This is a normal sinus rhythm with atrial bigeminy, a term meaning that every other beat is a PAC. If you look carefully, you can see slight differences in the sinus P waves and the atrial (premature) P waves. The PACs penetrate and reset the sinus node, causing what looks like a delay after the PAC. It is often just a return to the normal P to P interval, or nearly so. If you teach basic students in a clinical setting, they will learn from palpating the peripheral pulse and feeling the pattern of bigeminal beats. Sometimes, the premature beat feels much weaker due to less filling time available to the ventricles. Atrial bigeminy can have very benign causes, such as increased caffeine intake, or it can have more complex causes such as advanced heart disease or conduction blocks. In some patients, atrial bigeminy, or any PACs, can be a precursor to more serious atrial dysrhythmias, such as atrial fibrillation.