The Normal ADULT ECG

QRS

ST

PR QT

1.0 sec

0.1 mv

0.04 sec

0.20 sec

ECG Electrodes and Color Coding

TIP COLOR Red Yellow Green Black RED/white YELLOW/white GREEN/white BROWN/white BLACK/white VIOLET/white SYMBOL RA LA LF RF C1 C2 C3 C4 C5 C6 Electrode Position Right Arm Left Arm Left Foot Right Foot 4th ICS R sternal border 4th ICS L sternal border Midway b/w C2 & C4 5th ICS L MCL L AAL same level as C4 L MAL same level as C4

Guide in ECG Reading

1 2 3 4 5 6 7 8 9 10

Rhythm Rate: Atrial and Ventricular Axis P wave: morphology and duration P R interval QRS complex: morphology and duration ST segment T wave U wave Q T interval

Normal Rhythm

Arrythmia

Determination of Heart Rate

Rule of 300 1 BSq = 300/min 2 BSq = 150/min 3 BSq = 100/min 4 BSq = 75/min 5 BSq = 60/min 6 BSq = 50/min 7 BSq = 43/min 10 BSq = 30/min
2

FORMULA: #1: 300 . # of BS b/w R-R

#2:

1500 . # of SmS b/w R-R

Normal = 60 100 Bradycardia = < 60 Tachycardia = > 100

Determination of Axis
I neg AVF - neg Indeterminate Axis -90o Left Axis Deviation -30o 180o 0o Right Axis Deviation Normal Axis Deviation I pos AVF - pos 90o I pos AVF neg II -pos I pos AVF neg II -neg

I neg AVF - pos

P wave morphology
I AVR

Upright P

Inverted P

V1

Biphasic P

P R Interval
Normal
Short Prolonged

=
= =

0.12 0.22
< 0.12 > 0.22

QRS complex morphology & duration

I AVR

Positive QRS

Negative QRS
V3

Biphasic QRS

S T Segment
I V1

Normal V3

Elevated

Depressed

T wave Morphology
AVR

Upright T

Inverted T

Chamber Enlargement

Atria
Right Atrial Enlargement (RAE)
Tall P waves in II, III, AVF > 2.5mm

Left Atrial Enlargement (LAE)

P wave in I > 0.11 secs Terminal Negativity of P wave in VI = > 1mm squared

Bi-atrial Enlargement
RAE + LAE

Atria
Right Atrial Enlargement (RAE) - due to chronic lung diseases or pumonary embolus
Left Atrial Enlargement (LAE) - commonly seen in mitral valve diseases

RAE
I

LAE
I

LAE
I

Bi-Atrial Enlargement
II

V1

Ventricles
Right Ventricular Hypertrophy (RVH) Sokolow-Lyon Criteria: R in V1 + S in V5-V6 = > 11mm R in V1 = > 7mm R : S in V1 > 1 RAD > +90o

Ventricles
Right Ventricular Hypertrophy (RVH) - common causes: COPD, MS, PS, L R shunts - Differentials: Infero-posterior MI RBBB Hemiblocks WPW

AVR

V1

V4

II

AVL

V2

V5

III

AVF

V3

V6

Ventricles
Left Ventricular Hypertrophy (LVH) Sokolow-Lyon Criteria: S in V1 + R in V6 = > 35mm R in AVL = > 12mm R in AVF = > 20mm R in I + S in III = > 25mm S in V1 > 24mm

Ventricles
Left Ventricular Hypertrophy (LVH) - common causes: HPN, AS (concentric hypertrophy) AI, CAD (eccentric hypertrophy) - initial compensatory mechanisms in: Obesit, smoking, dyslipidemia, DM - Differentials: Anterior MI LBBB WPW

AVR

V1

V4

II

AVL

V2

V5

III

AVF

V3

V6

Ischemia, Injury & Infarction

Stages of Ischemic States

Ischemia
- Deficient O2 delivery for given O2 demand - Symmetrical T wave inversion and ST depression

Injury
- Lack of critical blood supply - ST elevation in leads corresponding to involved area

Infarction
- Irreversible cell necrosis and death - Pathologic Q waves (but may occur w/o Q waves)

Criteria for Myocardial Ischemia

Symmetrical T wave inversions on leads overlying involved areas ST depression on either resting or exercise ECG: - At least 1.0mm depression at the J point lasting 80 msecs - Horizontal or downward slope toward the end of the ST segment at its junction with the T wave

Criteria for Myocardial Injury

Elevation of the origin of the ST segment at its J point with the QRS of: - 1.0mm in 2 limb leads lasting 0.80 msecs - 2.0mm in precordial leads Depression of the origin of the ST segment at the J point 1.0mm in at least 2 leads * ST segment deviation typically either horizontal or slope toward the
direction of the T waves

Criteria for Myocardial Infarction

Development of new Q waves on areas overlying the infarct:

- 0.04 secs duration - > 25% of the height of assoc R wave

Rules regarding Q waves:

1. 2. 3. 4. 5.

6.
7.

Q waves in AVR are not significant Q waves in V1 are ignored unless with abnormalities in other precordial leads Q waves in III are ignored unless with abnormalities in II & AVF Q waves assoc w/ ST changes are more reliable than those without Q waves in the presence of LBBB are not significant if located in V1 V3. Q waves located in V1 V2 are always significant in the presence of RBBB Pathologic Q waves should be 0.04 secs duration and > 25% of the R wave amplitude

Evolution of changes in MI

Normal

Acute

Recent

Old

Acute - Changes appear w/n minutes to hours - ST segment elevation over involved area - ST segment depression in the opposing leads (reciprocal changes) - T waves symmetrically peaked or deeply inverted - Arrythmias or conduction abnormalities may occur Recent - Changes remain days to weeks after the event - ST segment may or may not have returned to baseline - Localized Q waves or QS complexes have appeared - T waves symmetrically inverted in areas involved Old - Abnormal Q waves, QS complexes or regression or R waves persist indefinitely - ST segments are isolectric (otherwise consider aneurysm) - T wave inversion may persist indefinitely - Abnormalities may remain unchanged for 6 months

Time of Onset of MI

Anatomy of MI
Infarction Area Extensive Anterior Anteroseptal Anterolateral Inferior True Posterior ECG Leads I, AVL, V1 V6 V1 V3 I AVL, V4 V6 II, III, AVF V1 V2 Cor Artery Left, LM Left Left Right 80% Variable Left/Right Branch LAD, LCX LAD LCX PDA LCX, PL

LAD = left anterior descending artery; LCX = left circumflex artery; LM = left main artery; PDA = posterior descending artery; PL = posterolateral branch

ECG Criteria for Infarct Location

Anteroseptal wall MI
- Q waves or QS complexes in leads V1 V3 - may lose the septal q wave in leads I, AVL, V6 - S waves in leads V1 V3 may be deeper than before infarct

Anterolateral wall MI
- Qr, QR or QS complexes in leads V4 V6 or V5 V6 - If acute or recent: - convex ST segment elevation in leads V4 V6 &/or I & AVL - T wave inversion may occur in leads V4 V6 &/or I & AVL - If this is a part of a longer anterior infarction there is loss of the R wave in leads V2 V6 and often in leads I & AVL

ECG Criteria for Infarct Location

High Lateral wall MI
- abnormal Q in I & AVL

Inferior wall MI
- Q waves in leads II, III, AVF; if present only in leads III & AVF, the diagnosis is weaker - If acute or recent: ST segment elevation in II, III, AVF Varying T wave inversion in leads II, III, AVF - extension to the lateral wall is indicated by changes in leads V5 V6 True Posterior Wall MI - dominant R in leads V1 V2 - there is progression of the R waves in leads V1 V3 - St segment depression in leads V1 & V2 with upright T waves

ECG Criteria for Infarct Location

Right Ventricle Infarct
- 1.0mm ST segment elevation V4R sensitivity 100%, specificity 68% - ST elevation in V1 and ST depression in V2 - depth of ST depression in lead V2 50% ST elevation in AVF - ST elevation in lead III exceeds that in lead II
Differential Dx of ST elevation in V1 V3 or V3 & V4R include: Pulmonary embolism LBBB LVH prior Anterior wall infarction Pericarditis with aneurysm formation

Non-Q MI
I AVR V1 V4

II

AVL

V2

V5

III

AVF

V3

V6

Complications of MI
Rhythm disorders
- bradycardia: sinus bradycardia, SA node arrest, AV blocks - tachycardia: extrasystoles, SVT, V tach, V flutter, V fib

Cardiac wall rupture

Heart failure Aneurysm of heart wall

Bundle Branch Blocks

QRS<0.12s

P<0.12s

Intraventricular Conduction Delays

Incomplete Bundle Branch Blocks Left Bundle Branch Blocks Right Bundle Branch Blocks Fascicular Blocks - Left Anterior Fascicular Block (Hemiblock) - Left Posterior Fascicular Block (Hemiblock) - Bifascicular Block - Trifascicular Block

Intraventricular Conduction Delays

Incomplete Bundle Branch Blocks

- Loss of septal q - slurred and notched upstroke of R - modest prolongation of QRS (100120 msecs)

Intraventricular Conduction Delays

Complete Left Bundle Branch Blocks

- QRS 120 msecs - Broad, notched R - Prolonged intrinsicoid deflection in V5, V6 (and I, AVL) - Small or absent r in V1, V2 followed by deep S waves - Absent septal q waves in left sided leads

Complete LBBB
I AVR V1 V4

II

AVL

V2

V5

III

AVF

V3

V6

Intraventricular Conduction Delays

Conditions Assoc with CLBBB - Ischemic heart disease - LVH
a. Hypertension b. Aortic valve disease

- Cardiomyopathy - Hyperkalemia - Previous conditions assoc with RBBB

Intraventricular Conduction Delays

Complete Right Bundle Branch Blocks

- QRS 120 msecs - Broad, notched R (RSR pattern) in V1, V2 - Wide and deep S in V5, V6 - ST displacement and T waves opposite in direction of the terminal deflection of the QRS complex

Complete RBBB
I AVR V1 V4

II

AVL

V2

V5

III

AVF

V3

V6

Intraventricular Conduction Delays

Conditions Assoc with CRBBB - Ischemic heart disease - Aortic stenosis - Infective endocarditis with abscess of the conduction system - Hyperkalemia - Ventriculat hypertrophy

Intraventricular Conduction Delays

Fascicular Blocks Delayed conduction in a fascicle results in activation of these sites sequentially rather than simultaneously Abnormal sequence of early left ventricular activation

Intraventricular Conduction Delays

Left Anterior Fascicular Blocks - QRS duration < 120 msecs - QRS axis of 45o to 90o - rS patterns in II, III, AVF and a qR in AVL

*Common assoc conditions include occlusion of the left anterior descending artery, LVH, hypertrophic and dilated cardiomyopathy, degenerative diseases

AVR

V1

V4

II

AVL

V2

V5

III

AVF

V3

V6

Intraventricular Conduction Delays

Left Posterior Fascicular Blocks - QRS duration < 120 msecs - QRS axis of +120o - RS pattern in I, AVL - qR pattern in II, III, AVF - exclusion of other factors causing RAD: RV overload, lateral infarction

Intraventricular Conduction Delays

Bifascicular Blocks
RBBB - QRS complex 0.12s - rR pattern or a wide slurred R wave in leads V1,V2 - late, broad s or S in leads V5, V6 (and/or I) - ST displacement and T waves opposite in direction to the terminal deflection of the QRS complex LAFB - QRS axis of 45o or more

OR
LPFB - QRS axis of 110o or more

Intraventricular Conduction Delays

Trifascicular Blocks
RBBB - QRS complex 0.12s - rR pattern or a wide slurred R wave in leads V1,V2 - late, broad s or S in leads V5, V6 (and/or I) - ST displacement and T waves opposite in direction to the terminal deflection of the QRS complex

LAFB - QRS axis of 45o or more

+
OR

LPFB - QRS axis of 110o or more

CLBBB - QRS duration msecs measured in lead where it is widest - Broad, notched R wave in V5, V6 and usually in I, AVL - Small or absent initial r waves in V1, V2 followed by deep S waves - prolonged intrinsicoid deflection (>60 msec) in V5, V6

Bradyarrythmias

QRS<0.12s

P<0.12s

0.12-0.22s

Types of Bradyarrythmias
Sinus Bradycardia Junctional rhythm Idioventricular rhythm Sino-atrial blocks Atrio-ventricular blocks

Types of Bradyarrythmias

Sinus Bradycardia - Pacemaker: SA node

- Firing Rate: < 60 beats per minute - P waves: normal/uniform contour; occur before each QRS complex

- Rhythm: regular - QRS: < 0.12 secs - PR interval: < 0.20 secs

Types of Bradyarrythmias

AV junctional Rhythm - Pacemaker: AV Junction

- Firing Rate: 40 - 60 beats per minute - Any independent atrial arrythmia may exist - P waves: may be captured retrogadely (negative in lead II)

- Rhythm: regular - QRS: < 0.12 secs - PR interval: < 0.12 secs

V3

Sinus Bradycardia
II

AV Junctional Rhythm

Types of Bradyarrythmias

Idioventricular Rhythm - Pacemaker: HIS Purkinge system

- Firing Rate: 20 - 40 beats per minute

- Rhythm: regular - QRS: > 0.12 secs - PR interval:

- P waves generally absent - AV dissociation may be present

Types of Bradyarrythmias

Sino-atrial Block - Failure of impulse transmission from sinus node to adjacent atrial myocardium - Complete failure of a P wave to appear, and a cycle appears which is twice the anticipated P P interval - Transient doubling of P P interval

Types of Bradyarrythmias

SA Exit Block
- No visible PQRST complex for 1 cycle - Normal P wave morphology before and after the pause - Pause is preceded and followed by a normal P P cycle - P P interval of the pause is a multiple of the normal P P interval

V3

Idioventricular Rhythm
V3

SA Exit Block

Types of Bradyarrythmias
Atrio-ventricular

Block (1st degree)

- There must b P waves - P R interval is prolonged ( > 20 secs) - one P wave to each QRS complex - P waves and QRS have morphology and axis usual for the subject - P R interval is constant

V3

1st Degree AV Block

Types of Bradyarrythmias

Atrio-ventricular Block (2nd degree) WENKEBACH / MOBITZ TYPE I

- There must be P waves & QRS complexes - P waves & QRS must have morphology and axis usual for the subject - Progressive prolongation of P R interval with each beat until there is a dropped beat - Longest P R interval is the one immediately before the dropped beat - shortest P R interval is the one assoc with the first conducted beat after the dropped beat - The P R interval before the blocked beat increases, and do so by progressively decreasing amounts so that consecutive R R intervals before dropped beat progressively shortens

Types of Bradyarrythmias

Atrio-ventricular Block (2nd degree) MOBITZ TYPE II

- There must be P waves & QRS complexes - P waves & QRS must have morphology and axis usual for the subject - P R interval of conducted beats may be normal or long but fixed, then there is a dropped beat - P R interval must be constant for all conducted beats - failure of conduction is not seen in relation to two or more consecutive P waves - QRS complexes after the transient AV conduction failure have the same morphology as those preceding it

2nd Degree AV Block

V3

Mobitz Type I
V3

Mobitz Type II

Types of Bradyarrythmias

Atrio-ventricular Block (3rd degree) COMPLETE AV BLOCK

- No consistent or meaningful relationship between atrial and ventricular activity. Variable PR and RP intervals - QRS rate is usually constant and lies within the range of 15 70 beats/min - QRS may be normal in shape, duration and axis but more often are abnormal and are of constant morphology

V3

3rd Degree AV Block

Miscellaneous ECG Abnormalities

ST T Wave Changes
Usually isoelectric May normally deviate between + 0.5 & 1.0 mm from the baseline in standard and unipolar extremity leads Upward displacement of 2 3 mm may be normal provided ST segment is concave and T wave is full, broad-based & upright Average duration is 0.05 0.155

Criteria for NSSTTW Changes

ST segment and T wave abnormalities that lack specifically defined characteristics Flattened or slightly inverted T waves ST segment slightly above or below the isoelectric line Changes may be diffuse or localized

ST - T Wave Changes in other Conditions

ST elevation - Juvenile ST changes - Early ventricular repolarization - Acute pericarditis - Acute epicardial/myocardial injury ST depression - Anxiety - Fasting - Positioning of patient - Repiratory variation

ST - T Wave Changes in other Conditions

Hypokalemia ( < 2.5 meq/L) - ST depression - Decrease in T wave amplitude - Increase in U wave amplitude
V3

ST - T Wave Changes in other Conditions

Sequential ECG Changes w/ Hypokalemia
K meq/L 5
normal

3.5

low T wave

3.0

Low T wave High U wave

2.5

Low T wave High U wave Low ST segment

T U

ST - T Wave Changes in other Conditions

Hyperkalemia ( 8.8 meq/L) - Broad QRS - Slow heart rate - Usually LAD - Loss of P wave - Loss of ST segment (continuous with S wave) - Tall tented T wave - QTc interval abnormal or shortened

AVR

V1

V4

II

AVL

V2

V5

III

AVF

V3

V6

ST - T Wave Changes in other Conditions

Sequential ECG Changes w/ Hyperkalemia
K meq/L 5

Normal

High T wave

High T wave Depressed ST segment Auricular standstill Intraventricular block Ventricular fibrillation
T U

10

K+ level 8.8 meq/L

V4

V5

V6

Thank You