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ECG: Atrial Rhythm
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  • 1. ECG of the week
    Prof. P. Vijayaraghavan Unit
    A.KarthickRamalingam
    FIRST YEAR PGM 5
  • 2. Background
    60 year old Mrs. Ponnamma, known hypertensive presented with history suggestive of anginal type of chest pain, ECG was taken.
  • 3. ECG-1
  • 4. Findings
    Rate 88/min
    NSR
    P wave axis 60
    QRS axis Normal
    ST straightening LII ,LIII, aVF
    T inversion L III
  • 5. ECG-2
  • 6. Findings
    Rate: 84/min
    Atrial rhythm
    P wave axis - 90
    P ‘ – L II , L III,
    aVF ,V2 to V6
    P --L I, aVR , a VL, V1
    QRS axis normal
    T inversion L II , L III, aVF
    ST depression L III, aVF
    Findings of ectopic atrial rhythm
  • 7. Repeat ECG taken for the patient reverted back to sinus rhythm and was similar to ECG 1
  • 8.
    • To differentiate rightatrial from left atrial rhythm
    • 9. P wave morphology is useful in differentiating left from right atrial foci.
    • 10. This is a function of the anatomical relationship of the atria, with the left atrium being a more posterior and leftward structure than the right atrium.
    • 11. As such, leads V1 and aVL are useful discriminators.
  • Left atrial
    Right atrial
    • A positive or biphasic P wave in aVL has a positive predictive accuracy of 83% and negative predictive value of 85% for a right atrial focus.
    • 12. In contrast, a positive P wave in V1 is a feature of left atrial foci. It has a sensitivity and specificity of 93% and 88% respectively.
  • Right Atrial Rhythm
    In right atrial rhythm the depolarization begins in the right atrium and spreads posteriorly and superiorly towards the left atrium (towards aVL). This inscribes a positive deflection (p wave) in aVL.
  • 13.
    • LEFT ATRIAL RHYTHM
    • 14. In left atrial rhythm the depolarization of atria begins in the left atria and spreads anteriorly towards right atrium(in the direction of V1). This inscribes a positive deflection (p wave) in lead V1.
  • The exceptions to the above criteria are ectopic foci with origin at the high crista terminalis (right atrial - near SA node) and impulse originating near the atrial septum.
  • 15. In our patient a positive p wave in V1 with a negative p in V6 is suggestive of a left atrial rhythm.
  • 16. THANKYOU

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