Sinus and Escape Rhythms

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Chapter 13 Sinus and Escape Rhythms

Please go to expertconsult.com for supplemental chapter material.

Part II of this book deals with cardiac rhythms in health and disease. A key set of questions asks the following: What pacemaker(s) is (are) controlling the heartbeat? Is the controller entirely in the sinus node (the normal pacemaker)? Or is sinus rhythm present, accompanied by extra (ectopic) heartbeats? Ectopic beats come in two general classes: (1) they may be premature, occurring before the next sinus beat is due, or (2) they may come after a pause or delay, so-called escape beats.

This chapter discusses sinus rhythms and on certain escape or subsidiary pacemakers that act as “backup electrical generators.” Subsequent chapters deal with premature beats and major ectopic rhythms, both supraventricular and ventricular, as well as with the major forms of atrioventricular (AV) heart block and AV dissociation. In complete AV block, sinus rhythm may control the atria while the ventricles are controlled by a lower pacemaker, in the AV junction or in the His-Purkinje-ventricular system.

Sinus Rhythms

“Normal” Sinus Rhythm

Sinus rhythm is the primary physiologic mechanism of the heartbeat. You diagnose it by finding P waves with a predictable polarity (see Chapter 4). When the sinus (also called the sinoatrial or SA) node is pacing the heart, atrial depolarization spreads from right to left and downward toward the AV junction. An arrow representing this depolarization wave points downward and toward the (patient’s) left. Therefore, with normal sinus rhythm, the P wave is always positive in lead II and negative in lead aVR (see Figs. 4-3 and 13-1).

By convention, normal sinus rhythm in a resting subject is usually defined as sinus rhythm with a heart rate between 60 and 100 beats/min. Sinus rhythm with a heart rate greater than 100 beats/min is termed sinus tachycardia (Fig. 13-2). Sinus rhythm with a heart rate of less than 60 beats/min is called sinus bradycardia (Fig. 13-3). Some authors define sinus bradycardia based on a heart rate of less than 50 beats/min.

Regulation of the Heart Rate

The heart, like other organs, has a special nerve supply from the autonomic nervous system, which controls involuntary muscle action. The autonomic nerve supply to the heart (in particular, the SA and AV nodes) consists of fibers with opposing effects: the sympathetic nerves and the parasympathetic nerves. Sympathetic stimulation increases the heart rate and the strength of myocardial contraction. Sympathetic stimulation also occurs by secretion of circulating hormones called catecholamines (especially, norepinephrine and epinephrine), produced by the adrenal glands.

Parasympathetic stimulation (from the vagus nerve) produces slowing of the sinus rate as well as increased conduction time through the AV nodal area. It can also cause a pacemaker “shift” from the SA node to the low right atrial area producing so-called low atrial rhythm with negative P waves in leads II, III, and aVF (Fig. 13-4).

In this way the autonomic nervous system exerts a counterbalancing control of the heart rate. The sympathetic nervous system acts as a cardiac accelerator, whereas the parasympathetic (vagal) stimulation produces a braking effect. For example, when you become excited or upset, or are exercising, increased sympathetic stimuli (and diminished parasympathetic tone) result in an increased heart rate and increased contractility, producing the familiar sensation of a pounding sensation in the chest (palpitations).

Note that the sensation of “palpitations” may be associated with an entirely normal heartbeat, with isolated premature beats (atrial or ventricular), or, more seriously, with an actual run of ectopic (nonsinus) heartbeats (e.g., from atrial fibrillation, paroxysmal supraventricular tachycardia, or ventricular tachycardia).