EKG 101

Deborah Goldstein Georgetown University Department of Internal Medicine

Steps to Interpreting an EKG
• • • • • • • • Rate Rhythm Axis Intervals (PR, QRS, QTc) Hypertrophy ST segments T waves Q waves


Naming stuff

Normal Sinus Rhythm
• P before every QRS
– Best places to look: II, V1

• QRS after each P

1. The direction of the mean electrical vector, representing the average of current flow in the frontal plane. 2. Normal axis: –30 to +90 degrees.


• Look at lead I and aVF. • Then find the isoelectric lead (where the QRS complex is most nearly biphasic). • Then go 90 degrees perpendicular to the isoelectric lead.



Rate, Rhythm, Axis

Rate, Rhythm, Axis

Rate, Rhythm, Axis

Ddx of Axis Deviation
LAD • Left ventricular hypertrophy, Left anterior fascicular block, LBBB, Inferior wall MI • Pregnant, ascites, short/fat RAD • Right ventricular hypertrophy, Left posterior fascicular block, RBBB, lateral wall MI • PE

PR Interval
• Normal PR = 0.12 – 0.20 seconds (3-5 little boxes) • Long PR >0.20 seconds (>5 little boxes) =Delayed conduction from atria to ventricles • First-degree AV block
– PR>0.20 seconds – NO dropped QRS

Second Degree AV Block
• Wenckebach (Type 1) =block within AV node – PR interval progressively lengthens...then dropped QRS • Mobitz (Type 2) =block within His-Purkinje system – Fixed PR with dropped QRS – WORSE! – Sarcoid, Lyme.... – Pacemaker!

Third Degree AV Block
=Failure of conduction of any atrial impulses to get to the ventricles =Complete AV block Causes of Acute AV Block: • Calcium channel blockers • Acute RCA occlusion • Digoxin toxicity

What kind of AV Block?

What kind of AV Block?

What kind of AV Block?

What kind of AV Block?

QRS Interval
Normal = 0.06-0.10 seconds Wide QRS = >0.12 seconds (>3 little boxes) • PVC...if >3 in a row or >6/min=VTach • RBBB, LBBB • Left fascicular hemiblock • Hyperkalemia Narrow QRS= <0.06 sec • SVT (150-250 bpm) • Idiojunctional rhythm (40-60 bpm) • Premature junctional complex

Chest Leads



Bundle Branch Block
V1-V2 = Right precordial leads V5-V6 = Left precordial leads LBBB • Rabbit ears in V6 represent delay between depolarization from the septum  to the LV RBBB • Rabbit ears in V1 represent delay between depolarization from the septum to the RV


Normal: V1: rS complex V6: qR complex RBBB: V1: Rabbit Ears (rSR) V6: qRS complex LBBB: V1: wide QS complex V6: Rabbit Ears

Wide QRS—Why?

Wide QRS—Why?

QT Interval
• • • • • Should be < ½ (R-R’ interval) Measure from the start of the QRS to end of T wave Varies with heart rate, so correct for RR interval Normal QTc: women=0.44, men=0.42 QTc = QT (#of small squares) x 0.04 √RR

• Long QT can lead to ‘R on T’Death

Causes of Long QT
**Think ‘Lytes and Meds first! • Low K, Low Ca, Low Mg

• Macrolides, Quinolones • All Antipsychotics (Haldol worst, Geodon least) • SSRIs • Sotalol, Quinidine, Ondansetron, Amio, TCAs
• Pts w/LVH or CHF are predisposed to medicationrelated lengthening of QT interval! – Avoid Macrolides, Quinolones in them!

Long QT: Less common causes
• • • • • • • Hypothyroid Hypothermia AV Block MI CVA Head injury Congenital long QT

Atrial Enlargement
RAE • P wave is tall and peaked (>2.5mm high) • OR Biphasic P wave with initial positive inflection • Ddx: Pulmonary HTN, COPD, PE LAE • P wave is wide (>0.12 sec) and notched in the middle “M” • OR Biphasic P wave with terminal negative inflection • Ddx: Systemic HTN, Aortic Insufficiency, Mitral Stenosis

Which Atria is Enlarged?

Which Atria is Enlarged?

LVH Criteria
• Sokolow + Lyon – S V1+ R V5 or V6 > 35 mm • Cornell criteria (Circulation, 1987;3: 565-72) – S V3 + R avl > 28 mm in men – S V3 + R avl > 20 mm in women • Framingham criteria (Circulation,1990; 81:815-820) – R avl > 11mm, R V4-6 > 25mm – S V1-3 > 25 mm, S V1 or V2 + – R V5 or V6 > 35 mm, R I + S III > 25 mm • Romhilt + Estes (Am Heart J, 1986:75:752-58) – Point score system (Am Heart J, 1999;37:161)

LVH “S V1+ R V5 or V6 > 35mm”

ST changes: axis + anatomy
• Lateral:
– I, aVL – LCA, CFX

• Anterior:
– V1, V2, V3, V4 – LAD

Inferior: -II, III and aVF -RCA (or LCA)

Memorize this slide

Q waves
• Normal Q wave:
– Small septal Qs in I, aVL, V5, V6 – Isolated Qs in III, V1

• Pathologic Q wave:
– wider than 1 small box (0.04 sec) – OR >25% height of the R wave in that complex

Normal Q waves

Abnormal Q Waves

Non-ST Elevation MI
=Severe subendocardial ischemia • Marked, diffuse ST depressions in I, II, III, aVL , aVF , V2-V6

2 EKGs, several hours apart

Acute ST Elevation MI
1. 2. 3. 4. 5. 6. Normal Hyperacute • T wave Elevation Acute • ST Elevation Hours Later • ST Elev, Q begins to form, T wave inverts Days Later • Q wave, T wave inversion Weeks Later • Q wave

A 55 year old man with 4 hours of "crushing" chest pain.

Acute Inferior Wall MI
• ST elev in II, III, AVF • Reciprocal ST depression in anterior leads (V2-V4) =RCA occlusion (some LCx)

A 53 year old man with Ischemic Heart disease

Old Inferior Wall MI
• Pathologic Q wave in II, III, AVF:
– wider than 1 small box (0.04 sec) – OR >25% height of the R wave in that complex

An 83 year old man with aortic stenosis.

• • Romhilt-Estes LVH Point System: 3 points for Left Atrial Enlargement – M shaped P wave in II – P has prominent terminal negative component in V1

• 3 points for:
– R wave in V5 or V6 >30mm – or S wave in V1 or V2 >30mm – or R or S in limb leads>20mm • >5 points: definite LVH

A 76 year old man with breathlessness.

Afib with RVR
• Irregularly irregular ventricular rhythm. • Must look carefully to see it is NOT regular

A 72 year old man on routine office visit

Ventricular Pacemaker
•Pacer spikes—hard to see! •Wide QRS complexes •Pacemaker starts after a long R - R interval following a blocked atrial premature beat...then NSR

A 58 year old man on hemodialysis presents with profound weakness after a weekend fishing trip.

K >8.0 • Wide, tall and tented T waves • Wide QRS • Small or absent P waves • Atrial fibrillation • Shortened or absent ST segment • Ventricular fibrillation

Atrial Flutter
• Saw tooth baseline with rate of 250-300 • Causes:
– – – – – Ischemic heart disease Hypertension Mitral valve disease Thyrotoxicosis Cardiomyopathy

Evolves over hours-weeks • PR depression, ST elevation (concave up) in same leads, upright T • Normal P, normal ST, flat T • Normal P, normal ST, T Wave inversion • normal P, normal ST, upright T

• Long QT • Inverted T waves