Cardiac Rhythm Analysis

Let’s Get Started…

Mohd Hosni Abdullah, ETD QEH
 Cardiac Rhythms - Overview
Objectives

At the conclusion of this training module the participants will be able to recall the following:
• Time is represented horizontally • Recognize the difference between regular
and irregular rhythms
• Voltage/amplitude is represented
vertically on the graph paper • Utilize proper method for determining
heart rate
• Each small box has a time value of 0.04
second • Properly describe P wave and recall the
origin of the electrical activity
• Each large box has a time value of 0.20
second • Accurately measure the PR interval and
recall the normal range
• Standard paper speed is 25mm/sec and
can be adjusted • Properly describe the QRS complex and
recall what this electrical event represents
• Standard calibration is 10mm/mV and can
be adjusted • Accurately measure QRS complex and
recall the normal range
 Cardiac Rhythms - Introduction
Part 1
• Basic principles of rhythm analysis
require an understanding of speed and
voltage (amplitude).
• Standard recording speed is 25
mm/sec.
• It is important to remember this unit
of measure because it lends
consistency to measurement when
analyzing interval, complex and
segment durations.
 Cardiac Rhythms - Introduction
Part 2

• If the print speed is increased or decreased, it will not only affect the distance of
one cardiac complex to the next, it will affect the measurement duration of critical
aspects of the cardiac complex.
• Paper speed is often marked on the tracing. It is important to check this setting
prior to printing and analyzing any tracing.
 Cardiac Rhythms - Introduction
Part 3
• Voltage is represented vertically in the
cardiac tracing.
• Standard calibration or gain is set at
10 mm/mV.
• If the gain is increased (20 mm/mV) or
decreased (5 mm/mV), it will affect
the size of the waves in a cardiac
complex.
 Cardiac Rhythms
• Rhythms are often named according
to the source of the electrical activity
in the heart or the structure where the
problem is occurring.
• Pacemaker Rhythms are aptly named
due to the focus of stimulation coming
from an artificial impulse generator
called a pacemaker.
• The fastest electricity in the heart
(regardless of location or source) will
dictate the heart rate.
 Cardiac Rhythms - Graph Paper
Time 1

• The grid is broken down in small boxes (1 X 1 millimeter) and heavier darkened
lined boxes.
• There are five small boxes going from left to right and bottom to top of each large
box (5 X 5 mm).
 Cardiac Rhythms - Graph Paper
Time 2
• Each small box has a time value of 0.04 second.
• If there are five small boxes going across each large box, then the value of time for
each large box equals 0.20 second
• (5 small boxes X 0.04 second = 0.20 second)
• (5 LARGE BOXES X 0.20 SECOND = 1 SECOND)
 Cardiac Rhythms - Graph Paper
Voltage 1

• Voltage is important when measuring the height or depth of a waveform.

• The height or depth provides an indication of the amount of electrical activity
occurring within the heart.
• Voltage can be affected by a number of different factors to include the amount of
viable muscle mass in the heart.
• When analyzing cardiac tracings, the question always comes up “where do I
measure from”?
 Cardiac Rhythms - Graph Paper
Voltage 2
• It is important to establish the isoelectric line or baseline.
• Sometimes, this can prove to be impossible, but in most cases if you can see the PR
segment, ST segment and TP segment, you should have a strong sense that this is
where the isoelectric line is located.
• However, all three segments are not always on the isoelectric line
• Where two out of the three of them are located when analyzing horizontally, this is
typically where the isoelectric line is located.
 Cardiac
Rhythms - Step
1 - Rhythm
Analysis
Introduction

• When analyzing cardiac

rhythm strips it is
important to recognize
what the cardiac complex
represents and what is
considered normal versus
abnormal.
 Cardiac Rhythms - Step 1 - Rhythm Analysis

Description
• First check R wave to R wave across the strip. If the intervals vary by
1 ½ small boxes or less the rhythm is considered regular.
• R wave to R wave analysis refers to the rhythmicity of the ventricles.
• Now measure the P wave to P wave intervals. This refers to the
rhythmicity of the atria. Normal Cardiac Cycle
 Cardiac Rhythms - Step 1 - Rhythm Analysis
Practice 1

Analyze this tracing. Its is regular or irregular?

Regular
Irregular
 Cardiac Rhythms - Step 1 - Rhythm Analysis

Practice 2

Analyze this tracing. Its is regular or irregular?

Regular
Irregular
 Cardiac Rhythms - Step 2 - Heart Rate Regular
Regular Rhythms

• If the rhythm varies by less than two small boxes, then the rhythm is considered regular.
• The heart rate determination technique used will be the 1500 technique.
• Starting at the beginning of the tracing through the end, measure from one R wave to
the next R wave (ventricular assessment), then P wave to P wave (atrial assessment),
then count the number of small boxes between each and divide that number into 1500.
• You may include ½ of a small box i.e. 37.5/1500 = 40 bpm (don’t forget to round up or
down if a portion of a beat is included in the answer).

21/1500 = 71/min
Cardiac Rhythms - Step 2 - Heart Rate Irregular
Irregular Rhythms

• If the rhythm varies by two small boxes or more, the rhythm is considered
“irregular”.
• The heart rate determination technique used for irregular rhythms will be the “six-
second technique”.
• Simply count the number of complete cardiac complexes in six seconds and
multiply by ten.

HR = No of RR x 10 ( 9 x 10 = 90/min )
 Cardiac Rhythms - Step 2
Practice 1

Analyze this tracing. What is the heart rate?

Answer
Regular Rhythm – 1500 technique – 22 small boxes divided into 1500 = 68.18. Rate: 68 bpm
 Cardiac Rhythms - Step 2
Practice 2

Analyze this tracing. What is the heart rate?

Answer
Irregular Rhythm – Six-second technique – 5 complete complexes. Rate: 50 bpm.
Cardiac Rhythms - Step 3 - P wave Morphology
(Shape)
Description

• The lead most commonly referenced in cardiac monitoring is lead II.

• The P wave in lead II in a normal heart is typically rounded and upright in
appearance.
• P waves may come in a variety of morphologies i.e. rounded and upright, peaked,
flattened, notched, biphasic (second complex, pictured), inverted and even buried
or absent!
Cardiac Rhythms - Step 3 - P wave Morphology
(Shape)
P Wave Practice 1

Analyze this tracing. Describe the P waves.

Answer
Upright and uniform
Cardiac Rhythms - Step 3 - P wave Morphology
(Shape)
P Wave Practice 2

Analyze this tracing. Describe the P waves.

Answer
Variable, upright, inverted and absent
 Cardiac Rhythms - Step 4 – PR interval
(PRi)
Description

• PR interval reflects the time from the beginning of atrial depolarization to the
beginning of ventricular depolarization.
• From the beginning of the P wave to the beginning of the QRS complex.
• The normal range for PR interval is: 0.12 – 0.20 seconds (3 to 5 small boxes)
• Some tracings do not have the same PRi measurement from one cardiac complex to the
next. Sometimes there is a prolonging pattern, sometimes not.
• If the PR intervals are variable, report them as variable, but note if a pattern is present
or not.
 Cardiac Rhythms - Step 4 – PR interval
(PRi)
PR Interval Practice 1

Analyze this tracing. What is the PR interval Measurement?

Answer
4 small boxes (4 X 0.04 second) = 0.16 second
 Cardiac Rhythms - Step 4 – PR interval
(PRi)
PR Interval Practice 2

Analyze this tracing. What is the PR interval Measurement?

Answer
Variable – inverted P wave has shorter PR, plus one complex has no P wave
 Cardiac Rhythms - Step 5 – QRS Complex
Description

• The QRS represents ventricular depolarization.

• It is very important to analyze each QRS complex on the
tracing and report the duration measurement and
describe the shape (including any changes in shape).
• As discussed earlier in step 3, when referring to P waves,
remember changes in the shape of the waveform can
indicate the focus of stimulation has changed or a
different conduction pathway was followed. It is no
different when analyzing the QRS complex.
• The difference is that in step 3, we were looking at atrial
activity. Now we are looking at ventricular activity.
• Measure from the beginning to the end of ventricular
depolarization.
 Cardiac Rhythms - Step 5 – QRS Complex
Description 2

• The normal duration of the QRS complex

measures from: 0.06 – 0.12 second
• When the QRS measurement is 0.12 seconds or
greater it indicates a delay in the electrical
impulse as it is passing through the ventricular
conduction system

• Abnormal duration QRS

 Cardiac Rhythms - Step 5 – QRS Complex
QRS Practice 1

Analyze this tracing. What is the QRS duration?

Answer
2 small boxes (2 X 0.04 second) = 0.08 second
 Cardiac Rhythms - Step 5 – QRS Complex
QRS Practice 2

Analyze this tracing. What is the QRS duration?

Answer
4 1/2 small boxes (1/2 X 0.04 second) = 0.18 second
 Cardiac Rhythms - Closing
Interpretation

• The previous slides presented the five-steps of rhythm analysis. These

five steps must be followed regardless of how simple of complex the
tracing is you are reviewing.
• The information gathered in these steps are telling a story.
• The title of that story is the interpretation.
 Question
Other method of Heart Rate Calculation