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In humans, for an ECG to be described as showing a sinus rhythm, the shape of the P wave in each of the 12 standard ECG leads should be consistent with a "typical P vector" of +50° to +80°. [2] This means that the P wave should be: always positive in lead I, lead II, and aVF; always negative in lead aVR
Absent P waves with "irregularly irregular" QRS complexes are the hallmark of atrial fibrillation. A "saw tooth" pattern with QRS complexes is the hallmark of atrial flutter. A sine wave pattern is the hallmark of ventricular flutter. Absent P waves with wide QRS complexes and a fast heart rate are ventricular tachycardia.
A sine wave, sinusoidal wave, or sinusoid (symbol: ∿) is a periodic wave whose waveform (shape) is the trigonometric sine function. In mechanics , as a linear motion over time, this is simple harmonic motion ; as rotation , it corresponds to uniform circular motion .
A P wave with increased amplitude can indicate hypokalemia. [3] It can also indicate right atrial enlargement. [4] A P wave with decreased amplitude can indicate hyperkalemia. [5] P-wave changes in left and right atrial hypertrophy. Bifid P waves (known as P mitrale) indicate left-atrial abnormality - e.g. dilatation [6] or hypertrophy. [1]
P waves: Upright, consistent, and normal in morphology and duration. PR interval: Between 0.12 and 0.20 seconds in duration. QRS complex: Less than 0.12 seconds in width, and consistent in morphology. [7] Taking a thorough medical history and physical exam by healthcare providers can also help with narrowing differential diagnosis.
An R wave follows as an upward deflection, and the S wave is any downward deflection after the R wave. The T wave follows the S wave, and in some cases, an additional U wave follows the T wave. To measure the QRS interval start at the end of the PR interval (or beginning of the Q wave) to the end of the S wave.
To summarize, classic ECG changes associated with hyperkalemia are seen in the following progression: peaked T wave, shortened QT interval, lengthened PR interval, increased QRS duration, and eventually absence of the P wave with the QRS complex becoming a sine wave.
Other common changes that are seen on ECG with wandering atrial pacemaker include differing PR intervals and PP intervals. Another heart rhythm similar to wandering atrial pacemaker is multifocal atrial tachycardia. Both arrhythmias have at least 3 different P-wave morphologies in a single ECG lead, but the heart rate is different.