Junctional rhythm (Case 1)
Patient. 41 year old male admitted with chest pain and diagnosis of acute inferior MI. Other history includes hypertension, hyperlipidemia and cigarette smoker.

• Retrograde P wave (invert in inferior leads, II, III, aVF) may be infront, inside or follow the QRS complex.
• When the junctional P wave appears infront the QRS, the PR interval is usually < .0.11 sec.
• When the junctional P wave appears behind the QRS, the RP interval can be as long as 0.20 sec or longer.

There are wide range in variation of sinus P wave since several factors may effect the P wave. These include: Anatomic cardiac position to the anterior chest wall; state of autonomic influence; intra and/or interatrial conduction abnormality; pressure and/or volume load; atrial/atria diseases; electrode positioning (precordial lead).

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