Ginter, James F

Loftis, Patrick

English

epublications@Marquette

Marquette Universitye-Publications@MarquettePhysician Assistant Studies Faculty Research andPublications Physician Assistant Studies, Department6-14-2011Interpreting the ECG of a Patient with a PacemakerJames F. GinterAurora Cardiovascular ServicesPatrick LoftisMarquette University, patrick.loftis@marquette.eduPublished version. Journal of the American Academy of Physician Assistants, ( June 14, 2011). :Permalink. © 2011, American Academy of Physician Assistants and Haymarket Media Inc. Usedwith permission.Interpreting the ECG of a patient with a pacemaker - JAAPAhttp://www.jaapa.com/interpreting-the-ecg-of-a-patient-with-a-pacemaker/article/205262/[8/13/2012 4:28:00 PM]Home CME Departments Articles Research Current Issue Archive Blogs Authors News Tools & Links AAPACommentary Online Only PAPR Drug Information Meetings & Conferences Newsletters Jobs  RSS | Log out | My AccountMORE INTERPRETING ECGSPericarditisECG changes from medicationsHypothermiaMyocardial infarction on ECGMyocardial ischemiaRELATED TOPICSCardiology Diagnostic ImagingDiagnostic MedicineElectrophysiologyJames F. Ginter, MPAS, PA-C, Patrick Loftis, PA-C, MPAS, RN June 14, 2011INTERPRETING ECGSInterpreting the ECG of a patient with a pacemaker  PRINT   EMAIL   REPRINT   PERMISSIONS  TEXT: A | A | A   Interpreting ECGs 0611 Figures view full slideshow >>Originally developed for the treatment of symptomatic bradyarrhythmias,artificial cardiac pacemakers (PMs) consist of a battery and electricalcircuits that are encased in a sealed container. PMs deliver electricalstimuli over leads that are connected to the right atrium, right ventricle, orboth right-sided chambers.HISTORYThe first pacemakers were classified as atrial, ventricular, or dual-chamberdevices. A single-chamber atrial PM has a generator and an electrode thatis placed in the right atrium. A ventricular PM has a generator and anelectrode that is placed in the right ventricle. A dual-chamber PM has twoseparate electrodes: one that is placed in the right atrium and one that isplaced in the right ventricle.The earliest pacemakers were capable of stimulating the heart at a fixedrate only. They could not recognize or sense the recipient's spontaneousrhythm. To avoid competition between the PM and the patient's ownrhythm, second-generation devices were equipped with the capability tosense the intrinsic atrial or ventricular impulse. Whenever a spontaneousatrial or ventricular impulse was detected, the PM was inhibited fromdelivering an impulse. These devices were called demand pacemakers.As pacemakers became more advanced, a coding system evolved to identify the different functions a PM wascapable of performing. The first universally accepted coding system was developed by the IntersocietyAUTHOR GUIDELINES  EDITORIAL BOARD  ABOUT US  CONTACT US  ADVERTISE  SUBSCRIBE  ISSUE ARCHIVE JAAPA > Online-Only > Interpreting ECGs > Interpreting the ECG of a patient with a pacemaker22LikeThe cardiovascular physician assistant:The angel in the roomMost Popular Most Emailed Most RecentInterpreting the ECG of a patient with a pacemaker - JAAPAhttp://www.jaapa.com/interpreting-the-ecg-of-a-patient-with-a-pacemaker/article/205262/[8/13/2012 4:28:00 PM]Commission on Heart Disease Resources in 1974.1 This system consisted of three characters that identified thetype and basic function of the PM. The first character indicated the chamber that was being paced: A for atrium,V for ventricle, or D for dual (both atrium and ventricle). The second character indicated which chamber wasbeing sensed: A for atrium, V for ventricle, D for dual (both atrium and ventricle), or the number 0 for none. Thethird character described the response of the PM to a sensed event: I for inhibit, T for trigger, D for dual (atrialinhibition followed by ventricular triggering), or 0 for no response. This system applied to a PM'santibradyarrhythmia function only.In 1981, the North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing andElectrophysiology Group (BPEG) developed a five-function coding system known as the NBG code for pacingnomenclature.2 The first three characters are the same as the original coding system. The fourth character is Ror 0; R refers to the pacemaker's ability to adjust its programmed paced rate based upon patient activity, and 0indicates that the PM has no such ability. The fifth character identifies the location or absence of multisitepacing, defined as stimulation sites in both atria, both ventricles, and more than one stimulation site in anysingle chamber. The number 0 signifies no multisite pacing, A indicates multisite pacing in the atria, V indicatesmultisite pacing in the ventricles, and D indicates dual multisite pacing in both atria and ventricles. The mostcommon presentation of multisite pacing is biventricular pacing for the management of heart failure. Apacemaker in such a patient could be identified as a VVTRV pacemaker.PACEMAKER'S EFFECT ON AN ECGA paced rhythm is easy to recognize. When a pacemaker fires, a small spike is seen on the ECG. An atrialpacemaker will generate a spike followed by a P wave and a normal QRS complex. Figure 1 shows the ECG ofa patient with an atrial pacemaker that was placed to address a problem in the sinoatrial (SA) node. Once theelectrical cycle is started, it proceeds through the atrioventricular (AV) node and continues distally as normal.With a ventricular pacemaker, a spike is seen before the QRS complex. In Figure 2, a normal P wave isfollowed by a pacemaker spike in front of a wide QRS complex. In this patient, the electrical cycle startednormally in the SA node but was blocked at the AV node. The electrode was placed in the right ventricle, whichdepolarized first, followed by the left ventricle. This placement generates a wide QRS complex similar to thatseen in left bundle branch block.A sequential pacemaker stimulates the atrium first and then the ventricle. With a sequential PM, two spikes areseen, one before the P wave and the other before the QRS complex.ECG CHALLENGEA PA student asks for help interpreting an ECG (Figure 3), saying that it does not look right. You take himthrough the step-by-step process for evaluating ECGs.(1) Is the rhythm regular? Use your calipers and march out the QRS complexes. It is a regular rhythm.(2) Now look at the heart rate.  Method A: Assign each big box between QRS complexes a number as follows: 300, 150, 100, 75. The secondQRS appears at about 75, so you can estimate the rate at 75 beats per minute.  Method B: Count the number of QRS complexes in 6 seconds (30 boxes), and multiply by 10. 7.5 × 10 = 75beats per minute.  Method C: Count the number of large boxes between QRS complexes, and then divide 300 by that number.300 divided by 4 = 75 beats per minute.(3) Is there a P wave before every QRS? Do all the P waves look the same? The answer to both questions isyes. We also see a pacer spike before the P wave. This is an atrial paced rhythm.(4) Is the PR interval greater than 3 small boxes and less than one large box? Yes. Therefore, the patient'sheartbeat is in sinus rhythm.PEOPLE RECENT POPULARRecent CommentsConstance WengerThe picture of the healthy mouthbears careful observation as helooks to have a bilateral crossbite. They areeasily addressed and corrected once the 6year molars are well erupted. Without...Maximizing oral health in children: A reviewfor physician assistants · 19 hours agoDave Mittman, PAI agree with David. So anotherDavid will say thank you very muchfor the kind words for my profession.DaveThe cardiovascular physician assistant:The angel in the room · 3 days agoMarjorie ShanksGood article on a difficult topic. This inspired me to write a post onmy blog: http://ow.ly/cRCf3On taking down a colleague: Is there anethical mandate to report? · 4 days agoDave Mittman, PAAre you kidding? A PA smellingalcohol on any other cliniciansbreath WHILE ON DUTY must to two things.One is tell them to go home by taxiimmediately. Two is to have them go fortreatment and...On taking down a colleague: Is there anethical mandate to report? · 4 days agoOn taking down a colleague: Is therean ethical mandate to report?The safety and efficacy of physicianassistants as first assistant surgeons incardiac surgeryCan coconut oil replace caprylidene forAlzheimer disease?What's new in dermatology: Tanningbed use causes melanomaAvoiding overtransfusion: An update onrisks and latest indicationsAsk a Librarian—August 2012Leadership case study: Martha Flores,PA-CIs this papule on the thigh concerning?Time, money, and compassionInterpreting the ECG of a patient with a pacemaker - JAAPAhttp://www.jaapa.com/interpreting-the-ecg-of-a-patient-with-a-pacemaker/article/205262/[8/13/2012 4:28:00 PM]LikeSort by popular now(5) Does the QRS complex span fewer than 3 small boxes? No. We also see a pacer spike before the QRScomplex. This is a ventricular paced rhythm causing a left bundle branch block appearance in the QRScomplexes(6) Is the ST segment neutral, elevated, or depressed? The ST segment cannot be interpreted in a ventricularpaced rhythm.(7) The T waves are normal.(8) There are no U waves.You tell the student that this ECG indicates an atrial/ventricular-paced rhythm at a rate of 75 beats per minute.JAAPAClick on the view full slideshow link above to examine the figures in greater detail.REFERENCES1. Parsonnet V, Furman S, Smyth NP. Implantable cardiac pacemakers status report and resource guideline.Pacemaker Study Group. Circulation. 1974;50(4):A21-A35.2. Bernstein AD, Daubert JC, Fletcher RD, et al. The revised NASPE/BPEG generic code for antibradycardia,adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing andElectrophysiology Group. Pacing Clin Electrophysiol. 2002;25(2):260-264. From the June 2011 Issue of JAAPAAds by GoogleECG SimulatorGenerate 24 rhythms, 12 LEAD, SPO2 Simulate Pacing, Sync,ETCO2, NIBPwww.ECG-Simulator.com Real-time updating is enabled. (Pause)Showing 2 commentsLike 22 likes. Sign Up to see what your friends like.0liked this.LogoutJAAPA COMMENTS POLICYComments are moderated. We do not post comments that contain personal attacks, profanity or other abusivelanguage, perseveration, advertisements, or other inappropriate material. Approved comments are postedwithout editing.Add New CommentCarolyn AndrewsDavid BunnellThank-you to Dr. Furnary for yourcontinuing support and thoughtfulcommentary.The cardiovascular physician assistant:The angel in the room · 4 days agoInterpreting the ECG of a patient with a pacemaker - JAAPAhttp://www.jaapa.com/interpreting-the-ecg-of-a-patient-with-a-pacemaker/article/205262/[8/13/2012 4:28:00 PM]M  Subscribe by email S  RSSSPONSORED LINKSIdentifying and Co-Managing the HIV-Infected Adult: A Guide for Primary Care CliniciansSurmounting barriers to opt-out screening, making an HIV diagnosis, and preventing transmission andopportunistic infections will be discussed, as will selection of initial therapy and considerations for patientsreceiving ART.Click HereNewsDrug InformationMedical NewsConference CoverageReviews & Case ReportsCase ReportsReview ArticlesSurgical ReviewsMoreAuthor GuidelinesEditorial BoardAbout UsContact UsAdvertiseSubscribeIssue ArchiveSitemapPermissionsReprints RSSAd ChoicesDepartmentsA Day in the LifeAsk a Librarian!Case of the MonthClinical WatchCritically Appraised TopicDermatology DigestDiagnostic Imaging ReviewEditorialEliminating Health Disparities: What Works?Genomics in PA PracticeHumane MedicinePA QuandariesPOEMsQuick Recertification SeriesResearch CornerSounding BoardThe Surgical PatientWhat's New?When the Patient AsksAAPAAAPA HomeCME CalendarCME PosttestThe PA Job LinkAnnual ConferenceJoin AAPAPA CensusPA CompetenciesCMECME ArticlesCME PosttestsCME Supplements & WebcastsFor AuthorsRoadmap to Better WritingWriting for Publication WebcastsJAAPA Submission GuidelinesOther Haymarket Medical WebsitesMPR (drug database)Clinical AdvisorRenal and Urology NewsmyCME - Online CMEMcKnights Long Term Care NewsOncology Nurse Advisor Chemotherapy AdvisorInternationalhealthcare republicMIMS (drug database)JAAPA SITEMAP © 2012 American Academy of Physician Assistants and Haymarket Media, Inc.This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization.Your use of this website constitutes acceptance of Haymarket Media's Privacy Policy and Terms & ConditionsThis is a nice review/explanation.  For 15 years I  worked with Seymour Furman, who developed the firsttransvenous pacemaker. It was good to see him in the bibliography.  I also know the others mentionedin the credits.  I was a member of NASPE, and helped found the organization for paraprofessionalsworking in pacing and electrophysiology and took the first board certification offered in this field. Like Reply1 year agoFigure 1 is AP VP. Figure 3 is sensing in V...Not APVP. Must have scanned in backwardsGina Spino-RogersLike Reply1 year ago

Interpreting the ECG of a Patient with a Pacemaker

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Interpreting the ECG of a Patient with a Pacemaker

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