Dysrhythmia Recognition

Dysrhythmia
Recognition
This pocket reference gives nurses quick and convenient
information about dysrhythmia recognition, including:

x≤ • Steps for ECG rhythm analysis

120 for common P dysrhythmias
÷=+
• Risk factors C
• Waveform 80characteristics of common dysrhythmias
• Images of various dysrhythmias
140 I O
Additional Resources: AACN Practice Alerts for
Dysrhythmia Monitoring in Adults and for ST-Segment
Monitoring at: http://www.accn.org and type in
search box: Dysrhythmia Monitoring or ST Segment
Monitoring. AACN’s eLearning course on ECG
Interpretation at: https://www.aacn.org/education/
online-courses
NOTE: This pocket card is for quick reference only. Please
review and follow your institutional policies and procedures
before clinical use.

To order more cards, call

1 (800) 899-AACN or visit www.aacn.org. Prod #400758
Copyright ©2019 American Association of Critical-Care Nurses REV 03/19
 Dysrhythmia Recognition
ECG Rhythm Analysis
Determine the atrial and  a. Is the P-P interval consistent?
ventricular regularity b. Is the R-R interval consistent?
Determine the atrial and  a. Are they the same?
ventricular rates b. Is the rate > 100 beats/min? (tachycardia)
c. Is the rate < 60 beats/min? (bradycardia)
Identify P waves a. Are P waves present? If not, what atrial activity is seen?
b. Do the P waves all look the same?
c. Is every P wave followed by a QRS complex?
Measure the P-R interval a. Is the P-R interval within normal limits (0.12-0.20 sec)?
b. Is the P-R interval the same for each ECG complex?
Identify the QRS complex a. Are QRS complexes present?
b. Do the QRS complexes all look the same?
c. Is there 1 and only 1 P wave before each QRS complex?
Measure the QRS interval a. Is the QRS interval within normal limits (0.04-0.10 sec)?
b. Is the QRS interval the same for every ECG complex?

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 Dysrhythmia Descriptions
Atrial Tachycardia
When it occurs episodically and/or suddenly, it is called paroxysmal atrial tachycardia (PAT)

Risk Factors:
• Most common dysrhythmia in childhood • Valvular heart disease
• Anxiety or fatigue • Sympathomimetic drugs
• Caffeine • Digoxin toxicity
• Tobacco • Cardiomyopathy
• Alcohol
Rate Characteristics: 
• Atrial: 3 or more consecutive ectopic • Ventricular: varies, depending on AV
atrial beats at 120-250 beats/min. Rarely conduction ratio
exceeds 250 beats/min
Rhythm: 
• Atrial: regular • P-R interval: consistent, but may be
• Ventricular: regular or irregular based on normal, short, or long, depending on
AV conduction ratio and type of atrial ectopic atrial site.
tachycardia • QRS interval: 0.04-0.10 sec; may be wide
• P waves: may be hidden in preceding if aberrant conduction is present
T wave, usually upright and preceding • P:QRS ratio: 1 P for every QRS complex,
each QRS unless conduction block occurs

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Atrial Flutter

Risk Factors:
• Ischemic heart disease • Alcoholism
• Hypoxia • Chronic lung disease
• Acute myocardial ischemia/infarction • Hypertension
• Digoxin toxicity • Diabetes
• Mitral or tricuspid valve disease • Cardiac surgery
• Thyrotoxicosis • Pulmonary embolism
• Heart failure
Rate Characteristics:
• Atrial: 250-350 beats/min • Ventricular: 60-175 beats/min
Rhythm: 
• Atrial: regular • P-R interval becomes F-R interval: may
• Ventricular: regular or irregular based on be consistent or may vary
degree of AV conduction • QRS interval: 0.04-0.10 sec; aberration
• P waves: not identifiable can occur
• Flutter waves (F waves): uniform • P:QRS ratio: varies depending on degree
(sawtooth or picket-fence appearance) of AV block

Atrial Fibrillation

Risk Factors:
• Athletic training • Thyroid disease
• Family history • Mitral or tricuspid valve disease
• Advanced age • Heart failure
• Sleep apnea • Pulmonary disease
• Ischemic heart disease • After cardiac surgery
• Hypertension • Atherosclerotic heart disease
• Hypoxia • Acute MI
• Cardiomyopathy • Congenital heart disease
• Digoxin toxicity • Nonprescription cold remedies
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Atrial Fibrillation (cont.)
Rate Characteristics: 
• Atrial: cannot be determined • Ventricular: depends on degree of
conduction at AV node; uncontrolled AF,
> 100 beats/min; controlled AF, 60-100
beats/min
Rhythm: 
• Atrial: wavy or coarse baseline • P-R interval: indiscernible
• Ventricular: irregular • QRS interval: 0.04-0.10 sec; aberration
• P waves: indiscernible can occur
• P:QRS ratio: unable to determine

Supraventricular Tachycardia
Defined as any rhythm with a rate faster than 100 that originates above the ventricles;
can include sinus tachycardia, atrial tachycardia, atrial flutter, and junctional tachycardia.
The term is also meant to describe a regular, narrow QRS tachycardia in which the exact
mechanism cannot be determined from the surface ECG.

Risk Factors:
• Same for atrial dysrhythmias and • AV nodal reentry tachycardia (AVNRT)
junctional dysrhythmias and circus movement tachycardia (CMT)
each can occur when an accessory
pathway is present.
Rate Characteristics: 
• Atrial: not always discernible; 140-250 • Ventricular: 140-250 beats/min
beats/min
Rhythm: 
• Atrial and ventricular: regular • QRS interval: 0.04-0.10 sec, unless
• P waves: may not be visible, may be aberrancy or bundle branch block
hidden in QRS complex or T wave • P:QRS ratio: 1 P for every QRS; may vary
• P-R interval: not measurable based on degree of AV block

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Junctional Rhythm

Risk Factors:
• Athletic training • Related to some medications, such as
• Rheumatic heart disease ß-blockers and calcium-channel blockers,
• After cardiac surgery and to digoxin toxicity
• Valvular disease • Acute MI, especially inferior wall
• SA node disease • Increased parasympathetic tone
• Hypoxia

Rate Characteristics: 
• Atrial: if P waves present, 40-60 beats/min • Ventricular: 40-60 beats/min
Rhythm: 
• Atrial and ventricular: regular • P-R interval: < 0.12 sec when inverted P
• P waves: inverted in leads II, III, and aVF; is before QRS
occurs before or after QRS or not visible • QRS interval: 0.04-0.10 sec
and hidden in QRS because conduction is • P:QRS ratio: 1 P for every QRS, if P wave
retrograde through the atria and normal is present
through the ventricles • NOTE: This rhythm occurs when normal
sinoatrial node rate slows or fails to
initiate beats

Accelerated Junctional Rhythm

Risk Factors:
• Increased automaticity of AV node • Isoproterenol infusion
• Digoxin toxicity • Athletic heart (benign finding)
• Acute myocardial ischemia/infarction • Cardiac surgery or procedures near AV node

Rate Characteristics:
• Atrial: if P waves present, 60-100 beats/min • Ventricular: 60-100 beats/min

Rhythm: same as Junctional Rhythm

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Junctional Tachycardia

Risk Factors:
• Myocardial ischemia • More common in children
• After cardiac surgery

Rate Characteristics:
• Atrial: if P waves present, > 100 beats/min • Ventricular: > 100 beats/min

Rhythm: same as Junctional Rhythm

1st Degree AV Block

Risk Factors:
• Coronary artery disease • Electrolyte imbalances
• Rheumatic heart disease • Intrinsic AV node disease
• Medications (eg, digoxin, ß-blockers, • Myocarditis
calcium-channel blockers, • Acute MI, especially inferior MI
antidysrhythmics, magnesium) • Athletic training

Rate Characteristics: usually 60-100 beats/min, if underlying rhythm is sinus

Rhythm: 
• Atrial and ventricular: regular • QRS interval: 0.04-0.10 sec, unless
• P waves: consistent bundle branch block
• P-R interval: prolonged > 0.20 sec and • P:QRS ratio: 1 P wave for every QRS
constant. Conduction is delayed through
the AV node.

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 Dysrhythmia Descriptions (cont.)
2nd Degree AV Block (Type I)

Risk Factors:
• Increased parasympathetic tone • Inflammatory diseases: endocarditis,
• Coronary heart disease myocarditis, rheumatic fever, Lyme disease
• Medications (eg, digoxin, ß-blockers, • Amyloidosis, hemochromatosis, and
calcium-channel blockers, sarcoidosis
antidysrhythmics) • Cardiac tumors, malignant lymphomas,
• Acute anterior or inferior MI and multiple myeloma
• Aortic and mitral valve disease and • Electrolyte disturbances: hyperkalemia,
valve surgery hypermagnesemia
• Atrial septal defects and corrective • Thyroid and adrenal gland dysfunction
congenital heart surgery • Rheumatoid arthritis and other collagen
vascular diseases

Rate Characteristics: usually 60-100 beats/min, if underlying rhythm is sinus

Rhythm: 
• Atrial: regular • P:QRS ratio: more P waves than QRS
• Ventricular: irregular complexes
• P waves: normal • NOTE: Type I is characterized by a
• P-R interval: progressively increases; the progressive prolongation of the
P-R interval preceding the pause is P-R interval. Ultimately, the atrial impulse
longer than the one following the pause. is blocked, a QRS complex is not
generated, and there is no ventricular
• QRS interval: normal unless bundle
contraction. Appears as a P wave without
branch block
a QRS, then the cycle repeats itself.

2nd Degree AV Block (Type II)

Risk Factors: same as Type I
Rate Characteristics: can occur at any rate; atrial rate > ventricular rate. If many beats are
blocked, rate will be slow

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2nd Degree AV Block (Type II) (cont.)
Rhythm:
• Atrial: regular • P:QRS ratio: more P waves than QRS;
• Ventricular: may be regular or irregular conduction ratios vary from 2:1 to only
based on the frequency of the block occasional blocked beats
• P waves: normal • NOTE: Type II is characterized by an
• P-R interval: constant before each unexpected nonconducted atrial impulse
conducted ventricular beat and has a higher incidence of
progression to complete AV block.
• QRS interval: usually wide (> 0.10 sec) if
the block is at the bundle of His or lower

3rd Degree AV Block (Complete heart block)

Risk Factors:
• Extensive conduction system disease • Inflammatory diseases: endocarditis,
• Coronary heart disease myocarditis, rheumatic fever,
• Acute myocardial ischemia/infarction Lyme disease
• Progressive familial cardiac conduction • Amyloidosis, hemochromatosis, and
defect sarcoidosis
• Cardiac surgery • Cardiac tumors, malignant lymphomas,
and multiple myeloma
• Congenital heart disorders
• Neuromuscular disease
• Medications (eg, digoxin, ß-blockers,
calcium-channel blockers, antidysrhythmics) • Toxins
Rate Characteristics: 
• Atrial: usually 60-100 beats/min • Ventricular: 20-60 beats/min
Rhythm:
• Atrial: regular; no relationship to • QRS interval: narrow if ventricles are
ventricular rhythm controlled by a junctional pacemaker;
• Ventricular: regular; no relationship to wide if ventricles are controlled by a
atrial rhythm ventricular pacemaker
• P waves: normal • P:QRS ratio: more P waves than QRS
• P-R interval: varies, no relationship to the complexes
QRS complexes • NOTE: The hallmark of 3rd degree AV
block is that there is no relationship
between the P waves and QRS complexes.
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Ventricular Tachycardia

Risk Factors:
• Ischemic heart disease • Electrolyte imbalances
• Acute myocardial ischemia/infarction • Illicit drugs
• Cardiomyopathy • Sarcoidosis, amyloidosis, systemic lupus
• Valvular heart disease erythematosus, hemochromatosis, and
• R-on-T phenomenon rheumatoid arthritis
• Proarrhythmic effects of many • Arrhythmogenic right ventricular
medications, especially dysplasia
sympathomimetics • Cardiac tumors
• Congenital heart disorders • Cardiac surgery
• Inherited conduction disorders • Heart failure

Rate Characteristics: ventricular > 100 beats/min and usually not > 220 beats/min
Rhythm:
• Atrial: not discernable • QRS interval: wide (> 0.10 sec), bizarre
• Ventricular: monomorphic (QRS appearance
complexes have the same shape) is • P:QRS ratio: not discernable
usually regular; polymorphic (QRS • ST/T wave: has polarity that is opposite
complexes vary randomly in shape) can to the QRS complex
be irregular. • NOTE: A group of 3 or more PVCs in a
• P waves: usually absent; if present, P row at a rate ≥ 100 beats/min constitutes
waves are not associated with QRS and ventricular tachycardia.
may be buried in the QRS
• P-R interval: not measurable

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Idioventricular Rhythm

Risk Factors:
• Acute myocardial ischemia/infarction • Digoxin toxicity
• Postresuscitation rhythm • Metabolic imbalances

Rate Characteristics: ventricular 20-40 beats/min

Rhythm:
• Atrial: difficult to discern or absent • QRS interval: > 0.10 sec, often notched,
• Ventricular: usually regular bizarre appearance
• P waves: no P waves associated with • P:QRS ratio: absent or variable if seen
QRS complexes, or they are absent • ST/T wave: opposite direction of QRS
• P-R interval: not measurable complexes
• NOTE: Do not treat with antidysrhythmics.

Accelerated Idioventricular Rhythm

Risk Factors:
• Related to enhanced automaticity of the • Reperfusion of damaged myocardium
ventricular tissue and slowing of the SA node after thrombolysis
• Acute myocardial ischemia/infarction • Dilated cardiomyopathy
• Digoxin toxicity • Myocarditis

Rate Characteristics: ventricular 40-100 beats/min

Rhythm: same as Idioventricular Rhythm

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Ventricular Fibrillation

Risk Factors:
• Previous episode of ventricular fibrillation • Electrolyte imbalances
• Cardiomyopathy • Electrical shock
• Congenital heart defect • Hypothermia
• Acute MI • Proarrythmic effects of antidysrhythmic
• Untreated ventricular tachycardia and other medications
• R-on-T premature ventricular contractions
Rate Characteristics: indeterminate
Rhythm: completely erratic and irregular
• P waves: absent • P:QRS ratio: none
• P-R interval: absent • NOTE: There is no pulse with this rhythm,
• QRS interval: no formed QRS complexes because the ventricles are not contracting.
seen; rapid irregular undulations without
any specific pattern

Asystole

Risk Factors:
• Extensive myocardial damage • Ventricular aneurysm
• Ischemia/infarction • Countershock
• Traumatic cardiac arrest • Hypoxia
• Acute respiratory failure • Electrolyte imbalances
Rate Characteristics: none
Rhythm:
• Atrial: if P waves are present, may be • P-R interval, QRS interval, and P:QRS 
regular or irregular ratio: none
• Ventricular: none • NOTE: Must verify the rhythm in
• P waves: may be present if the sinus 2 or more leads.
node is functioning
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Premature Ventricular Contraction (PVC) 

Risk Factors:
• Can be a normal occurrence • Electrolyte imbalance, most often
• Stress or exercise hypokalemia and/or hypomagnesemia
• Acute coronary syndromes • Acid-base imbalance
• Heart failure • Stimulants such as caffeine or tobacco
• Hypoxia

Rate Characteristics: Rate will depend on underlying supraventricular rhythm

Rhythm:
• Atrial and ventricular: will be irregular due to one or more early QRS-T
• P waves: usually no P associated with PVC, although it is possible for impulse to trigger
retrograde atrial depolarization
• P-R interval: none; P wave either is absent or after PVC
• QRS interval > 0.10 sec, often notched, bizarre appearance. PVCs may be uniform in
appearance if they arise from a single ventricular site (unifocal) or may have 2 or more
shapes if from multiple sites (multifocal)
• P:QRS ratio: more QRSs than Ps
• ST/T wave: opposite direction of PVC complex
• NOTE: May occur in pairs (couplet), in patterns of every other beat (bigeminy), every
third beat (trigeminy), or every 4th beat (quadrigeminy)

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 Bundle Branch Block (BBB) 

Risk Factors:
• Underlying heart disease such • Degenerative changes in the conduction
as myocarditis, myocardial system
ischemia/infarction • Trauma to a bundle branch such as
• Ventricular structural changes with cardiac surgery or placement of an
cardiomyopathies intracardiac device

Rate Characteristics: Rate will depend on underlying supraventricular rhythm

Rhythm:
• Rhythm, P waves, P-R interval and P:QRS  • NOTE: A right BBB will have a triphasic
ratio all depend on the underlying rhythm (rsR’) configuration in V1, as seen in the
• QRS interval > 0.10 sec. example; a left BBB will have a uniphasic
• ST/T wave: opposite direction of last (QS) or biphasic (rS) configuration in V1
portion of QRS complex

Legend: AF, atrial fibrillation; AV, atrioventricular; AVNRT, atrioventricular nodal reentry
tachycardia; BBB, bundle branch block; CMT, circus movement tachycardia; ECG,
electrocardiogram; F wave, flutter wave; MI, myocardial infarction; PAT, paroxysmal atrial
tachycardia; PSVT, paroxysmal supraventricular tachycardia; PVC, premature ventricular
contraction; SA, sinoatrial

REFERENCES
Aehlert B. ECGs Made Easy. 6th ed. St Louis, MO: Elsevier; 2018.
American Association of Critical-Care Nurses. eLearning course on ECG Interpretation.
https://www.aacn.org/education/online-courses. Accessed February 1, 2019.
Atwood S, Stanton C, Storey-Davenport J. Introduction to Basic Cardiac Dysrhythmias. 5th ed.
Burlington, MA: Jones and Barlett Learning; 2019.
Burns SM, Delgado SA, eds. Essentials of Progressive Care Nursing. 4th ed. New York, NY:
McGraw-Hill Education; 2019.
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