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Atrial Fibrillation (AF)
Diagnostic criteria
P waves are absent.
There are fibrillation (f) waves instead of P waves.
The f waves result in an oscillating irregular baseline.
The R-R intervals are not equal resulting in an irregular rhythm (irregularly irregular).
Triggers of atrial fibrillation
Atrial premature contractions - APC ( the most frequent )
Atrial flutter
Supraventricular tachycardias
Bradycardia
Acute atrial stretch
Clinical significance
Atrial fibrillation patients usually have a ventricular rate of 100-180 beats/minute. This is why these patients frequently complain of palpitation.
Wolff-Parkinson-White (WPW) Syndrome should be suspected if there is a higher ventricular rate. This high ventricular response may cause syncope or even death in these patients.
At first glance, atrial fibrillation with slow ventricular response may give the impression of complete atrioventricular (AV) block.
A lower ventricular rate with IRREGULAR QRS intervals may suggest the use of medications decreasing the ventricular rate (digoxin, beta blocker, verapamil, diltiazem, amiodarone).
A lower ventricular rate with REGULAR QRS intervals should suggest the presence of complete atrioventricular (AV) block (may or may not be due to the use of medications decreasing the ventricular rate (digoxin, beta blockers, verapamil, diltiazem, amiodarone).
Since R-R intervals continously change in atrial fibrillation patients, the heart rate on the monitor) also changes continously. In such patients, the instantenous heart rates depicted on the monitor does not give the average ventricular rate of that patient.
Since there is no atrial contraction, atrial fibrillation decreases cardiac output by 20-25%. This is the reason why these patients usually complain of exercise intolerance and easy fatigability.
Atrial fibrillation results in atrial stasis which predisposes to the thrombus formation and systemic embolism. Unless contraindicated, patients with atrial fibrillation are advised to be anticoagulated.
If ventricular rate is very high during atrial fibrillation, it may be difficult to recognize irregularity of R-R intervals, at first glance.
In some patients, atrial fibrillation is not persistent. 24-hour Holter monitoring may be used to diagnose these paroxysmal episodes.
When compared with atrial flutter, controlling of ventricular rate is easier in atrial fibrillation.
ECG 1. Three criteria of the atrial fibrillation: absent P waves, oscillating irregular baseline, irregular R-R intervals.
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ECG 2. Atrial fibrillation with a slow ventricular response.
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ECG 3. Paroxysmal atrial fibrillation attack observed in Holter recording.
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ECG 4. Atrial fibrillation in a patient with old anterior myocardial infarction. P waves are absent, R-R intervals are irregular
and baseline is oscillating.
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ECG 5. Fine atrial fibrillation with a slow ventricular response. P waves are absent, R-R intervals are irregular and baseline is
finely oscillating (no coarse fibrillation waves are observed).
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ECG 6a. The above ECG resembles atrial fibrillation at a first glance: P waves seem to be absent, baseline is oscillating and
R-R intervals are irregular. The calibration of the ECG is 10mm/mV.
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ECG 6b. Immediately after recording of the ECG 6a, the calibration of the ECG was adjusted as 20mm/mV to see the details
clearly. The P waves are easily observed now excluding the diagnosis of atrial fibrillation. The patient will not receive
unnecessary oral anticoagulant therapy.
Click here for a more detailed ECG
ECG 7. f (fibrillation) waves are very clearly seen in this patient with coarse wave atrial fibrillation. Fibrillation waves are
irregular and are not uniform in shape. These findings differentiate it from atrial flutter. Generally, f waves are not this large in
patients with AF.
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ECG 8. Paroxysmal atrial fibrillation detected in the Holter recording of an old woman.
The first and the last beats of the paroxysmal atrial fibrillation are marked above.
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ECG 9. Coexistence of left bundle branch block and atrial fibrillation.
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ECG 10a. The ECG above is from a 62 years-old woman with baseline drift, sinus arrhythmia and low amplitude P waves.
The diagnosis may be atrial fibrillation at first glance.
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ECG 10b. The ECG was recorded again. Sinus arrhythmia still persists but lesser baseline drift permits easy recognition
of P waves.
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ECG 10c. Re-recording of the ECG at a calibration of 20 mm/mV shows P waves more clearly.
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ECG 11. The ECG above belongs to a 58 years-old man. The rhythm is atrial fibrillation.
Right bundle branch block pattern (incomplete right bundle branch block) is seen.
The fibrillatory waves in lead V1 make the rSr' pattern hard to notice at first glance.
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EKG 12. Atrial fibrillation with slow ventricular response. The ECG above belongs to an 80 years-old man who had undergone
coronary artery bypass graft operation. Now, he has congestive heart failure.
His medications include Digoxin and beta blocker which are responsible for the slow ventricular rate.
Click here for a more detailed ECG
ECG 13a. The ECG above was recorded from a 44 years-old man with mitral stenosis.
The rhythm is atrial fibrillation with a high ventricular rate.
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ECG 13b. The ECG above belongs to the same man. It was recorded several months after the ECG 13a.
Now he has hypothyroidism and the TSH level is > 100 mIU/mL. This time, the rhythm is atrial fibrillation with a very low
ventricular rate. He is not taking beta blocker or calcium channel blocker. However, the ventricular rate is still low.
Click here for a more detailed ECG
ECG 14. The ECG above is from a 63 years-old man experiencing acute anterior myocardial infarction.
Right bundle branch block is seen. The rhythm is atrial fibrillation: P waves are absent and the RR intervals are irregular.
Coronary angiography, soon after recording of the above ECG, showed total ostial occlusion of the LAD artery.
Click here for a more detailed ECG
ECG 15. Oscillating irregular baseline and irregular RR intervals do not always denote atrial fibrillation.
In the presence of baseline drift and/or tremor artifact P waves may be difficult to detect at first glance.
In the 6-channel ECG above, the basic rhythm is sinus with first degree AV block ( prolonged PR interval )
The precordial recording shows two VPCs. Terminal portion of the first VPC and the second VPC are seen.
Click here for a more detailed ECG
ECG 16a. The ECG above is from a 60 years-old man with ischemic cardiomyopathy due to old anterior myocardial infarction.
His left ventricle is dilated and severely depressed with an ejection fraction of about 20%.
His LAD (Left Anterior Descending) and RCA (Right Coronary Artery) arteries are stented.
The rhythm may look as atrial fibrillation at first glance.
Click here for a more detailed ECG
ECG 16b. Low amplitude P waves and frequent atrial premature beats give the impression of atrial fibrillation at first glance.
The rhythm is NOT atrial fibrillation.
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ECG 17a. The above ECG is from a 52 years-old man. He was diagnosed as having severe mitral stenosis just 2 weeks ago.
(with a mitral valve area of 0.7 cm2). The wide and fragmented P waves denote interatrial block.
The duration of the P wave is more than 4 small squares (>160msec).
The initial portion of the P wave and the second part of it are easily discernible.
ECG 17b. The above ECG belongs to the same man. It was recorded 1 week after ECG 17a when he complained of palpitations.
Interatrial block is associated with the development of atrial fibrillation.
Click here for a more detailed ECG
ECG 18. Sometimes, baseline drift may result in the appearance of atrial fibrillation at first glance.
P waves may not be clearly visible in most of the leads.
The ECG above is from a 69 years-old woman with normal coronary arteries and right bundle branch block.
Low amplitude P waves are barely noticeable in lead V1.
The rhythm is NOT atrial fibrillation, but sinus. The regularity of RR intervals is another sign against atrial fibrillation.
Click here for a more detailed ECG
ECG 19. The ECG above is from a 69 years-old man with coronary artery disease.
He had undergone coronary artery bypass graft operation and then stenting of the right coronary artery (RCA).
When the RR intervals are similar (but not exactly the same) atrial fibrillation may be difficult to diagnose at first glance.
In the above ECG, P waves are absent, oscillating baseline is seen in lead V1 and the RR intervals are not the same:
the rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 20. The ECG above is from a 79 years-old man with coronary artery disease.
He had undergone coronary artery bypass graft surgery several years ago.
His recent coronary angiography showed significant diffuse stenoses in the LAD coronary artery and its Diagonal branches.
Horizontal ST segment depression is seen in left lateral precordial leads.
The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 21. The above ECG shows atrial fibrillation and ventricular bigeminy.
Fibrillatory waves are especially seen in lead V1. P waves are absent.
Each narrow QRS complex is followed by a wide QRS complex (VPC).
The coupling interval of the VPCs are very similar.
Click here for a more detailed ECG
ECG 22a. The ECG above is from a 95 years-old woman with atrial fibrillation and complete av block.
Although atrial fibrillation is known as an "irregularly irregular rhythm", it becomes a regular rhythm
when complete av block developes. RR intervals are regular in the above ECG.
The above ECG is recorded at a standard calibration of 10mm/mV and the fibrillatory waves are hardly noticeable.
Click here for a more detailed ECG
ECG 22b. The above ECG belongs to the same patient.
It is recorded at a calibration of 20 mm/mV.
Now, it is more easy to see the fibrillatory waves.
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ECG 23. Atrial fibrillation or not?
Most of the leads show baseline undulations which suggest atrial fibrillation at first glance.
However, P waves are seen clearly in lead II and the rhythm is regular.
The rhythm is sinus in the above ECG.
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ECG 24. Above ECG is from a 87 years-old woman with old inferior myocardial infarction due to occlusion of the right
coronary artery (RCA). Q waves are seen in inferior leads. Leads III and aVF also show negative T waves.
The rhythm is atrial fibrillation.
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ECG 25. Above ECG is from a 85 years-old woman with normal coronary arteries.
Because of the low amplitude P waves and varying RR intervals, the rhythm seems as atrial fibrillation at first glance.
However, the rhythm is sinus arrhythmia.
Click here for a more detailed ECG
ECG 26a. The ECG above is from a 58 years-old diabetic woman with untreated hypertension.
It was recorded while she was complaining of chest pain and palpitation.
Atrial fibrillation with a rapid ventricular response is seen.
Click here for a more detailed ECG
ECG 26b. The above ECG belongs to the same patient. It was recorded 90 minutes after the ECG 26a.
The rhythm is sinus now. She underwent coronary angiography 2 hours after the above ECG.
Three-vessel (extensive) coronary artery disease was diagnosed and she underwent coronary artery bypass graft surgery.
Click here for a more detailed ECG
ECG 27a. The ECG above is from a 69 years-old woman with the complaints of palpitation and dyspnoea.
The rhythm may seem like supraventricular tachycardia at first glance.
However, it is atrial fibrillation with a rapid ventricular response.
The rhythm is irregularly irregular.
Cardiologist Sinan Altan Kocaman has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 27b. The above ECG belongs to the same patient. It was recorded 20 hours after the ECG 27a.
Medical therapy slowed the ventricular response.
The rhythm is still atrial fibrillation: irregularly irregular with no P waves.
Cardiologist Sinan Altan Kocaman has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 28a. The ECG above belongs to 76 years-old woman with hypertension and coronary artery disease.
She had previously undergone coronary artery bypass grafting surgery.
The ECG shows right bundle branch block.
At first glance, the rhythm may seem like sinus rhythm.
If looked carefully, the irregularity will be noticed. Also lead V1 shows irregular baseline due to fibrillatory waves.
The rhythm is atrial fibrillation but it is not "irregularly irregular" as usual.
The last beat may seem like an atrial premature contraction (APC) at first glance. However, it is not an APC.
Click here for a more detailed ECG
ECG 28b. The ECG above belongs to the same woman. It was recorded 30 seconds before the ECG 28a.
The rhythm is atrial fibrillation.
The 3rd and 6th beats from the left may seem like an atrial premature contraction (APC) at first glance.
However, they are not APCs, since they do not have preceding P waves.
Click here for a more detailed ECG
ECG 29. Above ECG is from a 71 years-old man.
At first glance, the rhythm may seem like sinus rhythm.
If looked carefully, the irregularity will be noticed. Also lead II shows irregular baseline due to fibrillatory waves.
The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 30a. The ECG above belongs to a 46 years-old woman with mitral stenosis.
The rhythm is atrial fibrillation with rapid ventricular response.
This ECG was recorded before the initiation of rate-slowing medications.
Click here for a more detailed ECG
ECG 30b. The ECG above belongs to the same woman. It was recorded 12 days after the ECG 30a.
The rhythm is still atrial fibrillation but the ventricular rate is under control now.
Fibrillatory waves are best seen in leads V1, V2, III and aVF.
Click here for a more detailed ECG
ECG 31. The above rhythm tracing shows transition from atrial fibrillation to sinus rhythm.
When he was admitted to the hospital, the diagnosis of new-onset atrial fibrillation was made and
intravenous Amidoarone infusion was started to convert it to sinus rhythm.
This rhythm tracing was recorded during Amiodarone infusion.
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ECG 32. The 3-channel Holter recording above is from a 71 years-old man with atrial fibrillation.
A long pause of 4.433 seconds is seen in the middle section.
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ECG 33. The ECG above belongs to an 84 years-old woman.
She has chronic obstructive pulmonary disease, left heart failure and chronic renal failure.
The ECG shows atrial fibrillation and low voltage.
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ECG 34. The ECG above is from a 73 years-old obese woman with hypertension.
She has a dilated left ventricle (LV) and left atrium.
The rhythm is atrial fibrillation.
Despite the presence of hypertension and a dilated LV, the ECG shows low voltage due to obesity.
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ECG 35. Above ECG is from a 63 years-old hypoxic obese man with chronic obstructive pulmonary disease (COPD)
It was recorded when he was hospitalized at intensive care unit.
The rhythm is coarse-wave atrial fibrillation with rapid ventricular response.
P waves and a flat baseline are not seen, RR intervals are irregular.
Limb leads show low voltage due to obesity and COPD.
ECHOcardiography showed dilated left atrium, right atrium and right ventricle.
His left ventricular systolic function was normal.
The thickened ECG tracing of chest leads is due to 50/60 Hz AC interference artifact.
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ECG 36. Above is an ECG from a 49 years-old woman with a mechanical mitral valve prosthesis.
ECHOcardiography showed normal left ventricular dimensions with normal systolic function.
Her left atrium, right atrium and right ventricle were dilated.
The rhythm may seem like sinus at first glance. However, it is not.
The rhythm is atrial fibrillation: P waves are not seen, baseline is not stable and RR intervals are irregular.
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ECG 37a. The ECG above belongs to a 63 years-old man with mechanical mitral valve prosthesis.
ECHOcardiography showed dilation of left atrium, right atrium and right ventricle with normal left ventricular systolic function.
Right bundle branch block is seen. What about the rhythm? Is it nodal rhythm or atrial fibrillation?
This ECG was recorded at standard calibration of 10 mm/mV.
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ECG 37b. The ECG above belongs to the same man.
It was recorded a few minutes after the ECG 15a, at a calibration of 20 mm/mV.
Now baseline undulations due to fibrillatory waves are clearly seen. The rhythm is atrial fibrillation.
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ECG 38. The ECG above belongs to a 69 years-old man with coronary artery disease.
He had undergone coronary artery bypass graft surgery and tricuspid annuloplasty in the past.
The rhythm may seem like atrial fibrillation at first glance, but it is not.
The RR intervals are usually regular. P waves become visible when the level of AV block increases.
Isoelectric flat line between the P waves show that the rhythm is not atrial flutter.
If looked carefully, P waves deforming the descending limb of the preceding T waves may be seen in inferior leads.
The rhythm is ectopic atrial tachycardia.
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ECG 39. The ECG above belongs to a 54 years-old man with systemic arterial hypertension.
Coronary angiography did not show significant coronary artery stenosis.
His only medication is Ramipril 2.5mg/day.
He is not taking any beta blocker, non-dihydropyridine calcium channel blocker or ivabradine.
His usual heart rate is below 50/minute.
This ECG shows a short-lasting episode of atrial fibrillation during bradycardia (vagally-mediated atrial fibrillation).
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ECG 40. The ECG above is from a 68 years-old woman with systemic hypertension and atrial fibrillation.
She is taking Digoxin tablets.
Sagging-type ST depression is seen in most of the leads.
The ventricular response is slow due to Digoxin effect. RR intervals are irregular.
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ECG 41. The above ECG shows atrial fibrillation on the left side which suddenly converts to narrow QRS complex tachycardia.
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ECG 42a. The ECG above belongs to a 68 years-old woman with hypertension, heart failure and permanent pacemaker.
Pacemaker rhythm is seen in the above ECG.
Would you anticoagulate this patient?
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ECG 42b. The ECG above belongs to the same woman.
It was recorded 25 minutes after the ECG 42a. The rhythm is irregular.
Now, the rhythm is atrial fibrillation with intermittent pacemaker-induced beats.
She needs anticoagulation.
Sometimes pacemaker rhythm may mask the underlying atrial fibrillation (with slow ventricular rate, as in 42a)
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ECG 42c. The ECG above belongs to the same woman.
It was recorded one minute after the ECG 42b. The rhythm is irregularly irregular.
The rhythm is atrial fibrillation with no pacemaker-induced beats.
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Diagnostic criteria
P waves are absent.
There are fibrillation (f) waves instead of P waves.
The f waves result in an oscillating irregular baseline.
The R-R intervals are not equal resulting in an irregular rhythm (irregularly irregular).
Triggers of atrial fibrillation
Atrial premature contractions - APC ( the most frequent )
Atrial flutter
Supraventricular tachycardias
Bradycardia
Acute atrial stretch
Clinical significance
Atrial fibrillation patients usually have a ventricular rate of 100-180 beats/minute. This is why these patients frequently complain of palpitation.
Wolff-Parkinson-White (WPW) Syndrome should be suspected if there is a higher ventricular rate. This high ventricular response may cause syncope or even death in these patients.
At first glance, atrial fibrillation with slow ventricular response may give the impression of complete atrioventricular (AV) block.
A lower ventricular rate with IRREGULAR QRS intervals may suggest the use of medications decreasing the ventricular rate (digoxin, beta blocker, verapamil, diltiazem, amiodarone).
A lower ventricular rate with REGULAR QRS intervals should suggest the presence of complete atrioventricular (AV) block (may or may not be due to the use of medications decreasing the ventricular rate (digoxin, beta blockers, verapamil, diltiazem, amiodarone).
Since R-R intervals continously change in atrial fibrillation patients, the heart rate on the monitor) also changes continously. In such patients, the instantenous heart rates depicted on the monitor does not give the average ventricular rate of that patient.
Since there is no atrial contraction, atrial fibrillation decreases cardiac output by 20-25%. This is the reason why these patients usually complain of exercise intolerance and easy fatigability.
Atrial fibrillation results in atrial stasis which predisposes to the thrombus formation and systemic embolism. Unless contraindicated, patients with atrial fibrillation are advised to be anticoagulated.
If ventricular rate is very high during atrial fibrillation, it may be difficult to recognize irregularity of R-R intervals, at first glance.
In some patients, atrial fibrillation is not persistent. 24-hour Holter monitoring may be used to diagnose these paroxysmal episodes.
When compared with atrial flutter, controlling of ventricular rate is easier in atrial fibrillation.
ECG 1. Three criteria of the atrial fibrillation: absent P waves, oscillating irregular baseline, irregular R-R intervals.
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ECG 2. Atrial fibrillation with a slow ventricular response.
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ECG 3. Paroxysmal atrial fibrillation attack observed in Holter recording.
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ECG 4. Atrial fibrillation in a patient with old anterior myocardial infarction. P waves are absent, R-R intervals are irregular
and baseline is oscillating.
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ECG 5. Fine atrial fibrillation with a slow ventricular response. P waves are absent, R-R intervals are irregular and baseline is
finely oscillating (no coarse fibrillation waves are observed).
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ECG 6a. The above ECG resembles atrial fibrillation at a first glance: P waves seem to be absent, baseline is oscillating and
R-R intervals are irregular. The calibration of the ECG is 10mm/mV.
Click here for a more detailed ECG
ECG 6b. Immediately after recording of the ECG 6a, the calibration of the ECG was adjusted as 20mm/mV to see the details
clearly. The P waves are easily observed now excluding the diagnosis of atrial fibrillation. The patient will not receive
unnecessary oral anticoagulant therapy.
Click here for a more detailed ECG
ECG 7. f (fibrillation) waves are very clearly seen in this patient with coarse wave atrial fibrillation. Fibrillation waves are
irregular and are not uniform in shape. These findings differentiate it from atrial flutter. Generally, f waves are not this large in
patients with AF.
Click here for a more detailed ECG
ECG 8. Paroxysmal atrial fibrillation detected in the Holter recording of an old woman.
The first and the last beats of the paroxysmal atrial fibrillation are marked above.
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ECG 9. Coexistence of left bundle branch block and atrial fibrillation.
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ECG 10a. The ECG above is from a 62 years-old woman with baseline drift, sinus arrhythmia and low amplitude P waves.
The diagnosis may be atrial fibrillation at first glance.
Click here for a more detailed ECG
ECG 10b. The ECG was recorded again. Sinus arrhythmia still persists but lesser baseline drift permits easy recognition
of P waves.
Click here for a more detailed ECG
ECG 10c. Re-recording of the ECG at a calibration of 20 mm/mV shows P waves more clearly.
Click here for a more detailed ECG
ECG 11. The ECG above belongs to a 58 years-old man. The rhythm is atrial fibrillation.
Right bundle branch block pattern (incomplete right bundle branch block) is seen.
The fibrillatory waves in lead V1 make the rSr' pattern hard to notice at first glance.
Click here for a more detailed ECG
EKG 12. Atrial fibrillation with slow ventricular response. The ECG above belongs to an 80 years-old man who had undergone
coronary artery bypass graft operation. Now, he has congestive heart failure.
His medications include Digoxin and beta blocker which are responsible for the slow ventricular rate.
Click here for a more detailed ECG
ECG 13a. The ECG above was recorded from a 44 years-old man with mitral stenosis.
The rhythm is atrial fibrillation with a high ventricular rate.
Click here for a more detailed ECG
ECG 13b. The ECG above belongs to the same man. It was recorded several months after the ECG 13a.
Now he has hypothyroidism and the TSH level is > 100 mIU/mL. This time, the rhythm is atrial fibrillation with a very low
ventricular rate. He is not taking beta blocker or calcium channel blocker. However, the ventricular rate is still low.
Click here for a more detailed ECG
ECG 14. The ECG above is from a 63 years-old man experiencing acute anterior myocardial infarction.
Right bundle branch block is seen. The rhythm is atrial fibrillation: P waves are absent and the RR intervals are irregular.
Coronary angiography, soon after recording of the above ECG, showed total ostial occlusion of the LAD artery.
Click here for a more detailed ECG
ECG 15. Oscillating irregular baseline and irregular RR intervals do not always denote atrial fibrillation.
In the presence of baseline drift and/or tremor artifact P waves may be difficult to detect at first glance.
In the 6-channel ECG above, the basic rhythm is sinus with first degree AV block ( prolonged PR interval )
The precordial recording shows two VPCs. Terminal portion of the first VPC and the second VPC are seen.
Click here for a more detailed ECG
ECG 16a. The ECG above is from a 60 years-old man with ischemic cardiomyopathy due to old anterior myocardial infarction.
His left ventricle is dilated and severely depressed with an ejection fraction of about 20%.
His LAD (Left Anterior Descending) and RCA (Right Coronary Artery) arteries are stented.
The rhythm may look as atrial fibrillation at first glance.
Click here for a more detailed ECG
ECG 16b. Low amplitude P waves and frequent atrial premature beats give the impression of atrial fibrillation at first glance.
The rhythm is NOT atrial fibrillation.
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ECG 17a. The above ECG is from a 52 years-old man. He was diagnosed as having severe mitral stenosis just 2 weeks ago.
(with a mitral valve area of 0.7 cm2). The wide and fragmented P waves denote interatrial block.
The duration of the P wave is more than 4 small squares (>160msec).
The initial portion of the P wave and the second part of it are easily discernible.
ECG 17b. The above ECG belongs to the same man. It was recorded 1 week after ECG 17a when he complained of palpitations.
Interatrial block is associated with the development of atrial fibrillation.
Click here for a more detailed ECG
ECG 18. Sometimes, baseline drift may result in the appearance of atrial fibrillation at first glance.
P waves may not be clearly visible in most of the leads.
The ECG above is from a 69 years-old woman with normal coronary arteries and right bundle branch block.
Low amplitude P waves are barely noticeable in lead V1.
The rhythm is NOT atrial fibrillation, but sinus. The regularity of RR intervals is another sign against atrial fibrillation.
Click here for a more detailed ECG
ECG 19. The ECG above is from a 69 years-old man with coronary artery disease.
He had undergone coronary artery bypass graft operation and then stenting of the right coronary artery (RCA).
When the RR intervals are similar (but not exactly the same) atrial fibrillation may be difficult to diagnose at first glance.
In the above ECG, P waves are absent, oscillating baseline is seen in lead V1 and the RR intervals are not the same:
the rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 20. The ECG above is from a 79 years-old man with coronary artery disease.
He had undergone coronary artery bypass graft surgery several years ago.
His recent coronary angiography showed significant diffuse stenoses in the LAD coronary artery and its Diagonal branches.
Horizontal ST segment depression is seen in left lateral precordial leads.
The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 21. The above ECG shows atrial fibrillation and ventricular bigeminy.
Fibrillatory waves are especially seen in lead V1. P waves are absent.
Each narrow QRS complex is followed by a wide QRS complex (VPC).
The coupling interval of the VPCs are very similar.
Click here for a more detailed ECG
ECG 22a. The ECG above is from a 95 years-old woman with atrial fibrillation and complete av block.
Although atrial fibrillation is known as an "irregularly irregular rhythm", it becomes a regular rhythm
when complete av block developes. RR intervals are regular in the above ECG.
The above ECG is recorded at a standard calibration of 10mm/mV and the fibrillatory waves are hardly noticeable.
Click here for a more detailed ECG
ECG 22b. The above ECG belongs to the same patient.
It is recorded at a calibration of 20 mm/mV.
Now, it is more easy to see the fibrillatory waves.
Click here for a more detailed ECG
ECG 23. Atrial fibrillation or not?
Most of the leads show baseline undulations which suggest atrial fibrillation at first glance.
However, P waves are seen clearly in lead II and the rhythm is regular.
The rhythm is sinus in the above ECG.
Click here for a more detailed ECG
ECG 24. Above ECG is from a 87 years-old woman with old inferior myocardial infarction due to occlusion of the right
coronary artery (RCA). Q waves are seen in inferior leads. Leads III and aVF also show negative T waves.
The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 25. Above ECG is from a 85 years-old woman with normal coronary arteries.
Because of the low amplitude P waves and varying RR intervals, the rhythm seems as atrial fibrillation at first glance.
However, the rhythm is sinus arrhythmia.
Click here for a more detailed ECG
ECG 26a. The ECG above is from a 58 years-old diabetic woman with untreated hypertension.
It was recorded while she was complaining of chest pain and palpitation.
Atrial fibrillation with a rapid ventricular response is seen.
Click here for a more detailed ECG
ECG 26b. The above ECG belongs to the same patient. It was recorded 90 minutes after the ECG 26a.
The rhythm is sinus now. She underwent coronary angiography 2 hours after the above ECG.
Three-vessel (extensive) coronary artery disease was diagnosed and she underwent coronary artery bypass graft surgery.
Click here for a more detailed ECG
ECG 27a. The ECG above is from a 69 years-old woman with the complaints of palpitation and dyspnoea.
The rhythm may seem like supraventricular tachycardia at first glance.
However, it is atrial fibrillation with a rapid ventricular response.
The rhythm is irregularly irregular.
Cardiologist Sinan Altan Kocaman has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 27b. The above ECG belongs to the same patient. It was recorded 20 hours after the ECG 27a.
Medical therapy slowed the ventricular response.
The rhythm is still atrial fibrillation: irregularly irregular with no P waves.
Cardiologist Sinan Altan Kocaman has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 28a. The ECG above belongs to 76 years-old woman with hypertension and coronary artery disease.
She had previously undergone coronary artery bypass grafting surgery.
The ECG shows right bundle branch block.
At first glance, the rhythm may seem like sinus rhythm.
If looked carefully, the irregularity will be noticed. Also lead V1 shows irregular baseline due to fibrillatory waves.
The rhythm is atrial fibrillation but it is not "irregularly irregular" as usual.
The last beat may seem like an atrial premature contraction (APC) at first glance. However, it is not an APC.
Click here for a more detailed ECG
ECG 28b. The ECG above belongs to the same woman. It was recorded 30 seconds before the ECG 28a.
The rhythm is atrial fibrillation.
The 3rd and 6th beats from the left may seem like an atrial premature contraction (APC) at first glance.
However, they are not APCs, since they do not have preceding P waves.
Click here for a more detailed ECG
ECG 29. Above ECG is from a 71 years-old man.
At first glance, the rhythm may seem like sinus rhythm.
If looked carefully, the irregularity will be noticed. Also lead II shows irregular baseline due to fibrillatory waves.
The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 30a. The ECG above belongs to a 46 years-old woman with mitral stenosis.
The rhythm is atrial fibrillation with rapid ventricular response.
This ECG was recorded before the initiation of rate-slowing medications.
Click here for a more detailed ECG
ECG 30b. The ECG above belongs to the same woman. It was recorded 12 days after the ECG 30a.
The rhythm is still atrial fibrillation but the ventricular rate is under control now.
Fibrillatory waves are best seen in leads V1, V2, III and aVF.
Click here for a more detailed ECG
ECG 31. The above rhythm tracing shows transition from atrial fibrillation to sinus rhythm.
When he was admitted to the hospital, the diagnosis of new-onset atrial fibrillation was made and
intravenous Amidoarone infusion was started to convert it to sinus rhythm.
This rhythm tracing was recorded during Amiodarone infusion.
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ECG 32. The 3-channel Holter recording above is from a 71 years-old man with atrial fibrillation.
A long pause of 4.433 seconds is seen in the middle section.
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ECG 33. The ECG above belongs to an 84 years-old woman.
She has chronic obstructive pulmonary disease, left heart failure and chronic renal failure.
The ECG shows atrial fibrillation and low voltage.
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ECG 34. The ECG above is from a 73 years-old obese woman with hypertension.
She has a dilated left ventricle (LV) and left atrium.
The rhythm is atrial fibrillation.
Despite the presence of hypertension and a dilated LV, the ECG shows low voltage due to obesity.
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ECG 35. Above ECG is from a 63 years-old hypoxic obese man with chronic obstructive pulmonary disease (COPD)
It was recorded when he was hospitalized at intensive care unit.
The rhythm is coarse-wave atrial fibrillation with rapid ventricular response.
P waves and a flat baseline are not seen, RR intervals are irregular.
Limb leads show low voltage due to obesity and COPD.
ECHOcardiography showed dilated left atrium, right atrium and right ventricle.
His left ventricular systolic function was normal.
The thickened ECG tracing of chest leads is due to 50/60 Hz AC interference artifact.
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ECG 36. Above is an ECG from a 49 years-old woman with a mechanical mitral valve prosthesis.
ECHOcardiography showed normal left ventricular dimensions with normal systolic function.
Her left atrium, right atrium and right ventricle were dilated.
The rhythm may seem like sinus at first glance. However, it is not.
The rhythm is atrial fibrillation: P waves are not seen, baseline is not stable and RR intervals are irregular.
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ECG 37a. The ECG above belongs to a 63 years-old man with mechanical mitral valve prosthesis.
ECHOcardiography showed dilation of left atrium, right atrium and right ventricle with normal left ventricular systolic function.
Right bundle branch block is seen. What about the rhythm? Is it nodal rhythm or atrial fibrillation?
This ECG was recorded at standard calibration of 10 mm/mV.
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ECG 37b. The ECG above belongs to the same man.
It was recorded a few minutes after the ECG 15a, at a calibration of 20 mm/mV.
Now baseline undulations due to fibrillatory waves are clearly seen. The rhythm is atrial fibrillation.
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ECG 38. The ECG above belongs to a 69 years-old man with coronary artery disease.
He had undergone coronary artery bypass graft surgery and tricuspid annuloplasty in the past.
The rhythm may seem like atrial fibrillation at first glance, but it is not.
The RR intervals are usually regular. P waves become visible when the level of AV block increases.
Isoelectric flat line between the P waves show that the rhythm is not atrial flutter.
If looked carefully, P waves deforming the descending limb of the preceding T waves may be seen in inferior leads.
The rhythm is ectopic atrial tachycardia.
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ECG 39. The ECG above belongs to a 54 years-old man with systemic arterial hypertension.
Coronary angiography did not show significant coronary artery stenosis.
His only medication is Ramipril 2.5mg/day.
He is not taking any beta blocker, non-dihydropyridine calcium channel blocker or ivabradine.
His usual heart rate is below 50/minute.
This ECG shows a short-lasting episode of atrial fibrillation during bradycardia (vagally-mediated atrial fibrillation).
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ECG 40. The ECG above is from a 68 years-old woman with systemic hypertension and atrial fibrillation.
She is taking Digoxin tablets.
Sagging-type ST depression is seen in most of the leads.
The ventricular response is slow due to Digoxin effect. RR intervals are irregular.
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ECG 41. The above ECG shows atrial fibrillation on the left side which suddenly converts to narrow QRS complex tachycardia.
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ECG 42a. The ECG above belongs to a 68 years-old woman with hypertension, heart failure and permanent pacemaker.
Pacemaker rhythm is seen in the above ECG.
Would you anticoagulate this patient?
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ECG 42b. The ECG above belongs to the same woman.
It was recorded 25 minutes after the ECG 42a. The rhythm is irregular.
Now, the rhythm is atrial fibrillation with intermittent pacemaker-induced beats.
She needs anticoagulation.
Sometimes pacemaker rhythm may mask the underlying atrial fibrillation (with slow ventricular rate, as in 42a)
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ECG 42c. The ECG above belongs to the same woman.
It was recorded one minute after the ECG 42b. The rhythm is irregularly irregular.
The rhythm is atrial fibrillation with no pacemaker-induced beats.
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