Jon W. Atkinson, B.S., RPSGT
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1 Jon W. Atkinson, B.S., RPSGT
2 State the AASM technical considerations and reporting guidelines Describe normal ECG parameters Understand systematic arrhythmia analysis steps Explain the rule of differing morphology Understand polysomnographic monitoring and recording techniques
3 Modified lead II is recommended Additional leads may be placed if clinically indicated at the discretion of the practitioner Filters: HFF 70 Hz, LFF 0.3 Hz Digital Resolution, 12 bits Sampling rate, desirable 500 Hz, minimal 200 Hz Standard ECG electrodes are suggested rather than gold cups
4 A different lead derivation should be employed if the P wave is not clearly defined or the QRS complex is not of sufficient amplitude If muscle artifact is present, it is appropriate to lower the high frequency filter to 35 or even 15 Hz If slow wave artifact is present (respiratory or sweat), it is appropriate to raise the low frequency filter to as low as 1 Hz Document and changes to derivation or filters
5 Score SINUS TACHYCARDIA during sleep for sustained HR > 90 BPM for adults Score BRADYCARDIA during sleep for sustained HR < 40 BPM, ages 6-adult Score ASYSTOLE for cardiac pauses > 3 seconds duration, ages 6-adult Score WIDE COMPLEX TACHYCARDIA for a rhythm lasting a minimum of 3 consecutive beats at a rate > 100 BPM with a QRS duration > 0.12 seconds
6 Score NARROW COMPLEX TACHYCARDIA for a rhythm lasting a minimum of 3 consecutive beats at a rate > 100 BPM with a QRS duration < 0.12 seconds Score ATRIAL FIBRILLATION if there is an irregularly irregular ventricular rhythm associated with the replacement of consistent P waves by rapid oscillations that vary in size, shape and timing
7 OTHER ARRHYTHMIAS Significant arrhythmias such as BLOCKS should be reported if the quality of the single ECG lead is sufficient for accurate scoring ECTOPIC BEATS should be reported if clinically significant
8 A basic understanding of the normal conduction pathway of the heart and the interrelation of the events in the cardiac cycle is essential prior to discussion of abnormal heart rhythms
9 SA node AV Node Bundle of His Left and Right Bundle Branches Purkinje System
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12 Relationship between anatomy and cardiac cycle events P wave = atrial depolarization QRS complex = ventricular depolarization T wave = ventricular repolarization PR interval (last portion from the end of the P wave) = the pause between atrial and ventricular depolarization
13 Atrial depolarization Ventricular repolarization PR interval QRS interval Ventricular depolarization and Atrial repolarization
14 HR = bpm PR interval = sec QRS interval < 0.12 sec SA node discharge = /min AV node discharge = 40-60/min Ventricular tissue discharge = 20-40/min Rhythm = regular
15 Parameter/waveform Value/characteristic P wave Present, each appears the same QRS complex Present, each appears the same PR interval seconds QRS interval seconds P:QRS ratio 1:1 Rate bpm Rhythm Regular Normal sinus rhythm, 30 second display Normal sinus rhythm, 10 second display
16 An arrhythmia is present if there is: Disturbance of impulse formation Disturbance of impulse conduction Both of the above occur The rate is too fast or too slow
17 Tools for the systematic analysis of cardiac arrhythmias Rule of identical morphology: If the wave form looks the same, it has started from the same location and taken the same pathway Rule of differing morphology: If the wave form looks different, it has started from a different location, taken a different pathway, or both
18 P Wave Absent or present? Morphology the same? QRS Complex Absent or present? Morphology the same?
19 P for every QRS QRS for every P 1:1 relationship Measure the PR interval Normal, too short, too long? Measure the QRS interval Normal or too long?
20 Rhythm Is R-R interval constant? Is P-P interval constant? How to calculate rate Times 2 method - count the number of beats in a 30 sec screen and multiply by 2 Times 4 method - count the number of beats in 15 seconds and multiply by 4 Times 6 method - count the number of beats in 10 seconds and multiply by 6 Don t rely on the cardiotachometer on the study This rate is usually derived from the pulse oximeter and can be inaccurate
21 PAC s Sinus bradycardia Atrial tachycardias Sinus arrhythmia Sinus pauses Paroxysmal tachycardias Atrial fibrillation Atrial flutter Except for atrial fibrillation where the P waves have been replaced by waves of variable size, shape and duration, and atrial flutter where the P waves are replaced by saw-tooth appearing flutter waves, atrial arrhythmias will demonstrate P waves.
22 Parameter/waveform Value/characteristic P wave Present, appearance of the P wave of the abnormal beat is different (arises from a different location.) QRS complex Present, each appears the same PR interval seconds (may vary slightly with the abnormal beat) QRS interval seconds P:QRS ratio 1:1 Rate bpm Rhythm Irregular, P-P and R-R intervals are different Premature atrial contraction, 30 second display Premature atrial contraction, 10 second display
23 Key features: Aberrant P wave associated with a beat occurring earlier than expected (at the arrows) Note that it is more clearly visualized when spread out in a 10 second display, a feature true of viewing almost all arrhythmias
24 Parameter/waveform Value/characteristic P wave Present, each appears the same QRS complex Present, each appears the same PR interval seconds QRS interval seconds P:QRS ratio 1:1 Rate <60 bpm (<40 in sleep) Rhythm Regular Sinus bradycardia, 30 second display Sinus bradycardia, 10 second display
25 Key features: Looks like normal sinus rhythm except the rate is too slow Note that bradycardia in sleep is defined as a sustained rhythm with rate less than 40 beats per minute
26 Parameter/waveform Value/characteristic P wave Present, each appears the same; may not be well defined in SVT QRS complex Present, each appears the same PR interval seconds QRS interval seconds P:QRS ratio 1:1 Rate Rhythm >100 bpm (> 90 bpm in sleep) Regular Atrial tachycardia, 30 second display Atrial tachycardia, 10 second display
27 Key features: Looks like normal sinus rhythm except rate is too fast Note that tachycardia in sleep is defined as a sustained rhythm with rate greater than 90 beats per minute
28 Parameter/waveform Value/characteristic P wave Present, each appears the same QRS complex Present, each appears the same PR interval seconds QRS interval seconds P:QRS ratio 1:1 Rate Usually bpm Rhythm Irregular Sinus arrhythmia, 30 second display Sinus arrhythmia, 10 second display
29 Key features: A usually benign phenomenon where the HR increases with inhalation and slows with exhalation mediated by stimulation of the vagus nerve Often seen in youngsters and athletic individuals Similar shifts in HR can be seen with apnea (slowing) and resumption of breathing (acceleration) This bradytachy phenomenon has been recognized as the most prevalent arrhythmia in patients with sleep disordered breathing
30 Parameter/waveform Value/characteristic P wave Absent during pause QRS complex Absent during pause PR interval Absent during pause QRS interval Absent during pause P:QRS ratio 1:1 Rate bpm, but any rate is possible Rhythm Irregular Sinus pause, 30 second display Sinus pause, 10 second display
31 Key features: Abrupt absence of both P waves and QRS complexes, if lasting longer than 3 seconds, should be scored as asystole per AASM guidelines May be due to sinus arrest or block of sinus excitatory impulse (sinus exit block) This usually cannot be determined on surface ECG and requires an electrophysiological heart study
32 Parameter/waveform P wave QRS complex PR interval Value/characteristic Present, aberrant, often hidden Present, appearance is the same may be aberrant seconds QRS interval seconds P:QRS ratio 1:1 Rate bpm Rhythm Regular during paroxysm Paroxysmal atrial tachycardia, paroxysmal supraventricular tachycardia, 30 second display Paroxysmal atrial tachycardia, paroxysmal supraventricular tachycardia, 10 second display
33 Key features: Abrupt increase in HR and abrupt termination of the increase, typically with normal appearing QRS complexes This abrupt onset and offset is termed a paroxysm These events should be scored as Narrow Complex Tachycardia per AASM guidelines
34 Parameter/waveform P wave QRS complex PR interval QRS interval P:QRS ratio Rate Rhythm Value/characteristic None, fibrillatory wave present Present, appearance is the same Not measurable seconds Not applicable Ventricular rate highly variable Irregularly irregular Atrial fibrillation, 30 second display Atrial fibrillation, 10 second display
35 Key features: Irregularly irregular rhythm P waves are replaced by rapid oscillations of varying size, shape and duration Presence of A Fib should be scored per AASM guidelines
36 Parameter/waveform P wave QRS complex PR interval QRS interval P:QRS ratio Rate Rhythm Value/characteristic None, saw tooth appearance flutter waves present Present, appearance is the same Not measurable seconds Variable 2:1, 3:1, 4:1, etc Atrial , ventricular depends on degree of block Regular or irregular dependent on variability of block Atrial flutter, 30 second display Atrial flutter, 10 second display
37 Key Features: Distinct, regular, rapid flutter waves with saw tooth appearance Ventricular rhythm can be regular or irregular Atrial flutter should be note under other significant arrhythmias
38 Premature junctional contraction Junctional rhythm Accelerated junctional rhythm Junctional tachycardia
39 Key features: Junctional arrhythmias may have inverted P waves due to retrograde conduction or the P wave may not be seen as it occurs in concert with the QRS complex and is buried If the P wave is inverted, the PR interval is shorter than normal or the P wave may even occur after the QRS complex
40 Parameter/waveform P wave: QRS complex: PR Interval: QRS Interval: P to QRS Ratio: Rhythm: Rate: Value/characteristic Premature and abnormal configuration, will be inverted; can be before (with shortened PR interval), after or hidden in the QRS Present, appearance is the same Shorter than normal; < 0.12 seconds seconds?; < 1:1 if hidden; 1:1 if inverted P is seen Irregular Usually normal but can occur in sinus tachycardia or sinus bradycardia Premature junctional contraction, 30 second display Premature junctional contraction, 10 second display
41 Key features: Normal appearing QRS complex occurring earlier than expected No P wave or inverted P wave
42 Parameter/waveform P wave: QRS complex: PR Interval: QRS Interval: P to QRS Ratio: Rhythm: Rate: Value/characteristic If seen, abnormal configuration, will be inverted; can be before (with shortened PR interval), after or hidden in the QRS Present, appearance is the same Shorter than normal; < 0.12 seconds seconds?; < 1:1 if hidden; 1:1 if inverted P is seen Regular bpm Junctional (nodal) rhythm, 30 second display Junctional (nodal) rhythm, 10 second display
43 Key features: In the sample on the previous slide the P wave is inverted and occurs before the QRS complex with abbreviated PR interval the rhythm is regular and the rate is within the normal range for junctional tissue (40-60 beats per minute) Report as a significant arrhythmia if the single lead recording is quality of the single ECG lead is sufficient for accurate scoring
44 Parameter/waveform P wave: QRS complex: PR Interval: QRS Interval: P to QRS Ratio: Rhythm: Rate: Value/characteristic If seen, abnormal configuration, will be inverted; can be before (with shortened PR interval), after or hidden in the QRS Present, appearance is the same Shorter than normal; < 0.12 seconds seconds?; < 1:1 if hidden; 1:1 if inverted P is seen Regular bpm Accelerated junctional (nodal) rhythm, 30 second display Accelerated junctional (nodal) rhythm, 10 second display
45 Key features: In the sample on the previous slide no P wave is seen but it could be inverted before or after QRS complex rate is beats per minute and looks like normal sinus rhythm except for the absence or inversion of the P wave Report as a significant arrhythmia if the single lead recording is quality of the single ECG lead is sufficient for accurate scoring
46 Parameter/waveform P wave: QRS complex: PR Interval: QRS Interval: P to QRS Ratio: Rhythm: Rate: Value/characteristic If seen, abnormal configuration, will be inverted; can be before (with shortened PR interval), after or hidden in the QRS Present, appearance is the same Shorter than normal; < 0.12 seconds seconds?; < 1:1 if hidden; 1:1 if inverted P is seen Regular >100 bpm Junctional Tachycardia, 30 second display Junctional Tachycardia, 10 second display
47 Key features: In the sample on the previous slide note the inverted P wave following the QRS complex (arrow) rhythm is regular and rate is greater than 100 per minute Report as a significant arrhythmia if the single lead recording is quality of the single ECG lead is sufficient for accurate scoring
48 1 st degree AV block 2 nd degree AV block, Mobitz type I 2 nd degree AV block, Mobitz type 2 3 rd degree AV block As the name implies, there is a problem with the conduction of the electrical impulse between the atria and the ventricles. The impulse transmission is either delayed or totally blocked.
49 Parameter/waveform Value/characteristic P wave Present, each appears the same QRS complex Present, each appears the same PR interval >0.20 seconds QRS interval seconds P:QRS ratio 1:1 Rate Usually normal Rhythm Regular st degree AV block, 30 second display 1 st st degree AV block, 10 second display 1 st
50 Key features: Resembles normal sinus rhythm Prolonged PR interval (greater than 0.20 seconds)
51 Parameter/waveform Value/characteristic P wave Present, normal sinus P, some not followed by QRS QRS complex Present, each appears the same PR interval Progressively lengthening QRS interval seconds P:QRS ratio >1:1 Rate Usually slow to normal Rhythm Irregular 2nd degree AV block, type I, Wenkebach, 30 second display nd degree AV block, type I, Wenkebach, 10 second display 2 nd
52 Key features: Progressively increasing PR interval until there is a P wave without corresponding QRS complex (see the arrows on the previous slide) Note a 10 second window is necessary for adequate assessment P to QRS ratio is greater than 1:1 This is the Wenkebach phenomenon Report as a significant arrhythmia if the single lead recording is quality of the single ECG lead is sufficient for accurate scoring
53 Parameter/waveform Value/characteristic P wave Present, normal sinus P, some not followed by QRS complex, often >= 2 P waves before QRS complex QRS complex Present, each appears the same PR interval Constant PR interval before dropped QRS, may be normal or prolonged PR interval QRS interval seconds P:QRS ratio >1:1 Rate Usually slow to normal Rhythm Irregular 2nd degree AV block, type II, 30 second display nd degree AV block, type II, 10 second display 2 nd
54 Key features: Non-conducted P wave PR interval is constant before the dropped QRS complex Several non-conducted P waves may occur in a row This is the Hayes phenomenon Report as a significant arrhythmia if the single lead recording is quality of the single ECG lead is sufficient for accurate scoring
55 Parameter/waveform Value/characteristic P wave Present, normal sinus P, some not followed by QRS complex, often >= 2 P waves before QRS complex QRS complex Present, appearance is the same PR interval Highly variable QRS interval <0.12 if block is high conducting system (bundle of His) or >0.12 if lower conducting system (bundle branches) P:QRS ratio >1:1 Rate Ventricular rate if block is high, <40 if block is lower Rhythm Regular P-P and regular R-R intervals but not the same rate 3rd degree AV block, 30 second display rd degree AV block, 10 second display 3 rd
56 Key features: The P to P interval is constant and the R to R interval is constant but they do not occur at the same rate The atria and the ventricles are functioning independently This is also known as AV dissociation Report as a significant arrhythmia if the single lead recording is quality of the single ECG lead is sufficient for accurate scoring
57 Premature Ventricular Contractions Unifocal PVC s Multifocal PVC s Ventricular Trigeminy Ventricular Bigeminy Ventricular couplets Idioventricular Rhythm Accelerated Ventricular Rhythm Ventricular Tachycardia Runs of ventricular tachycardia Sustained ventricular tachycardia Ventricular Fibrillation
58 Key Features Ventricular arrhythmias are void of P waves prior to the abnormal beat(s) The QRS complexes are prolonged (greater than 0.12 seconds) and often bizarre in appearance
59 Parameter/waveform Value/characteristic P wave: Not present with abnormal beat(s) QRS complex: Occurs earlier than expected and appears widened and bizarre compared to sinus originated beats PR Interval: None QRS Interval: > 0.12 sec P to QRS Ratio: < 1:1 Rhythm: Irregular Rate: Usually but can occur with faster or slower rates Unifocal PVC s, 30 second display Unifocal PVC s, 10 second display
60 Key features: No P wave prior to the abnormal beat occurring earlier than expected The QRS complex duration is greater than 0.12 seconds and bizarre appearing Unifocal PVC s all look alike (originate from the same focus and take the same pathway) Rule of identical morphology Report as a significant arrhythmia if clinically significant (frequency >???)
61 Parameter/waveform Value/characteristic P wave: Not present with abnormal beat(s) QRS complex: Occurs earlier than expected and appears widened and bizarre compared to sinus originated beats. QRS complexes have different morphology PR Interval: None QRS Interval: > 0.12 sec P to QRS Ratio: < 1:1 Rhythm: Irregular Rate: Usually but can occur with faster or slower rates Multifocal PVC s, 30 second display Multifocal PVC s, 10 second display
62 Key features: No P wave prior to the abnormal beats occurring earlier than expected The QRS complex duration is greater than 0.12 seconds and bizarre appearing Multifocal PVC s look different from each other (originate from a different focus and take a different pathway) Rule of differing morphology Report as clinically significant ectopy
63 Parameter/waveform Value/characteristic P wave: Not present with abnormal beat(s) QRS complex: Occurs earlier than expected and appears widened and bizarre compared to sinus originated beats. Every other beat is abnormal PR Interval: None QRS Interval: > sec P to QRS Ratio: < 1:1 Rhythm: Irregular Rate: Usually but can occur with faster or slower rates Ventricular bigeminy, 30 second display Ventricular bigeminy, 10 second display
64 Key features: No P wave prior to the abnormal beat occurring earlier than expected The QRS complex duration is greater than 0.12 seconds and bizarre appearing Bigeminy refers to a pattern of every other beat being abnormal Atrial and junctional bigeminy patterns can occur, hence it is important to identify the origin as well as the pattern Report as clinically significant ectopy
65 Parameter/waveform Value/characteristic P wave: Not present with abnormal beat(s) QRS complex: Occurs earlier than expected and appears widened and bizarre compared to sinus originated beats. Every third beat is abnormal PR Interval: None QRS Interval: > sec P to QRS Ratio: < 1:1 Rhythm: Irregular Rate: Usually but can occur with faster or slower rates Ventricular trigeminy, 30 second display Ventricular trigeminy, 10 second display
66 Key features: No P wave prior to the abnormal beat occurring earlier than expected The QRS complex duration is greater than 0.12 seconds and bizarre appearing Trigeminy refers to a pattern of every third beat being abnormal Atrial and junctional trigeminy patterns can occur, hence it is important to identify the origin as well as the pattern Report as clinically significant ectopy
67 Parameter/waveform Value/characteristic P wave: Not present with abnormal beat(s) QRS complex: Occurs earlier than expected and appears widened and bizarre compared to sinus originated beats. Ventricular beats are paired, may be multifocal PR Interval: None QRS Interval: > 0.12 sec P to QRS Ratio: < 1:1 Rhythm: Irregular Rate: Usually but can occur with faster or slower rates Ventricular couplets, 30 second display Ventricular couplets, 10 second display
68 Key features: These are paired ventricular beats (occurring back to back) They may be unifocal as in the example on the previous slide Multifocal ventricular look different from each other Report as clinically significant ectopy
69 Parameter/waveform Value/characteristic P wave: Not present QRS complex: Widened and bizarre PR Interval: None QRS Interval: > 0.12 sec P to QRS Ratio: < 1:1 Rhythm: Regular Rate: < 40 bpm Ventricular rhythm, 30 second display Ventricular rhythm, 10 second display
70 Key features: No P wave and wide, bizarre QRS complex The rhythm is regular and the rate is normal for ventricular impulses (20-40 beats per minute)
71 Parameter/waveform Value/characteristic P wave: Not present QRS complex: Widened and bizarre PR Interval: None QRS Interval: > 0.12 sec P to QRS Ratio: < 1:1 Rhythm: Regular Rate: bpm Accelerated ventricular rhythm, 30 second display Accelerated ventricular rhythm, 10 second display
72 Key features: No P wave and wide, bizarre QRS complex Rhythm is regular and the rate is too fast for normal for ventricular impulses ( beats per minute) Report as clinically significant ectopy
73 Parameter/waveform Value/characteristic P wave: Not present QRS complex: Widened and bizarre PR Interval: None QRS Interval: > sec P to QRS Ratio: < 1:1 Rhythm: Regular Rate: bpm during the run Accelerated ventricular rhythm, 30 second display Runs of ventricular tachycardia, 30 second display Runs of ventricular tachycardia, 10 second display
74 Key features: No P wave and wide, bizarre QRS complex Rhythm is regular and the rate is greater than 100 beats per minute Report as wide complex tachycardia
75 Parameter/waveform Value/characteristic P wave: Not present QRS complex: Widened and bizarre PR Interval: None QRS Interval: > 0.12 sec P to QRS Ratio: < 1:1 Rhythm: Regular Rate: bpm Sustained ventricular tachycardia, 30 second display Sustained ventricular tachycardia, 10 second display
76 Key features: No P wave and wide, bizarre QRS complex Rhythm is regular and the rate is greater than 100 beats per minute Sustained - defined as exceeding 30 seconds duration This is an emergency arrhythmia Assess the patient and follow your institution s emergency protocol Report as wide complex tachycardia
77 Parameter/waveform P wave: QRS complex: PR Interval: QRS Interval: P to QRS Ratio: Rhythm: Rate: Value/characteristic Not present None, wave forms are chaotic and disorganized, variable size and morphology None Not measurable None Chaotic Not measurable Ventricular fibrillation, 30 second display Ventricular fibrillation, 10 second display
78 Key features: No identifiable P waves or QRS complexes This is an emergency situation Assess the patient and then activate the emergency medical response system according to your protocols Report as clinically significant ectopy
79 This presentation has reviewed: AASM guidelines for recording and reporting arrhythmias Basic anatomy and pathways of the cardiac conducting system Basic ECG waveforms and their relation to the cardiac cycle Presentation of normal ECGPresentation of a systematic way to analyze cardiac arrhythmias Examples of atrial, junctional, and ventricular arrhythmias and AV blocks
80 Atkinson JW. Cardiac Arrhythmias. in Mattice C, Brooks R, Lee-Chiong T, (Eds.), Fundamentals of Sleep Technology 2 nd Edition, pp Philadelphia: Lippincott Williams and Wilkins, Berry RB, Brooks R, Gamaldo CE, Harding SM, Marcus CL and Vaughn BV for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version 2.0, pp Darien, Illinois: American Academy of Sleep Medicine, 2012.
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