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A-FIB VERSUS JUNCTIONAL RHYTHMS

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A-FIB VERSUS JUNCTIONAL RHYTHMS


ATRIAL FIBRILLATION: On your rhythm strip, the two most important characteristics are:
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1) A rhythm that’s IRREGULARLY irregular (meaning there’s no way to predict the next beat)
2) No discernible P waves
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In fact, if you notice an irregularly irregular rhythm and you’re having to convince yourself that you see P waves... it’s probably A-fib (multifocal atrial arrhythmias like WAP/MAT could fit the differential)
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*In my opinion: Don’t get caught up in using fibrillation waves as an absolute criteria. Very fine A-fib can sometimes produce a near isoelectric line between beats.
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JUNCTIONAL RHYTHMS: The pacemaker cells surrounding the AV junction are capable of initiating regular impulses but at a slightly slower natural rate than their sinus and atrial superiors. The heart is built this way so that when the pacemaker cells with the fastest intrinsic rates are in action, those below are suppressed and function primarily to pass along the impulse from above.
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For these reasons, we should expect the junctional family to produce a REGULAR rhythm (marches out) unlike A-fib (from a basic rhythms perspective, exceptions exist; i.e. A-fib with CHB or ventricular pacing).
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P waves associated with junctional rhythms have three potential appearances: 1) inverted before the QRS 2) inverted after the QRS, or 3) buried within the QRS (absent). The appearance will depend upon how high or low the impulse is originating along the conduction pathway.
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*From a single lead, basic rhythms perspective. Exceptions exist in the real world*

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