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The presence of multiple P wave morphologies indicates multiple ectopic pacemakers within the atria and/or AV junction. If ≥ 3 different P wave morphologies are seen, then multifocal atrial rhythm is diagnosed:

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Representation of single, normal heart beat. Each waveform & deflection is labeled with a letter. They actually represent heart contractions. The first small vertical bump is known as the "P-wave," when the SA node generates an electrical impulse causing the Atrias (the top) of the heart to contract. Impulse travels down through the heart to the Ventricles. Normally, should be between 0.12-0.20 s. The P-wave & the space between it & next positive (upward) deflection are known as the PR…

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If ≥ 3 different P wave morphologies are seen and the rate is ≥ 100, then multifocal atrial tachycardia (MAT) is diagnosed:

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ECG Interpretation - 17 Sinus Tachycardia with pictures & what to expect with P waves, PR intervals with each arrhythmia

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We therefore interpret this tracing as showing “AV dissociation” – since at least some P waves are unrelated to the QRS complexes that follow them. The term AV dissociation should never be used as a “diagnosis” per se. Instead – it is the result of the underlying rhythm on the tracing. In this case – the underlying rhythm is sinus bradycardia at a rate of 50/minute (the P-P interval is precisely 6 large boxes in duration for each of the P waves on this tracing). AV dissociation occurs by…

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Atrial abnormalities are most easily seen in the inferior leads (II, III and aVF) and lead V1, as the P waves are most prominent in these leads.

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