrhythmias
Atrial dysrhythmias
• Caused by ectopic impulse in right or left atrium
• Occur from conditions that cause pressure on the atria

Fastest impulse controls the heart rate

• Ectopic impulses firing faster than the SA node override the
SA node impulses

Conditions that may cause atrial dysrhythmias

• Myocardial infarction that damages the atria
• Valvular problems
• Neurological influences
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 Learning Outcome 6.1
Apply Your Knowledge

What conditions cause pressure on the atria resulting in atrial

dysrhythmias?

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 Learning Outcome 6.1
Apply Your Knowledge
Answer
What conditions cause pressure on the atria resulting in atrial
dysrhythmias?

Myocardial infarction that causes atrial damage, valvular

problems, and/or neurological influences

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 Learning Outcome 6.2
Premature Atrial Complexes
Key Terms
Biphasic

Focus (plural: foci)

Trigeminy

Underlying rhythm

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 Premature Atrial Complexes (PACs)
• Electrical impulses that originate in the atria and initiate an
early impulse, disrupting the regular rhythm
• Often called PACs

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 Premature Atrial Complexes: Criteria 1
Rhythm: P-P and R-R intervals are constant except for early
complexes.
• Determine underlying rhythm

Rate:
• Atrial and ventricular rates usually within 60‒100 bpm
• May be faster, depending on PAC frequency

P wave morphology:
• In normal complexes: Uniform shape
• In PACs: May be flattened, notched, biphasic, or otherwise
unusual
• Early P wave may be hidden within T wave

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 Premature Atrial Complexes: Criteria 2

PR interval
• Between 0.12 and 0.20 second
• Early beat may have different PR measurement, but within
normal limit

QRS duration and morphology

• Between 0.06 and 0.10 second
• Within normal limits

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 Identifying Premature Atrial Complexes
Determine the underlying sinus rhythm.
Label tracing with:
• Underlying rhythm
• Type of PAC

Examples:
• Sinus bradycardia with trigeminal PACs
• Sinus rhythm with occasional PACs

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 Premature Atrial Complexes:
What You Should Know
• Patient may experience the symptoms of low cardiac output.
• Severity of patient’s complaint is related to the frequency of
PACs.
• Frequent PACs may indicate a more serious atrial
dysrhythmia.

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 Learning Outcome 6.2
Apply Your Knowledge

What is the PAC pattern in which every third complex is a

premature beat?

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 Learning Outcome 6.2
Apply Your Knowledge
Answer
What is the PAC pattern in which every third complex is a
premature beat?

Trigeminy

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 Learning Outcome 6.3
Wandering Atrial Pacemaker (WAP)
• Pacemaker site shifts between the SA node, other sites in the
atria, and/or the AV junction.
• P wave morphology is different for each pacemaker site.

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 Wandering Atrial Pacemaker: Criteria
• Rhythm: Slightly irregular
• Rate: 60-100 beats per minute
• P wave morphology: Continuous change
• PR interval: Varies
• QRS duration and morphology: Usually within normal limits

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 Wandering Atrial Pacemaker:
What You Should Know
Wandering atrial pacemaker is normal in children, older adults,
and well-conditioned athletes.
• No signs or symptoms

May be related to:

• Organic heart disease
• Drug toxicity

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 Learning Outcome 6.3
Apply Your Knowledge

What characteristics differentiate wandering atrial pacemaker

from other atrial dysrhythmias?

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 Learning Outcome 6.3
Apply Your Knowledge
Answer
What characteristics differentiate wandering atrial pacemaker
from other atrial dysrhythmias?

Wandering atrial pacemaker has changing P wave

configurations with at least three variations in one lead.

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 Learning Outcome 6.4
Multifocal Atrial Tachycardia (MAT)
A tachycardic version of WAP, with a rate of 100 to 130 beats per
minute.

Frequently mistaken for atrial fibrillation.

• Distinguishing feature: Visibly changing P waves

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 Multifocal Atrial Tachycardia:
What You Should Know
Usually triggered by another health condition
• Acute emphysema
• Congestive heart failure
• Acute mitral valve regurgitation

Report to licensed practitioner

Monitor patient’s vital signs and condition

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 Learning Outcome 6.4
Apply Your Knowledge #1

What is the distinguishing characteristic of multifocal atrial

tachycardia?

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 Learning Outcome 6.4
Apply Your Knowledge #1
Answer
What is the distinguishing characteristic of multifocal atrial
tachycardia?

Multifocal atrial tachycardia has a clearly changing P wave

and a heart rate of 101 to 150 bpm.

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 Learning Outcome 6.4
Apply Your Knowledge #2

Which of the atrial dysrhythmias can be mistaken for atrial

fibrillation?

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 Learning Outcome 6.4
Apply Your Knowledge #2
Answer
Which of the atrial dysrhythmias can be mistaken for atrial
fibrillation?

Multifocal atrial tachycardia

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 Learning Outcome 6.5
Atrial Flutter
Key Terms
Atrial kick

Automaticity

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 Atrial Flutter 1
Occurs when rapid impulse originates in atrial tissue.

Origin of ectopic focus

• Ischemic areas with enhanced automaticity
• Reentry pathway

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 Atrial Flutter 2

Characteristic sawtooth pattern (F waves)

Ratio of F waves to QRS complexes included in interpretation

Atrial flutter 3:1

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 Atrial Flutter: Criteria 1
Rhythm
• P-P interval or flutter-to-flutter wave interval is constant
• R-R interval is usually regular, but may be irregular

Rate: Atrial rate is 250 to 350 beats per minute

P wave morphology
• P wave not seen
• Flutter (F) waves resemble saw-tooth or picket fence and are
seen in leads II, III, and aVF.

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 Atrial Flutter: Criteria 2
• PR interval: not identifiable
• QRS duration and morphology: 0.06‒0.10 second; within
normal limits

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 Atrial Flutter:
What You Should Know
Loss of atrial kick reduces cardiac output by 10% to 30%.

Patients with increased heart rate demonstrate signs of low

cardiac output.

Notify licensed practitioner.

• Patient monitored continuously.
• Treatment plan may include oxygen.

Indicate treatment or intervention on tracing.

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 Learning Outcome 6.5
Apply Your Knowledge

What term is used to describe the sawtooth-shaped waves

present in atrial flutter?

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 Learning Outcome 6.5
Apply Your Knowledge
Answer
What term is used to describe the sawtooth-shaped waves
present in atrial flutter?

Flutter (F) waves

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 Learning Outcome 6.6
Atrial Fibrillation
Key Terms
Cerebrovascular accident (CVA)

Myocardial infarction (MI; heart attack)

Pulmonary embolism

Renal infarction

Thrombus

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 Atrial Fibrillation
Irregular QRS complex with a rate of 100 to 175 beats per
minute.

• Distinguishing feature: unrecognizable P waves

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 Atrial Fibrillation: Criteria 1
Rhythm
• P-P interval cannot be determined.
• R-R interval is irregular.

Rate
• Atrial rate cannot be determined.
• Electrical impulse activity rate is 375‒700.

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 Atrial Fibrillation: Criteria 2
P wave morphology
• P waves cannot be identified.
• Fibrillatory (f) waves may be identified.

PR interval: Cannot be identified

QRS duration and morphology: 0.06‒0.10 second and irregular

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 Atrial Fibrillation:
What You Should Know
Patient exhibits signs of decreased cardiac output.
When heart rate is controlled, patient may be able to tolerate
loss of atrial kick.
Blood collecting in atria can clot or form thrombi, which
increases risk of embolism.
• Cerebrovascular accident
• Myocardial infarction
• Pulmonary embolism
• Renal infarction

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 Learning Outcome 6.6
Apply Your Knowledge

What is the major health risk for patients with atrial fibrillation?

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 Learning Outcome 6.6
Apply Your Knowledge
Answer
What is the major health risk for patients with atrial fibrillation?

Thrombus formation and embolism due to blood collecting

in the atria; embolism may cause serious effects such as
MI, CVA, renal infarction, or pulmonary embolism.

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 Chapter Summary 1
• Atrial dysrhythmias are caused by an ectopic impulse in either
the right or the left atrium.
• Premature atrial complexes (PACs) originate in the atria and
initiate an early impulse that interrupts the inherent regular
rhythm.
• In wandering atrial pacemaker (WAP), the pacemaker site
shifts between the SA node, other sites in the atria, or the AV
junction; the P wave configuration changes in appearance
during the pacemaker shift.
• Multifocal atrial tachycardia (MAT) has a P wave that changes
from beat to beat and a heart rate of 101 to 150 beats per
minute.

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 Chapter Summary 22
• Atrial flutter (A flutter) occurs when a rapid ectopic impulse
originates in the atrial tissue and presents with a classic
sawtooth appearance known as flutter or F waves.
• Atrial fibrillation (A-fib) occurs when electrical impulses come
from areas of reentry pathways or multiple ectopic foci and
presents with classic chaotic fibrillatory or
f waves.

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