Paced Rhythm

A cardiac rhythm that is generated by current provided by an artificial pacemaker; vertical pacemaker spikes precede the waves.

An electronic pacemaker, or just pacemaker, delivers electrical current to the heart to stimulate depolarization. Pacemaker leads may connect with ventricular tissue and/or atrial tissue (permanent or transvenous pacemakers). Transcutaneous pacing delivers an electrical current through the chest wall to depolarize the ventricles.

Paced rhythms are fairly easy to detect because of the vertical spike present before the atrial (‘P’ waves) or ventricles depolarizations (QRS complexes). The spike represents the electrical impulse generated by the electronic pacemaker.

The wave immediately after the spike is the intended response to the initial electrical stimulus. If the spike is accompanied by a wave, the pacemaker is said to be capturing. Conversely, if spikes appear without accompanying waves, we have loss of capture.

Note that many older monitors will recognize the pacer spike as a QRS complex when determining rate, whether the spike captures the heart or not. As a result, many monitors do not alarm if the pacemaker is losing capture. Also, a monitor might provide a heart rate twice the pulse rate if both the pacer spike and the QRS complex are counted. Monitor your patient closely.

Pacer spikes should always have a waveform immediately afterwards. Failure to stimulate a depolarization is called loss of capture. Many older monitors will not inform you of any loss of capture. Again, always check the patient. The loss of capture of several complexes could result in poor cardiac output. Also, if the pacemaker is sensing the heart ineffectively, the pacemaker could deliver electrical impulses close to the T wave, potentially causing lethal dysrhythmias. Loss of capture or the presence of pacer spikes close to the T wave often requires an urgent response.

paced ventricular rhythm, HR 80/min

1. Six Second ECG Guidebook (2012), T Barill, p. 129, 201

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