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Quick Dx & Rx: Cardiology

Wandering Atrial Pacemaker

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Key features, clinical presentation, diagnostic evaluation, ongoing management.

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ESSENTIALS OF DIAGNOSIS

Progressive cyclic variation in P-wave morphology

Heart rate 60–100 bpm

Variation of P-wave morphology, P-P interval, and P-R interval

GENERAL CONSIDERATIONS

This rhythm is benign

This rhythm and multifocal atrial tachycardia are similar except for heart rate

The other possible explanation is that there is significant respiratory sinus arrhythmia, with uncovering of latent foci of pacemaker activity

Usually, it is associated with underlying lung disease

In the elderly, it may be a manifestation of sick sinus syndrome

In the young and athletic heart, it may represent enhanced vagal tone

SYMPTOMS AND SIGNS

Usually causes no symptoms and is incidentally discovered

Occasional patient may feel skipped beats

PHYSICAL EXAM FINDINGS

Variable S 1

DIFFERENTIAL DIAGNOSIS

Multifocal atrial tachycardia (heart rate > 100 bpm)

Frequent premature atrial complexes and atrial bigeminy

LABORATORY TESTS

None specific

ELECTROCARDIOGRAPHY

ECG to document rhythm

CARDIOLOGY REFERRAL

Not required

MEDICATIONS

No specific treatment

Monitor and treat the underlying cause, such as sick sinus syndrome or lung disease

DIET AND ACTIVITY

No restrictions

General healthy lifestyle

Once a year if sinus node abnormality is suspected; otherwise when symptoms arise

COMPLICATIONS

May progress to sick sinus syndrome

This condition by itself is benign

PRACTICE GUIDELINES

Indications for pacemaker:

– If part of sick sinus syndrome

– If associated with documented symptomatic bradycardia

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Wandering Pacemaker

description wandering pacemaker

When several pacemakers are competing, p-waves with different origins and thus configurations occur. The rhythm is slightly different from beat to beat.

note If the heart rate increases to above 100bpm, it is called Multifocal Atrial Tachycardia . Possible causes are hypoxia, COPD and medication such as digoxin.

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  • Wandering atrial pacemaker
  • 2 Clinical Features
  • 3.1 Palpitations
  • 4.2 Diagnosis
  • 5 Management
  • 6 Disposition
  • 8 External Links
  • 9 References
  • Three or more ectopic foci within the atrial myocardium serve as the pacemaker
  • Rate is less than 100bpm (in contrast to MAT )
  • Is irregularly irregular therefore sometimes confused with atrial fibrillation and sinus arrhythmia
  • Intrinsic cardiac or pulmonary disease
  • Metabolic derangements
  • Drug toxicity (including Digoxin )

Clinical Features

  • Often seen in the extremes of age and in athletes
  • Rarely causes symptoms

Differential Diagnosis

Palpitations.

  • Narrow-complex tachycardias
  • Wide-complex tachycardias
  • Second Degree AV Block Type I (Wenckeback)
  • Second Degree AV Block Type II
  • Third Degree AV Block
  • Premature atrial contraction
  • Premature junctional contraction
  • Premature ventricular contraction
  • Sick sinus syndrome
  • Acute coronary syndrome
  • Cardiomyopathy
  • Congenital heart disease
  • Congestive heart failure (CHF)
  • Mitral valve prolapse
  • Pacemaker complication
  • Pericarditis
  • Myocarditis
  • Valvular disease
  • Panic attack
  • Somatic Symptom Disorder
  • Drugs of abuse (e.g. cocaine )
  • Medications (e.g. digoxin , theophylline )
  • Thyroid storm
  • Pulmonary embolism
  • Dehydration
  • Pheochromocytoma

Wandering atrial pacemaker.JPG

  • ECG should show three distinct P wave morphologies with a ventricular rate <100bpm
  • Rarely requires treatment

Disposition

  • Outpatient management
  • Multifocal atrial tachycardia
  • Dysrhythmia

External Links

  • Richard Cunningham
  • fardis tavangary
  • Ross Donaldson
  • Privacy policy
  • Disclaimers

Wandering Atrial Pacemaker ECG Interpretation with Sample Strip

Wandering atrial pacemaker rhythm strip features, authors and reviewers.

  • ECG heart rhythm modules: Thomas O'Brien.
  • ECG monitor simulation developer: Steve Collmann
  • 12 Lead Course: Dr. Michael Mazzini, MD .
  • Spanish language ECG: Breena R. Taira, MD, MPH
  • Medical review: Dr. Jonathan Keroes, MD
  • Medical review: Dr. Pedro Azevedo, MD, Cardiology
  • Last Update: 11/8/2021
  • Electrocardiography for Healthcare Professionals, 6th Edition Kathryn Booth and Thomas O'Brien ISBN10: 1265013470, ISBN13: 9781265013479 McGraw Hill, 2023
  • Rapid Interpretation of EKG's, Sixth Edition Dale Dublin Cover Publishing Company
  • EKG Reference Guide EKG.Academy
  • 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs Aaron Reed Create Space Independent Publishing
  • Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition Elsevier-Health Sciences Division Barbara A. Erickson, PhD, RN, CCRN
  • The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG Jonathan Keroes, David Lieberman Publisher: Lippincott Williams & Wilkin) ISBN-10: 0781784425; ISBN-13: 978-0781784429
  • Project Semilla, UCLA Emergency Medicine, EKG Training Breena R. Taira, MD, MPH
  • ECG Reference Guide PracticalClinicalSkills.com

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ECG Interpretation

Thursday, March 4, 2021

Blog #200 — wandering pacemaker (vs mat).

There is no clinical information is available for the ECG and 2-lead rhythm strip shown below in  Figure-1 .

  • HOW would you interpret this tracing?
  • What treatment is likely to be needed? 

====================================

Editorial  Comment:

It is always challenging to interpret tracings without the benefit of clinical information. That said — this situation is common in clinical practice. My experience in this area derives from the 30 years during which I was charged with interpreting  all  ECGs ordered by 35 medical providers at a primary care clinic — as well periodic stints during which I interpreted hospital tracings without the benefit of any history. 

  • The challenge lies with having to decide  which  tracings in the  “pile of ECGs to be interpreted”  were those for which I needed to pull the medical chart ( or call the provider ) because of ECG findings of immediate potential concern.
  • Obvious time constraints made it impossible to pull the chart for each ECG that I was given to read ( I’d never get anything else done if I did so ).
  • I therefore became well versed in the skill of limiting the charts that I would pull to those patients whose ECGs showed findings I thought were important  and  potentially indicative of an acute situation that may have been overlooked.

=====================================

MY Thoughts  on the ECG in Figure-1:

As always — systematic interpretation of  any  ECG should begin with assessing the cardiac rhythm. In general —  lead II  and  lead V1  are the 2  best  leads on a 12-lead tracing for assessing atrial activity — and we have the advantage in  Figure-1  of a  simultaneously-recorded  2-lead rhythm strip of both of these leads.  By the  Ps ,  Qs and  3R Approach:

  • The rhythm in  Figure-1  is  clearly   irregular .
  • The  QRS  complex is  narrow ( ie,  not  more than half a large box in duration = ≤0.10 second ) . 
  • The rate  varies  from  50 /minute — to just under  100 /minute.
  • More than 1 P wave morphology is present . That said — P waves  do  appear to be related to neighboring QRS complexes, because the PR interval for the P wave shapes that we see remains constant  ( See   Figure-2 ) .

MY Thoughts  on Figure-2:

There are 2 different P wave shapes in  Figure-2 .

  • The tracing begins with  3  sinus  beats ( ie,  RED arrows highlight 3 similar-looking upright-in-lead-II P waves — all with the same PR interval ) .
  • P wave shape then changes  for beats #4, 5 and 6  ( ie,  BLUE arrows highlighting an almost isoelectric, if not negative P wave with fixed PR interval ) .
  • The atrial focus then shifts back , with return to sinus P waves for beats #7, 8, 9 and 10 (ie,  return of RED arrows highlighting similar-looking, upright P waves in lead II — albeit with variability in the R-R interval ).
  • The rhythm in  Figure-2  concludes with a  slowing-down  of the ventricular rate, as  the 2nd atrial focus returns , in which the P wave is almost isoelectric (ie,  BLUE arrows for beats #11 and 12 ).

BOTTOM LINE  regarding  Figure-1:  The rhythm in  Figure-2  is most consistent with a  Wandering  Atrial  Pacemaker . This is because the change from one atrial site to the next occurs gradually over a period of several beats.

  • PEARL:  The reason it is uncommon ( if not rare ) in clinical practice to see a wandering atrial pacemaker — is that most providers do not pay  long enough  attention to  beat-to-beat  change in P wave morphology needed to identify  gradual  shift between  at least  3 different atrial sites.

SUMMARY:  Review of the  KEY  features of wandering atrial pacemaker is the theme below for our  ECG  Media  Pearl #17 ( a 3:30 minute audio recording ).

  • Written review of wandering pacemaker appears below in  Figure-3 .
  • Review of  MAT  is covered in our  ECG Blog #199 .

description wandering pacemaker

Today’s   E CG  M edia   P EARL  # 17 ( 3:30 minutes   Audio )  —   What is a  Wandering  Atrial Pacemaker ( as opposed to MAT )?

description wandering pacemaker

A DDENDUM   ( 3/4/2021 ) :

I received the following note from  David Richley  regarding today’s tracing: “I think I would use different terminology to describe this because to me the atrial pacemaker doesn’t so much ‘wander’ as ‘jump’. I would describe this as sinus arrhythmia with junctional escape rhythm at 60-65/minute every time the sinus node discharge rate slows to below that rate. I interpret the escape beats as junctional rather than atrial, because athough the P waves, ( which are initially negative in II, aVF and V4-V6 — and positive in aVR ) precede the QRS — the PR segment is very short, suggesting an AV nodal origin. However, we describe this phenomenon — I do agree that it’s likely to be completely benign.

MY Thoughts:  Dave’s comment is one of the reasons why:  i )  The diagnosis of wandering pacemaker requires clear demonstration of shift in the atrial pacemaker in  at least  3 different sites. We  only  see 2 different sites here;  and ,  ii )  The diagnosis of wandering atrial pacemaker is  not  common. 

  • It’s impossible to rule out Dave’s theory from the single tracing we have.
  • That said — the BLUE arrow P wave site may or may not be of AV nodal origin ( you can see a similar, near-isoelectric P wave with short PR interval from a low atrial site ).
  • I also considered the possibility of the BLUE arrow P waves representing junctional escape — but decided against it because the difference in R-R interval from what we see between beats #9-10  vs  what we see between beats #10-11 is  more  than what I’d expect based on the cadence of rate variation I see from beats #7-10.
  • Bottom Line:  We both agree there is a shift in the pacemaker site in a rhythm that is likely to be benign. And, we both agree that additional monitoring would be needed for a definitive response.  THANK YOU Dave!

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A pacemaker is a small, battery-powered device that prevents the heart from beating too slowly. You need surgery to get a pacemaker. The device is placed under the skin near the collarbone.

A pacemaker also is called a cardiac pacing device.

There are different types of pacemakers.

  • Single chamber pacemaker. This type usually sends electrical signals to the lower right chamber of the heart.
  • Dual chamber pacemaker. This type sends electrical signals to the upper and lower right heart chambers.
  • Biventricular pacemaker. This type also is called a cardiac resynchronization pacemaker. It's for people who have heart failure and a slow heartbeat. The device stimulates both lower heart chambers. It helps make the heart muscle stronger.

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Why it's done

A pacemaker is used to control or increase the heartbeat. It stimulates the heart as needed to keep it beating regularly.

The heart's electrical system typically controls the heartbeat. Electrical signals, called impulses, move through the heart chambers. They tell the heart when to beat.

Changes in heart signaling may happen if the heart muscle is damaged. Heart signaling problems also may be caused by changes in genes before birth or by using certain medicines.

You may need a pacemaker if:

  • You have a slow or irregular heartbeat that lasts for a long time, also called chronic.
  • You have heart failure.

A pacemaker only works when it senses trouble with the heartbeat. For example, if the heart beats too slowly, the pacemaker sends electrical signals to correct the beat.

Some pacemakers can increase the heartbeat as needed, such as during exercise.

The heart's conduction system

The heart's conduction system

The heart's conduction system also is called the heart's electrical signaling system. Electrical signals start in a group of cells at the top of the heart called the sinus node. The signals tell the heart to beat. The sinus node also is called the heart's natural pacemaker. It can become weak as a person gets older.

A pacemaker may have two parts:

  • Pulse generator. This small metal box has a battery and electrical parts. It controls the rate of electrical signals sent to the heart.
  • Leads. These are flexible, insulated wires. One to three wires are placed in one or more of the heart's chambers. The wires send the electrical signals needed to correct an irregular heartbeat. Some newer pacemakers don't need leads. These devices are called leadless pacemakers.

Pacemaker

A pacemaker is a device used to control an irregular heart rhythm. A pacemaker has flexible wires called leads. The wires are placed in one or more chambers of the heart. They deliver electrical signals to fix the heart rate. Some newer pacemakers don't need wires.

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Possible complications of a pacemaker device or its surgery may include:

  • Infection near the site in the heart where the device is placed.
  • Swelling, bruising or bleeding, especially if you take blood thinners.
  • Blood clots near where the device is placed.
  • Damage to blood vessels or nerves.
  • Collapsed lung.
  • Blood in the space between the lung and the chest wall.
  • Moving or shifting of the device or leads, which could cause a hole in the heart. This complication is rare.

How you prepare

Several tests are done to determine if a pacemaker is right for you. These tests may include:

  • Electrocardiogram (ECG or EKG). This quick and painless test checks the heart's electrical activity. An ECG shows how the heart is beating. Some personal devices, such as smartwatches, can check the heartbeat. Ask a member of your health care team if this is an option for you.
  • Holter monitor. This portable device is worn for a day or more to record the heart's rate and rhythm during daily activities. It may be done if an ECG doesn't provide enough details about a heart problem. A Holter monitor may be able to see irregular heart rhythms that an ECG missed.
  • Echocardiogram. An echocardiogram uses sound waves to create pictures of the beating heart. It shows how blood flows through the heart and heart valves.
  • Stress or exercise tests. These tests often involve walking on a treadmill or riding a stationary bike while the heart's rate and rhythm are watched. Exercise tests show how the heart responds to physical activity. Sometimes, a stress test is done with other imaging tests, such as an echocardiogram.

What you can expect

Before the procedure.

Surgery is needed to place a pacemaker in the body. The surgery usually takes a few hours.

Your chest is cleaned with a special soap. A member of your health care team puts an IV into your forearm or hand. Medicine called a sedative goes through the IV. It helps you relax.

Usually, medicine is used to numb the skin where the pacemaker will be inserted. This medicine is called local anesthesia. During the pacemaker surgery, you may be fully awake or lightly sedated.

During the procedure

To place a pacemaker, a doctor inserts one or more wires into a major vein under or near the collarbone. The doctor uses X-ray images to guide the wires to the heart. One end of each wire attaches to the proper area in the heart. The other end connects to the part of the pacemaker that delivers electrical pulses. That part is called a pulse generator. It usually is placed under the skin beneath the collarbone.

A leadless pacemaker is smaller. All the parts are inside a single unit. It's placed into the heart using a thin, flexible tube called a catheter. The doctor inserts the tube into a blood vessel, usually in the groin. The leadless pacemaker goes through the tube. It's guided to the proper area in the heart.

After the procedure

You may stay in the hospital for a day after getting a pacemaker. The device is programmed to fit your heart rhythm needs before you leave. Make plans to have someone drive you home from the hospital.

For the first month after getting a pacemaker, you may be told not to do any heavy lifting or exercise that uses a lot of energy. Do not put pressure on the area where the pacemaker was placed. Your health care team tells you what medicines you safely can take if you have pain.

Special precautions

A pacemaker doesn't usually stop working because of electrical interference. But it's a good idea to follow a few safety tips if you have a pacemaker.

  • Mobile phones. It's safe to talk on a mobile phone. But keep the phone at least 6 inches (15 centimeters) away from your pacemaker. Don't keep your phone in a shirt pocket. When talking on your phone, hold it to the ear opposite the side where your pacemaker was placed.
  • Security systems. Passing through an airport metal detector won't interfere with a pacemaker. But the metal in the pacemaker could sound the alarm. Do not stay too long near a metal-detection system. Carry an ID card that says you have a pacemaker.
  • Medical equipment. Tell all of your health care team members, including dentists, that you have a pacemaker. Some imaging tests and treatments may interfere with the device. These tests and treatments include MRI or CT scans, radiation therapy for cancer, the use of an electric current to control bleeding during surgery, and sound wave therapy to break up large kidney stones or gallstones.
  • Power-generating equipment. Stand at least 2 feet (61 centimeters) from welding equipment, high-voltage transformers or motor-generator systems. If you work around such equipment, ask your health care team if a safety test can be done at your workplace. The test can check whether the equipment affects your pacemaker.

Devices that are not likely to interfere with a pacemaker include:

  • Electric blankets.
  • Electric razors.
  • Microwave ovens.
  • Personal computers.
  • Televisions and remote controls.

A pacemaker should improve symptoms caused by a slow heartbeat, such as extreme tiredness, lightheadedness and fainting. Most modern pacemakers automatically change the speed of the heartbeat to match the level of physical activity. A pacemaker may let you have a more active lifestyle.

Regular health checkups are recommended after getting a pacemaker. Ask your health care team how often you need to go into a medical office for such checkups. Tell your health care team if you gain weight, if your legs or ankles get puffy, or if you faint or get dizzy.

A health care professional should check your pacemaker every 3 to 6 months. Most pacemakers can be checked remotely. This means you don't have to go into a medical office for the checkup. A pacemaker sends information about the device and your heart electronically to your doctor's office.

A pacemaker's battery typically lasts 5 to 15 years. When the battery stops working, you'll need surgery to replace it. The surgery to change a pacemaker's battery is often quicker than the first surgery to place the device. You also should have a quicker recovery.

Pacemakers and end-of-life issues

If you have a pacemaker and become sick with a life-threatening condition that can't be cured, it's possible the device could make you live longer. There are mixed opinions about turning off a pacemaker in end-of-life situations.

Talk to your health care team if you have a pacemaker and are concerned about turning it off. You also may want to talk to your family or caregivers about what you'd like to do in an end-of-life situation. You might want to write your end-of-life wishes in an advanced directive. This is a legal document that tells your family and health care team what to do if you can't communicate.

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Pacemaker care at Mayo Clinic

  • Pacemaker. American Heart Association. https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/pacemaker. Accessed Dec. 13, 2022.
  • Pacemakers. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/pacemakers. Accessed Dec. 13, 2022.
  • How the healthy heart works. American Heart Association. https://www.heart.org/en/health-topics/congenital-heart-defects/about-congenital-heart-defects/how-the-healthy-heart-works. Accessed Dec. 13, 2022.
  • All about heart rate (pulse). American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/all-about-heart-rate-pulse. Accessed Dec. 19, 2022.
  • Mulpuru SK, et al. Cardiac pacemakers: Function, troubleshooting, and management: Part 1 of a 2-part series. Journal of the American College of Cardiology. 2017; doi:10.1016/j.jacc.2016.10.061.
  • Living with your pacemaker. American Heart Association. https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/living-with-your-pacemaker. Accessed Dec. 13, 2022.
  • Devices that may interfere with ICDs and pacemakers. American Heart Association. https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/devices-that-may-interfere-with-icds-and-pacemakers. Accessed Dec. 13, 2022.
  • Link MS. Permanent cardiac pacing: Overview of devices and indications. https://www.uptodate.com/contents/search. Accessed Dec. 13, 2022.
  • Madhavan M, et al. Advances and future directions in cardiac pacemakers: Part 2 of a 2-part series. Journal of the American College of Cardiology. 2017; doi:10.1016/j.jacc.2016.10.064.
  • Libby P, et al., eds. Diagnosis and management of acute heart failure. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Dec. 13, 2022.
  • Hutchison K, et al. Ethics and the cardiac pacemaker: More than just end-of-life issues. Europace. 2018; doi:10.1093/europace/eux019.
  • Ami TR. Allscripts EPSi. Mayo Clinic. Dec. 21, 2022.
  • Lee JZ, et al. Leadless pacemaker: Performance and complications. Trends in Cardiovascular Medicine. 2018; doi:10.1016/j.tcm.2017.08.001.
  • Noseworthy PA (expert opinion). Mayo Clinic. June 28, 2021.
  • Leadless pacing systems: Risk of major complications related to cardiac perforation during implantation ⸺ Letter to health care providers. U.S. Food and Drug Administration. https://www.fda.gov/medical-devices/letters-health-care-providers/leadless-pacing-systems-risk-major-complications-related-cardiac-perforation-during-implantation. Accessed Dec. 19, 2022.
  • Mankad R (expert opinion). Mayo Clinic. Nov. 22, 2021.
  • Cha YM (expert opinion). Mayo Clinic. April 30, 2023.
  • Stühlinger M, et al. EHRA consensus on prevention and management of interference due to medical procedures in patients with cardiac implantable electronic devices. Europace. 2022; doi:10.1093/europace/euac040.
  • Atrial flutter
  • Bradycardia
  • Bundle branch block
  • Cardiomyopathy
  • Chagas disease
  • Enlarged heart
  • Heart arrhythmia
  • Heart disease
  • Heart failure
  • Hypertrophic cardiomyopathy
  • Long QT syndrome
  • Multiple system atrophy (MSA)
  • Sick sinus syndrome
  • Tachycardia
  • The conduction system
  • Ventricular tachycardia

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  • Wandering atrial pacemaker

Term Hierarchy

  • C R O G V Wandering atrial pacemaker

Professional guidelines

Recent clinical studies, clinical prediction guides.

Introduction to Atrial Rhythms

This page provides an introduction to atrial rhythms and links to our EKG interpretation courses and drills.

Atrial rhythms originate in the atria rather than in the SA node. The P wave will be positive, but its shape can be different from a normal sinus rhythm because the electrical impulse follows a different path to the AV (atrioventricular) node. These EKG differences are covered on our atrial rhythms training module as well as in practice strips which are available via a link in the right column. Atrial rhythms are classified as:

  • Atrial Fibrillation (afib)
  • Atrial Flutter

Multifocal Atrial Tachycardia

Premature atrial complex, supraventricular tachycardia.

  • Wandering Atrial Pacemaker

Wolff-Parkinson-White Syndrome

Atrial rhythm categories.

  • Atrial Fibrillation

Irritable sites in the atria fire very rapidly, between 400-600 bpm. This very rapid pacemaking causes the atria to quiver. The ventricles beat at a slower rate due to the AV node's blocking some of the atrial impulses.

There are two types of atrial flutter. Type I (also called classical or typical) has a rate of 250-350 bpm. Type II (also called non-typical) are faster, ranging from 350-450 bpm. EKG tracings will show tightly spaced waves or saw-tooth waveforms (F-waves).

When multifocal atrial tachycardia occurs, multiple (non-SA) sites are firing impulses. The P waves will vary in shape and at least three different shapes can be observed. The PR Interval varies. Ventricular rhythm is irregular.

This occurs when an ectopic site within the atria fires an impulse before the next impulse from the SA node. If the ectopic site is near the SA node, the P wave will likely have a shape similar to a sinus rhythm. But this P wave will occur earlier than expected.

This term covers three types of tachycardia that originate in the atria, AV junction or SA node.

Wandering atrial pacemaker is an irregular rhythm. In is similar to multifocal atrial tachycardia but the heart rate is under 100 bpm. P waves are present but will vary in shape.

This occurs when the impulse travels between the atria and ventricles via an abnormal path, called the bundle of Kent. The impulse, not being delayed by the AV node, can cause the ventricles to contract prematurely. EKG characteristics include a shorter PR Interval, longer QRS complex and a delta wave.

Training Resources

Atrial rhythm training.

After a brief review of cardiac rhythm analysis, this module explains morphologic features and qualifying criteria of atrial rhythms.

Atrial Rhythms

EKG Rhythm Tests

Hundreds heart rhythms in this practice test. Test can be tailored for specific learning needs.

EKG Monitor Challenge

A quiz using a simulated patient monitor. Evaluate a scrolling waveform rather than a paper tracing.

Lesson #1: Rhythm Analysis Method 312

The five steps of rhythm analysis will be followed when analyzing any rhythm strip.

  • Analyze each step in the following order.

Rhythm Regularity

  • P wave morphology
  • P R interval or PRi
  • QRS complex duration and morphology
  • Carefully measure from the tip of one R wave to the next, from the beginning to the end of the tracing.
  • A rhythm is considered “regular or constant” when the distance apart is either the same or varies by 1 ½ small boxes or less from one R wave to the next R wave.

Heart Rate Regular (Constant) Rhythms

  • 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. This technique will give you the most accurate heart rate when analyzing regular heart rhythms. You may include ½ of a small box i.e. 1500/37.5 = 40 bpm (don’t forget to round up or down if a portion of a beat is included in the answer).

Step 2 (Cont)

Heart rate - 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 cardiac complexes in six seconds and multiply by ten.

P wave Morphology (shape)

  • Lead II is most commonly referenced in cardiac monitoring
  • In this training module, lead two will specifically be referenced unless otherwise specified.
  • The P wave in lead II in a normal heart is typically rounded and upright in appearance.
  • Changes in shape must be reported. This can be an indicator that the locus of stimulation is changing or the pathway taken is changing.
  • P waves may come in a variety of morphologies i.e. rounded and upright, peaked, flattened, notched, biphasic(pictured), inverted and even buried or absent!
  • Remember to describe the shape. This can be very important to the physician when diagnosing the patient.

PR interval (PRi)

  • Measurement of the PR interval reflects the amount of time from the beginning of atrial depolarization to the beginning of ventricular depolarization.
  • Plainly stated, this measurement is 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)
  • It is important that you measure each PR interval on the rhythm strip.
  • 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.

QRS complex

  • 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 in step 3, when referring to P waves, remember changes in the shape of the waveform can indicate the locus 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.
  • The normal duration of the QRS complex is: 0.06 – 0.10 second

Lesson #2: Interpretation 312

Introduction.

  • 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.

Atrial Dysrhythmias Types

The dysrhythmias in this category occur as a result of problems in the atria. These atrial dysrhythmias primarily affect the P wave. We will be discussing the following complexes and rhythms:

  • Premature Atrial Complexes (PAC’s)

Lesson #3: Premature Atrial Complex

Intro to pacs.

  • PACs can occur for a number of different reasons i.e., diet, fatigue, stress, disease, ischemia to name a few.
  • Premature complexes frequently occur in bradycardic rhythms, but may occur almost any time.
  • PACs occur when an early electrical impulse occurs from a location in the atria other than the SA node.

Intro to PACs 2

  • This early impulse causes an early cardiac complex which disrupts the underlying rhythm.
  • The locus of stimulation being different, results in a change in the morphology of the P wave.
  • PACs can occur occasionally or frequently.
  • PACs ECG can be observed with or without a pattern
  • The P wave with PAC's will always be upright

EKG Analysis

Notice the following: the R to R interval is irregular, the fifth complex is early and the P wave on the early complex is a different shape.

EKG Practice Strip

Analyze this tracing using the five steps of rhythm analysis.

  • Rhythm: Irregular
  • P wave: Upright & uniform (except early complexes - biphasic)
  • PR interval: 0.16 second
  • Interpretation: Sinus Bradycardia with PACs

Lesson #4: Wandering Atrial Pacemaker

Description.

  • Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring.
  • Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering.
  • These changes in the locus of stimulation affect the morphology of the P waves.
  • In Wandering Atrial Pacemaker ECG, you must observe at least three different shaped P waves. No other changes in the tracing may be observed. The rhythm may or may not be regular.
  • The PR interval is often affected, but does not have to be.
  • The bottom line, is you must observe at least three different shaped P waves.

Practice Strip

  • P wave: Changing Shapes (3 or more)
  • PR interval: Variable
  • Interpretation: Wandering Atrial Pacemaker

Lesson #5: Multifocal Atrial Tachycardia

  • Multifocal Atrial Tachycardia is just a faster version of Wandering Atrial Pacemaker. The criteria is the same as Wandering Atrial Pacemaker with the only difference being the heart rate exceeds 100 bpm.
  • These changes in the locus of stimulation within the atria affect the morphology of the P waves.
  • Remember, you must observe at least three different shaped P waves.
  • Due to the presence of irregular R to R intervals coupled with the changing P wave morphology, some people have confused this rhythm with Atrial Fibrillation.

Lesson #6: Atrial Flutter

  • Atrial Flutter (sometimes called a flutter) occurs when there is an obstruction within the atrial electrical conduction system.
  • Due to this impediment a series of rapid depolarizations occur.
  • These depolarizations may occur two, three, four or more times per QRS complex.
  • The AV node functions like a “gatekeeper” blocking the extra impulses until the ventricular conduction system is able to accept the impulse.
  • The impulse that is accepted will cause the QRS complex to occur.
  • Each atrial flutter ECG wave represents atrial depolarization. This will be noted next to the P wave step in rhythm analysis. Instead of P waves, this tracing has “F” waves. No P waves mean there is no PR interval measurement.
  • When the tracing is interpreted, the ratio of F waves to each QRS complex will be documented along with the rhythm i.e. Atrial Flutter 4:1 (indicates 4 “F” waves to each QRS complex). Not all Atrial Flutter rhythm strips will have a regular rhythm. In that case just document and report your observations.
  • Compare your answers with the answers on the next slide.

Practice Strip Answers

  • Rhythm: Regular
  • Rate: Ventricles - 80, Atria - 320
  • P wave: "F" waves
  • PR interval: absent
  • Interpretation: Atrial Flutter 4:1

Lesson #7: Atrial Fibrillation

  • Atrial Fibrillation (afeb) occurs when multiple electrical impulses occur within the atria. This chaotic electrical activity results in a chaotic wave form between the QRS complexes. P waves are absent. They are replaced by lower case "f" waves. No P waves means there is no PR interval measurement.
  • This rapid electrical activity overwhelms the AV node causing impulses to enter the ventricular conduction system at irregular points. This results in irregular R to R intervals.
  • Not all fibrillatory waves are created equal. The "f" waves can be coarse (majority measure 3 mm or more) or can be fine (majority of waveforms measure less than 3 mm) to almost absent. Regardless always report your observations. Many times when a patient has "new onset" Atrial Fibrillation the patient will report with a heart rate of 160 bpm or more.
  • When a patient experiences A-fib, the atria are not contracting as they normally would. They are just quivering. This absence of contraction of the atria can result in a loss of cardiac output anywhere from 15 - 30% due to the absence of "atrial kick". This is why the heart rate is so high. The body is trying to maintain homeostasis.
  • It will be impossible to determine the atrial rate. You will only be able to analyze and report the ventricular rate.
  • Atrial Fibrillation with a ventricular response in excess of 100 bpm is commonly referred to as Atrial Fibrillation with “rapid ventricular response” or "uncontrolled A-fib".
  • Rate: Ventricles - 90, Atria - Unable to determine (UTD)
  • P wave: "f" waves
  • Interpretation: Atrial Fibrillation

Lesson #8: Quiz Test Questions 312

Authors and reviewers.

  • EKG heart rhythm modules: Thomas O'Brien
  • Medical review: Dr. Jonathan Keroes, MD
  • Medical review: Dr. Pedro Azevedo, MD, Cardiology
  • Last Update: 11/8/2021
  • Electrocardiography for Healthcare Professionals, 6th Edition Kathryn Booth and Thomas O'Brien ISBN10: 1265013470, ISBN13: 9781265013479 McGraw Hill, 2023
  • Rapid Interpretation of EKG's, Sixth Edition Dale Dublin Cover Publishing Company
  • EKG Reference Guide EKG.Academy
  • 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs Aaron Reed Create Space Independent Publishing
  • The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG Jonathan Keroes, David Lieberman Publisher: Lippincott Williams & Wilkin) ISBN-10: 0781784425; ISBN-13: 978-0781784429
  • ECG Reference Guide PracticalClinicalSkills.com

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IMAGES

  1. Wandering pacemaker (WPM) : e-cardiogram

    description wandering pacemaker

  2. Alila Medical Media

    description wandering pacemaker

  3. WAP

    description wandering pacemaker

  4. What Is a Wandering Atrial Pacemaker and What Should You Know About It

    description wandering pacemaker

  5. Wandering atrial pacemaker (WAP)

    description wandering pacemaker

  6. Wandering Atrial Pacemaker Flashcards

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VIDEO

  1. One Quality Pacemaker

  2. Wandering Pacemaker Rhythm

  3. Multifocal Atrial Tachycardia (MAT)

  4. Pacemakers

  5. Universal Project

  6. Advances in Pacemaker Technology

COMMENTS

  1. Wandering atrial pacemaker

    Wandering atrial pacemaker (WAP) is an atrial rhythm where the pacemaking activity of the heart originates from different locations within the atria. This is different from normal pacemaking activity, where the sinoatrial node (SA node) is responsible for each heartbeat and keeps a steady rate and rhythm. Causes of wandering atrial pacemaker are unclear, but there may be factors leading to its ...

  2. Wandering Atrial Pacemaker: What Is It?

    A wandering atrial pacemaker is usually found with an electrocardiogram ( EKG or ECG). It's a test that lets your doctor see a record of the electrical signals in your heart. If the irregular ...

  3. Wandering Atrial Pacemaker (WAP) ECG Review

    Wandering Atrial Pacemaker (WAP) is a cardiac rhythm disorder that causes irregular and variable heartbeats. Learn the Heart - Healio provides a comprehensive ECG review of this condition ...

  4. WAP vs. MAT on ECG: What's the difference?

    This results in at least three different P wave morphologies, and often the PR interval may vary due to this. If the heart rate is less than 100 BPM we call this a wandering atrial pacemaker, or WAP. If it's greater than 100 BPM we call it a multifocal atrial tachycardia, or MAT for short.

  5. Wandering Atrial Pacemaker EKG Interpretation with Rhythm Strip

    This article is a guide for interpreting abnormal Wandering Atrial Pacemaker EKGs, including qualifying criteria and a sample EKG rhythnm strip. Wandering atrial pacemaker is an arrhythmia originating in shifting pacemaker sites from the SA node to the atria and back to the SA node. On an ECG, the p-waves reflect the pacemaker shifts by shape variations. The PRI interval may vary from one beat ...

  6. Wandering Atrial Pacemaker

    This rhythm and multifocal atrial tachycardia are similar except for heart rate. The other possible explanation is that there is significant respiratory sinus arrhythmia, with uncovering of latent foci of pacemaker activity. Usually, it is associated with underlying lung disease. In the elderly, it may be a manifestation of sick sinus syndrome.

  7. Wandering Atrial Pacemaker ECG Interpretation #312

    Description. Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring. Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering.

  8. Wandering Pacemaker

    Wandering Pacemaker. Wandering pacemaker. Every p-wave is different and thus has a different origin. When several pacemakers are competing, p-waves with different origins and thus configurations occur. The rhythm is slightly different from beat to beat. note If the heart rate increases to above 100bpm, it is called Multifocal Atrial Tachycardia.

  9. Wandering atrial pacemaker

    Wandering atrial pacemaker. Non-arrhythmic cardiac causes: Acute coronary syndrome. Cardiomyopathy. Congenital heart disease. Congestive heart failure (CHF) Mitral valve prolapse. Pacemaker complication. Pericarditis.

  10. Wandering Atrial Pacemaker ECG Interpretation with Sample Strip

    Wandering Atrial Pacemaker Rhythm Strip Features. Rate: Normal (60-100 bpm) Rhythm: May be irregular. P Wave: Changing shape and size from beat to beat (at least three different forms) PR Interval: Variable. QRS: Normal (0.06-0.10 sec) The electrical impulses causing the atrial activity are moving or wandering.

  11. ECG Interpretation: Blog #200

    Technically, for a rhythm to be classified as a wandering pacemaker — there should be gradual shift between at least 3 different atrial sites.Since we only see 2 different atrial sites (highlighted by RED and BLUE arrows) in Figure-2 — we would need a longer period of monitoring to prove this rhythm is a wandering pacemaker.That said — wandering pacemaker is the most logical explanation ...

  12. Heart Atrium Pacemaker

    Wandering atrial pacemaker Description. Wandering atrial pacemaker (WAP) (Fig. 3.12) is an atrial rhythm with multiple P-wave morphologies (three or more), often occurring in a repetitive pattern at a rate of less than 100 bpm. The pattern may be dependent on autonomic tone and the respiratory phase (with competing activation from the sinus ...

  13. What Is a Wandering Atrial Pacemaker?

    A wandering atrial pacemaker is a specific arrhythmia that can affect the heart. A condition that affects the rhythm or rate of the heartbeat is known as an arrhythmia. There are wide varieties of arrhythmia, including an irregular beat, an extra beat, and a fast or slow heart rate.

  14. Wandering Atrial Pacemaker: Understanding Your EKG (ECG)

    Diagnose Wandering Atrial Pacemaker with confidence! This video explores the shifting pacemaker sites and the resulting "multifocal P waves" observed on an E...

  15. Multifocal atrial tachycardia; EkG STRIP SEARCH

    If the rate is more than 100, this would be considered Multifocal Atrial Tachycardia (MAT). It is possible for a wandering atrial pacemaker to occur more often in the young and among athletes. The cause usually stems from an augmented vagal tone. An increase in the vagal tone causes a slower heart rate and allows the AV node or the atria to ...

  16. Electrical Injury and Wandering Atrial Pacemaker

    Wandering atrial pacemaker (WAP) is a benign atrial arrhythmia observed in elderly patients suffering from obstructive pulmonary diseases that result from an ischemic heart. This report discusses WAP as observed in a patient who suffered an electrical injury. Keywords: wandering atrial pacemaker, voltage, electrical injury, arrhythmia, ampere.

  17. Pacemaker

    A pacemaker is a small, battery-powered device that prevents the heart from beating too slowly. You need surgery to get a pacemaker. The device is placed under the skin near the collarbone. A pacemaker also is called a cardiac pacing device. There are different types of pacemakers. Single chamber pacemaker. This type usually sends electrical ...

  18. Wandering atrial pacemaker (Concept Id: C1321523)

    Wandering atrial pacemaker (195101003) Definition. An electrocardiographic finding of a supraventricular arrhythmia characterized by 3 or more distinct P wave morphologies with an isoelectric baseline, variable PR intervals and no predominant atrial rhythm. The ventricular rate is typically below 100 beats per minute.

  19. Pacemaker

    A pacemaker is a small battery-operated device that helps the heart beat in a regular rhythm. Traditional pacemakers have three parts: a generator, wires (leads) and sensors (electrodes). Some newer pacemakers are wireless. It produces electrical impulses to help control abnormal heartbeats.

  20. Atrial Rhythms

    Description. Rhythms are often named according to the origin of the electrical activity in the heart or the structure where the problem is occurring. Wandering Atrial Pacemaker is aptly named due to the electrical impulses causing the atrial activity are moving or wandering.

  21. Wandering Atrial Pacemaker Flashcards

    Wandering atrial pacemaker/ectopic tachycardia is the passive transfer of pacemaker sites to other latent pacemaker sites in the atria and AV junction. Often, more than one pacemaker will be active causing variation in RR interval and P wave morphology. Study with Quizlet and memorize flashcards containing terms like Description (WAP), Etiology ...

  22. Wandering atrial pacemaker

    Description. Wandering atrial pacemaker - ECG Diagnosis • The change in P wave contour is gradual • After several cycle the pacemaker shifts back to the sinus node. • Variant of sinus arrhythmia Note: A loooooonngggg strip is needed to appreciate this rhythm #wap #Wandering #atrial #pacemaker #cardiology #diagnosis #ekg #ecg # ...

  23. ECG

    Study with Quizlet and memorize flashcards containing terms like Rhythm is slightly irregular Rate 60-100 bpm P Wave has continuous changes (3 diff waves) PR interval varies QRS duration normal, WAP can be related to organic heart disease or drug toxicity WAP is a normal finding in children, older adults, and well-conditioned athletes., A more serious atrial Dysrhythmia and more.