Inverted P wave

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Ordinarily, an impulse traveling from a point high in the atrium to the ventricle is right side up on the electrocardiographic tracing, but if this pacemaker impulse originates in lower part of the atrium, the orientation of the electrical vector may cause it to appear upside down or to be an "inverted P-wave".

Pathophysiology

Retrograde Atrial Activation

This occurs when there is a ventriculoatrial conduction of electrical impulse through the AV node. The origin of the electrical impulses could either be from:

• Ectopic foci in the atrium - This could be a single or multiple foci in the atrium. Foci within the atrium usually originate below the crista terminalis in the right atrium for it to have a significant effect on the p wave.

• AV node - This results into the various junctional rhythms e.g. AVNRT, AVRT.

• Ventricles - This results into ventricular tachycardias or rhythm.

Causes

• Dextrocardia
• Lead switch or misplacement
• Causes of retrograde atrial activation