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:
Every Organ Tells a Story 3: A History of Anatomical Terms
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Accelerated Junctional Rhythm: occurs when the rate of the AV junctional pacemaker exceeds that of the sinus node. This situation arises when there is increased automaticity in the AV node coupled with decreased automaticity in the sinus node. Causes include myocardial ischaemia, digoxin toxicity, cardiac surgery, myocarditis and beta-agonists (e.g. isoprenaline). Looks familiar
Shepard Fairey and Craig Stecyk III Limited Edition Serigraph "P. O. P Wave (Gold)"
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…