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Sinus arrest, Sinoatrial exit block,
AV blocks, Escape Rhythms
Dr. Michael-Joseph F. Agbayani, MD FPCP FPCC

@HeartRhythmMD
Images used are mine or under a creative commons
license or public domain.
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
SA node: 60 to 100
SA node: 60 to 100
bpm
bpm
AV Junction: 40 to
AV Junction: 40 to
60 bpm
60 bpm

Ventricle: <40 bpm
Ventricle: <40 bpm
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Sinoatrial Exit Block
• Sinus node still firing
• Impulse fails to conduct beyond SA node
• Degrees
– First degree SA exit block
– Second degree SA exit block (Type 1 and type 2)
– Third degree SA exit block
First degree sinoatrial block
• First degree
– Delay in conduction of sinus impulse
– Not evident in a surface ECG
Second degree sinoatrial block
• Intermittent failure of the sinus impulse to
exit the node
• Type 1
– Progressive delay in sinus impulse resulting in
non-conducted impulse
– Group beating (Wenckebach periodicity)
Second degree sinoatrial block type 1
Second-degree sinoatrial block
• Type 2
– Failed conduction of sinus impulse without
progressive prolongation of sinoatrial conduction
time
– Pause is a multiple of baseline P-P interval
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Third-degree sinoatrial block
• None of the sinus node impulses are able to
exit the node
• Absence of p waves
• Indistinguishable from sinus arrest
Sinus Pause / Sinus Arrest
• Sinus node doesn’t fire
• P-P interval of the pause not a multiple of the
baseline P-P interval
• Usually said to be abnormal if > 3 seconds
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
First degree AV block
•
•
•
•

PR interval is > 200 ms and is constant
Each p wave is followed by QRS complex
Marked first degree is >300 ms
May be symptomatic
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Second Degree AV Block
•
•
•
•

One non-conducted p wave
Mobitz Type 1 (Wenckebach Block)
Mobitz Type 2
2:1 AV block
Mobitz Type 1 (Wenckebach)
• Gradual prolongation of PR interval until nonconducted p wave
• RP-PR reciprocity
• Lengthening of the PR interval at progressively
shorter decrements
• Progressively shorter R-R intervals and group beating
• Shortening back to baseline PR interval after the
blocked cycle
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Mobitz Type 2
• No change in PR before non-conducted P
wave
• Usually associated with His-Purkinje disease
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
2:1 AV block
• Second degree AV block
• Every other beat is conducted
• PR interval in conducted beats is usually
constant
2:1 AV block
• Classifying into Mobitz Type 1 or type 2 is
discouraged
• Clues to level of block
– Narrow vs wide complex
– Long or short PRs in conducted beats
– PR and RP relationship
– Presence of Mobitz Type 1 block
– Response to Atropine or exercise
2:1 AV block
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
High Grade AV Block
• At least 2 consecutive non-conducted P waves
(3:1 AV Block)
• Also called “advanced second-degree heart
block”
• Look at the PR interval of conducted beats:
should be constant
4:1 AV block
3rd Degree or Complete Heart Block
• None of the P waves are conducted
• P waves and QRS complexes occur
independently of each other
• R-R intervals are usually regular (junctional or
ventricular escape rhythm)
SA node: 60 to 100
SA node: 60 to 100
bpm
bpm
AV Junction: 40 to
AV Junction: 40 to
60 bpm
60 bpm

Ventricle: <40 bpm
Ventricle: <40 bpm
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
• R-R intervals are usually regular (escape
rhythm)
• “PR” intervals are not constant / no pattern
• Escape rhythm can be junctional or ventricular
Escape Rhythms
• Atrial escape rhythm (<60 bpm)
– P wave morphology abnormal

• Junctional rhythm (40 to 60 bpm)
– Narrow QRS
– Retrograde P waves shortly before or after QRS, if
any

• Ventricular rhythm (<40 bpm)
– Wide, “bizarre” QRS complexes
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
SA node: 60 to 100
SA node: 60 to 100
bpm
bpm
AV Junction: 40 to
AV Junction: 40 to
60 bpm
60 bpm

Ventricle: <40 bpm
Ventricle: <40 bpm
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Images
•
•
•
•
•
•
•
•
•
•
•

Heart image with conduction system: Public Domain image from Gray’s Anatomy
QRS complex: Public Domain image from Wikipedia user
http://en.wikipedia.org/wiki/User:Agateller
Road Block sign: http://en.wikipedia.org/wiki/File:Road_block.jpg
Traffic: http://en.wikipedia.org/wiki/File:Traffic_jam_on_Phu_Nhuan_district.JPG
Sinoartial exit block: http://commons.wikimedia.org/wiki/User:Jer5150
First degree AV block: http://www.flickr.com/photos/popfossa/
Second Degree AV block Mobitz Type 1:
http://commons.wikimedia.org/wiki/User:Jer5150
Mobitz type 2 and 2:1: http://commons.wikimedia.org/wiki/User:Jer5150
Complete heart block: http://commons.wikimedia.org/wiki/User:Jer5150
Complete heart block strip: http://en.wikipedia.org/wiki/User:MoodyGroove
Junctional rhythm: http://www.flickr.com/photos/nottinghamvets/
Images
•
•
•
•
•
•
•
•

Sinus pause: http://commons.wikimedia.org/wiki/User:Stevenfruitsmaak
Mobitz Type 1 with escape: Michael Rosengarten BEng, MD.McGill
(ecgpedia.org)
SCT with Pause: Michael Rosengarten BEng, MD.McGill (ecgpedia.org)
Mobitz type 1 and type 2 strips: Munther Homoud, M.D.
(http://ocw.tufts.edu/)
Mobitz Type II: http://lifeinthefastlane.com/author/edward-burns/
High Grade AV block: http://lifeinthefastlane.com/author/edward-burns/
Ventricular Escape rhythm: http://lifeinthefastlane.com/author/edwardburns/
Fixed ratio blocks: http://lifeinthefastlane.com/author/edward-burns/
SA exit block, Sinus Arrest, AV Blocks and Escape Rhythms

ECG EXERCISE
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Images
•
•
•
•
•
•
•
•
•

First Degree AV block: http://www.flickr.com/photos/popfossa/
4:1 AV block: http://www.flickr.com/photos/popfossa/
Mobitz type 1: http://www.flickr.com/photos/popfossa/
First Degree AV block: http://www.flickr.com/photos/popfossa/
Type II Sinoatrial exit block: http://lifeinthefastlane.com/author/edward-burns/
Mobitz type 1: http://lifeinthefastlane.com/author/edward-burns/
Complete Heart Block; http://lifeinthefastlane.com/author/edward-burns/
Sinus arrest: http://lifeinthefastlane.com/author/edward-burns/
High grade Av block and Mobitz Type 2:
http://lifeinthefastlane.com/author/edward-burns/
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ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

  • 1. Sinus arrest, Sinoatrial exit block, AV blocks, Escape Rhythms Dr. Michael-Joseph F. Agbayani, MD FPCP FPCC @HeartRhythmMD
  • 2. Images used are mine or under a creative commons license or public domain.
  • 5. SA node: 60 to 100 SA node: 60 to 100 bpm bpm AV Junction: 40 to AV Junction: 40 to 60 bpm 60 bpm Ventricle: <40 bpm Ventricle: <40 bpm
  • 8. Sinoatrial Exit Block • Sinus node still firing • Impulse fails to conduct beyond SA node • Degrees – First degree SA exit block – Second degree SA exit block (Type 1 and type 2) – Third degree SA exit block
  • 9. First degree sinoatrial block • First degree – Delay in conduction of sinus impulse – Not evident in a surface ECG
  • 10. Second degree sinoatrial block • Intermittent failure of the sinus impulse to exit the node • Type 1 – Progressive delay in sinus impulse resulting in non-conducted impulse – Group beating (Wenckebach periodicity)
  • 11. Second degree sinoatrial block type 1
  • 12. Second-degree sinoatrial block • Type 2 – Failed conduction of sinus impulse without progressive prolongation of sinoatrial conduction time – Pause is a multiple of baseline P-P interval
  • 14. Third-degree sinoatrial block • None of the sinus node impulses are able to exit the node • Absence of p waves • Indistinguishable from sinus arrest
  • 15. Sinus Pause / Sinus Arrest • Sinus node doesn’t fire • P-P interval of the pause not a multiple of the baseline P-P interval • Usually said to be abnormal if > 3 seconds
  • 18. First degree AV block • • • • PR interval is > 200 ms and is constant Each p wave is followed by QRS complex Marked first degree is >300 ms May be symptomatic
  • 20. Second Degree AV Block • • • • One non-conducted p wave Mobitz Type 1 (Wenckebach Block) Mobitz Type 2 2:1 AV block
  • 21. Mobitz Type 1 (Wenckebach) • Gradual prolongation of PR interval until nonconducted p wave • RP-PR reciprocity • Lengthening of the PR interval at progressively shorter decrements • Progressively shorter R-R intervals and group beating • Shortening back to baseline PR interval after the blocked cycle
  • 24. Mobitz Type 2 • No change in PR before non-conducted P wave • Usually associated with His-Purkinje disease
  • 28. 2:1 AV block • Second degree AV block • Every other beat is conducted • PR interval in conducted beats is usually constant
  • 29. 2:1 AV block • Classifying into Mobitz Type 1 or type 2 is discouraged • Clues to level of block – Narrow vs wide complex – Long or short PRs in conducted beats – PR and RP relationship – Presence of Mobitz Type 1 block – Response to Atropine or exercise
  • 32. High Grade AV Block • At least 2 consecutive non-conducted P waves (3:1 AV Block) • Also called “advanced second-degree heart block” • Look at the PR interval of conducted beats: should be constant
  • 34. 3rd Degree or Complete Heart Block • None of the P waves are conducted • P waves and QRS complexes occur independently of each other • R-R intervals are usually regular (junctional or ventricular escape rhythm)
  • 35. SA node: 60 to 100 SA node: 60 to 100 bpm bpm AV Junction: 40 to AV Junction: 40 to 60 bpm 60 bpm Ventricle: <40 bpm Ventricle: <40 bpm
  • 37. • R-R intervals are usually regular (escape rhythm) • “PR” intervals are not constant / no pattern • Escape rhythm can be junctional or ventricular
  • 38. Escape Rhythms • Atrial escape rhythm (<60 bpm) – P wave morphology abnormal • Junctional rhythm (40 to 60 bpm) – Narrow QRS – Retrograde P waves shortly before or after QRS, if any • Ventricular rhythm (<40 bpm) – Wide, “bizarre” QRS complexes
  • 40. SA node: 60 to 100 SA node: 60 to 100 bpm bpm AV Junction: 40 to AV Junction: 40 to 60 bpm 60 bpm Ventricle: <40 bpm Ventricle: <40 bpm
  • 44. Images • • • • • • • • • • • Heart image with conduction system: Public Domain image from Gray’s Anatomy QRS complex: Public Domain image from Wikipedia user http://en.wikipedia.org/wiki/User:Agateller Road Block sign: http://en.wikipedia.org/wiki/File:Road_block.jpg Traffic: http://en.wikipedia.org/wiki/File:Traffic_jam_on_Phu_Nhuan_district.JPG Sinoartial exit block: http://commons.wikimedia.org/wiki/User:Jer5150 First degree AV block: http://www.flickr.com/photos/popfossa/ Second Degree AV block Mobitz Type 1: http://commons.wikimedia.org/wiki/User:Jer5150 Mobitz type 2 and 2:1: http://commons.wikimedia.org/wiki/User:Jer5150 Complete heart block: http://commons.wikimedia.org/wiki/User:Jer5150 Complete heart block strip: http://en.wikipedia.org/wiki/User:MoodyGroove Junctional rhythm: http://www.flickr.com/photos/nottinghamvets/
  • 45. Images • • • • • • • • Sinus pause: http://commons.wikimedia.org/wiki/User:Stevenfruitsmaak Mobitz Type 1 with escape: Michael Rosengarten BEng, MD.McGill (ecgpedia.org) SCT with Pause: Michael Rosengarten BEng, MD.McGill (ecgpedia.org) Mobitz type 1 and type 2 strips: Munther Homoud, M.D. (http://ocw.tufts.edu/) Mobitz Type II: http://lifeinthefastlane.com/author/edward-burns/ High Grade AV block: http://lifeinthefastlane.com/author/edward-burns/ Ventricular Escape rhythm: http://lifeinthefastlane.com/author/edwardburns/ Fixed ratio blocks: http://lifeinthefastlane.com/author/edward-burns/
  • 46. SA exit block, Sinus Arrest, AV Blocks and Escape Rhythms ECG EXERCISE
  • 56. Images • • • • • • • • • First Degree AV block: http://www.flickr.com/photos/popfossa/ 4:1 AV block: http://www.flickr.com/photos/popfossa/ Mobitz type 1: http://www.flickr.com/photos/popfossa/ First Degree AV block: http://www.flickr.com/photos/popfossa/ Type II Sinoatrial exit block: http://lifeinthefastlane.com/author/edward-burns/ Mobitz type 1: http://lifeinthefastlane.com/author/edward-burns/ Complete Heart Block; http://lifeinthefastlane.com/author/edward-burns/ Sinus arrest: http://lifeinthefastlane.com/author/edward-burns/ High grade Av block and Mobitz Type 2: http://lifeinthefastlane.com/author/edward-burns/
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