LLLC1ROCARDIOGRAM LLLC1ROCARDIOGRAM

Marco Christopher G. Montaos, MD. Marco Christopher G. Montaos, MD.

Internal Medicine Internal Medicine
LLLC1ROCARDIOGRAM LLLC1ROCARDIOGRAM
is a graphical record o electric potentials is a graphical record o electric potentials
generated by the heart muscle during each generated by the heart muscle during each
cardiac cycle. 1he signals are detected on the cardiac cycle. 1he signals are detected on the
surace o the body using electrodes attached to surace o the body using electrodes attached to
the extremities and chest wall. 1hese signals are the extremities and chest wall. 1hese signals are
then ampliied by the electrocardiograph then ampliied by the electrocardiograph
machine and displayed on special graph paper. machine and displayed on special graph paper.
Indications : Indications :
Rate Rate
Rhythm Rhythm
Axis Axis
Hypertrophy Hypertrophy
Ischemic or Infarction Ischemic or Infarction
Indications or ordering an Indications or ordering an
electrocardiogram electrocardiogram
1o determine cardiac rate 1o determine cardiac rate
2 1o accurately define cardiac rhythm 2 1o accurately define cardiac rhythm
3 1o diagnose old or new myocardial infarction 3 1o diagnose old or new myocardial infarction
4 1o identify intracardiac conduction disturbances 4 1o identify intracardiac conduction disturbances
S 1o aid in the diagnosis of ischemic heart disease, S 1o aid in the diagnosis of ischemic heart disease,
pericarditis, myocarditis, electrolyte abnormalities pericarditis, myocarditis, electrolyte abnormalities
and pacemaker malfunction and pacemaker malfunction
!osition o the chest leads !osition o the chest leads
Leads Leads Position in the chest Position in the chest
V V 4th ICS at the right sternal border 4th ICS at the right sternal border
V2 V2 4th ICS at the left sternal border 4th ICS at the left sternal border
V3 V3 Halfway between V2 and V4 Halfway between V2 and V4
V4 V4 Sth ICS at the left midclavicular line Sth ICS at the left midclavicular line
VS VS Sth ICS at the left anterior axillary line Sth ICS at the left anterior axillary line
V6 V6 Sth ICS at the left mid Sth ICS at the left mid- -axillary line axillary line
V3R V3R Halfway between V and V4R Halfway between V and V4R
V4R V4R Sth ICS at the right midclavicular line Sth ICS at the right midclavicular line
I Rate I Rate
A Rate Interpretation has three possibilities: A Rate Interpretation has three possibilities:
Bradycardia Bradycardia - - (< 60 beats/min (< 60 beats/min
2ormal Rate 2ormal Rate ( 60 ( 60 00 beats per 00 beats per
minute minute
3 1achycardia 3 1achycardia ( > 00 beats per minute ( > 00 beats per minute
B Rate Analysis: B Rate Analysis:
Mnemonic: Memorize 300,S0,00.7S,60,S0 Mnemonic: Memorize 300,S0,00.7S,60,S0
= if R to R interval > S big squares: Bradycardia = if R to R interval > S big squares: Bradycardia
= if R to R interval between 3 = if R to R interval between 3- -S big squares: S big squares:
ormal Rate ormal Rate
= if R to R interval < 3 big squares: 1achycardia = if R to R interval < 3 big squares: 1achycardia
ORMULA ORMULA
Heart Rate = S00 or 300 Heart Rate = S00 or 300
------------ ------------ ------------- -------------
4 of small boxes 4 of big boxes 4 of small boxes 4 of big boxes
II RHY1HM II RHY1HM
A Common Rhythm Interpretations: A Common Rhythm Interpretations:
Sinus Rhythm Sinus Rhythm
2 Common Supraventricular Arrythmias: 2 Common Supraventricular Arrythmias:
a Atrial ibrillation a Atrial ibrillation
b Atrial lutter b Atrial lutter
c Supraventricular 1achycardia c Supraventricular 1achycardia
3 Heart Blocks 3 Heart Blocks
a irst degree AV block a irst degree AV block
b Second degree AV block Mobitz type I ( Wenckebach b Second degree AV block Mobitz type I ( Wenckebach
c Second degree AV block Mobitz type II c Second degree AV block Mobitz type II
d 1hird degree AV block d 1hird degree AV block
e Left or Right Bundle Branch Block ( complete and e Left or Right Bundle Branch Block ( complete and
incomplete incomplete
4 Ventricular Arrythmias 4 Ventricular Arrythmias
a Premature Ventricular Contractions a Premature Ventricular Contractions
b Ventricular 1achycardia ( sustained and unsustained b Ventricular 1achycardia ( sustained and unsustained
c Ventricular ibrillation c Ventricular ibrillation
B Rhythm Analysis: B Rhythm Analysis:
Identify the P wave Identify the P wave
Determine from the configuration if this is a sinus P Determine from the configuration if this is a sinus P
2 Check the relation of P wave to QRS 2 Check the relation of P wave to QRS
a P wave is before QRS ( normal a P wave is before QRS ( normal
b P wave is buried or after QRS ( eg SV1, complete heart b P wave is buried or after QRS ( eg SV1, complete heart
block block
3 Check PR interval ( ormal PR interval: 02 3 Check PR interval ( ormal PR interval: 02 020 sec 020 sec
a Short PR ( WPW syndrome a Short PR ( WPW syndrome
b ormal PR b ormal PR
c Prolonged PR ( st or 2nd degree AV block c Prolonged PR ( st or 2nd degree AV block
4 Check QRS duration ( ormal QRS duration < 00 sec 4 Check QRS duration ( ormal QRS duration < 00 sec
a ormal QRS a ormal QRS
b Wide QRS ( Bundle branch blocks b Wide QRS ( Bundle branch blocks
S Check the relation of R S Check the relation of R- -R and P R and P- -P interval P interval
a Lqual R a Lqual R- -R and P R and P- -P interval ( ormal P interval ( ormal
b P b P- -P interval shorter than R P interval shorter than R- -R interval ( Complete heart R interval ( Complete heart
block block
c P c P- -P interval longer than R P interval longer than R- -R interval ( AV dissociation R interval ( AV dissociation
III AXIS III AXIS
A Axis Interpretation has our A Axis Interpretation has our
Possibilities: Possibilities:
ormal Axis ormal Axis
2 Left Axis Deviation ( LAD 2 Left Axis Deviation ( LAD
3 Right Axis Deviation ( RAD 3 Right Axis Deviation ( RAD
4 Indeterminate Axis 4 Indeterminate Axis
B Axis Analysis: B Axis Analysis:
Getting the Axis Deiation Getting the Axis Deiation
( + QRS deflection: Average QRS vector ( + QRS deflection: Average QRS vector
above the baseline in leads I or AV above the baseline in leads I or AV
( ( - - QRS deflection: Average QRS vector QRS deflection: Average QRS vector
below the baseline in leads I or AV below the baseline in leads I or AV
ormal Axis ormal Axis ++ ++
Left Axis Deviation Left Axis Deviation ++ - -
Right Axis Right Axis
Deviation Deviation
- - ++
Indeterminate Axis Indeterminate Axis - - - -
LEAD I LEAD AVF
Dierential diagnosis or let and right axis Dierential diagnosis or let and right axis
deiation deiation
QRS Left Axis Deviation QRS Left Axis Deviation
normal variant ( short fat normal variant ( short fat
individuals individuals
2 left ventricular hypertrophy 2 left ventricular hypertrophy
3 inferior wall infarction 3 inferior wall infarction
4 left bundle branch block 4 left bundle branch block
S left anterior fascicular block S left anterior fascicular block
6 WPW syndrome 6 WPW syndrome
QRS Right Axis Deviation QRS Right Axis Deviation
normal variant (thin tall normal variant (thin tall
individuals individuals
2 right ventricular hypertrophy 2 right ventricular hypertrophy
3 lateral wall infarction 3 lateral wall infarction
4 pulmonary embolism 4 pulmonary embolism
S left posterior fascicular block S left posterior fascicular block
6 WPW syndrome 6 WPW syndrome
IV Hypertrophy IV Hypertrophy
A Hypertrophy interpretation has 6 A Hypertrophy interpretation has 6
possibilities: possibilities:
no hypertrophy no hypertrophy
2 2 LVH LVH
3 3 RVH RVH
4 4 LAL LAL
S S RAL RAL
6 6 a combination of the above a combination of the above
B Hypertrophy analysis: B Hypertrophy analysis:
1hree LVH LCG Criteria: these are distorted 1hree LVH LCG Criteria: these are distorted
by the presence of a complete LBBB but not by the presence of a complete LBBB but not
by complete RBBB by complete RBBB
S wave in V + R wave in vS or v6 > 3Smm S wave in V + R wave in vS or v6 > 3Smm
(commonly used (commonly used
sensitivity 43, Specificity 97 sensitivity 43, Specificity 97
2 R in AVL > mm 2 R in AVL > mm
sensitivity , specificity 00 sensitivity , specificity 00
3 Romhilt and Lstes Criteria (Best Criteria 3 Romhilt and Lstes Criteria (Best Criteria
sensitivity S0, specificity 9S sensitivity S0, specificity 9S
a amplitude a amplitude 3 points 3 points
largest R or S wave in the limb leads >= 20mm largest R or S wave in the limb leads >= 20mm
s wave in v or v2 >= 30mm s wave in v or v2 >= 30mm
r wave in vS or v6 >= 30mm r wave in vS or v6 >= 30mm
b S1 b S1- -1 segment changes typical of LV strain 1 segment changes typical of LV strain
pattern pattern
without digitalis without digitalis 3 points 3 points
with digitalis with digitalis point point
c LAL: terminal negativity c LAL: terminal negativity 3points 3points
of the P wave in v is of the P wave in v is
mm or more in depth mm or more in depth
with a duration of 004s or more with a duration of 004s or more
d LAD: 30 degrees or more d LAD: 30 degrees or more 2 points 2 points
e QRS duration >= 009s but < 02s e QRS duration >= 009s but < 02s point point
f intrinsicoid deflection f intrinsicoid deflection point point
in vS and v6 >= 00Ss in vS and v6 >= 00Ss
interpretation of total score: interpretation of total score: possible LVH 3 points possible LVH 3 points
probable LVH 4points probable LVH 4points
definitive LVH >= S definitive LVH >= S \ \
points points
our RVl LCG Criteria our RVl LCG Criteria
right axis deviation of 0 degrees or more, right axis deviation of 0 degrees or more,
with any of the ff with any of the ff
2 lead v R wave > S wave 2 lead v R wave > S wave
3 deep s wave in vS and v6 3 deep s wave in vS and v6
4 S1 depression and t wave inversion in v 4 S1 depression and t wave inversion in v- -v3 v3
AL LCG criteria: any o the AL LCG criteria: any o the
v: wide terminal component of P wave v: wide terminal component of P wave
which is >= mm wide and>= mm deep which is >= mm wide and>= mm deep
2 in any lead: P wave wider than 02s or with 2 in any lead: P wave wider than 02s or with
a >= mm notch in the middle a >= mm notch in the middle
RAL LCG criteria: any o the RAL LCG criteria: any o the
v: tall initial component of P wave which is v: tall initial component of P wave which is
>= 2mm wide and >= 2mm tall >= 2mm wide and >= 2mm tall
2 in any lead: P wave >= 2Smm tall 2 in any lead: P wave >= 2Smm tall
ientricular lypertrophy Diagnostic LCG ientricular lypertrophy Diagnostic LCG
criteria: any o the criteria: any o the
the LCG meets one or more of the the LCG meets one or more of the
diagnostic criteria for isolated left and diagnostic criteria for isolated left and
right ventricular hypertrophy right ventricular hypertrophy
2 2 the precordial leads show signs of left the precordial leads show signs of left
ventricular hypertrophy, but the QRS axis ventricular hypertrophy, but the QRS axis
in the frontal plane is > 90 degrees in the frontal plane is > 90 degrees
iatrial enlargement diagnostic LCG iatrial enlargement diagnostic LCG
criteria criteria
v: presence of a large diphasic P wave with the v: presence of a large diphasic P wave with the
initial positive component >= 2mm tall and the initial positive component >= 2mm tall and the
terminal negative component >= mm deep and terminal negative component >= mm deep and
>= 004s in duration >= 004s in duration
2 2 in any lead: increase in both the amplitude which in any lead: increase in both the amplitude which
is 2Smm or greater and duration of 02s or more is 2Smm or greater and duration of 02s or more
of the P wave of the P wave
V. Ischemia and Inarction V. Ischemia and Inarction
A interpretation has 4 possibilities: A interpretation has 4 possibilities:
within normal limits (WL S0 of within normal limits (WL S0 of
patients w/ CAD or chronic stable angina patients w/ CAD or chronic stable angina
have normal LCGs have normal LCGs
2 2 non non- -specific S1 specific S1- -1 wave changes 1 wave changes
3 3 myocardial ischemia changes myocardial ischemia changes
4 4 myocardial infarction changes myocardial infarction changes
Infarction and Ischemia analysis
Leads involved Leads involved Corresponding Areas Corresponding Areas
II, III, AV II, III, AV Inferior wall Inferior wall
I, AVL I, AVL High lateral wall High lateral wall
V,v2 V,v2 Septal wall Septal wall
V3, v4 V3, v4 Anterior wall Anterior wall
VS, v6 VS, v6 Lateral wall Lateral wall
V V- -v3 v3 Anteroseptal wall Anteroseptal wall
V3 V3- -v6, I, AVL v6, I, AVL Anterolateral wall Anterolateral wall
VS, v6, II, III, AV VS, v6, II, III, AV Inferolateral wall Inferolateral wall
Almost all leads Almost all leads Diffuse, global, massive Diffuse, global, massive
Mirror image of v, v2 Mirror image of v, v2 Posterior LV wall Posterior LV wall
V3R, v4R V3R, v4R RV wall RV wall
LCG indings in ischemia: LCG indings in ischemia:
at least mm S1 at least mm S1- -segment depression segment depression
2 2 symmetrically inverted t wave symmetrically inverted t wave
3 3 abnormallt tall 1 wave abnormallt tall 1 wave
4 4 normalization of abnormal 1 wave normalization of abnormal 1 wave
S S prolonged Q1 interval prolonged Q1 interval
6 6 arrhythmia, bundle branch blocks, AV arrhythmia, bundle branch blocks, AV
blocks blocks
LCG criteria for infarct: LCG criteria for infarct:
S1 elevation >= 2mm in 2 or more chest S1 elevation >= 2mm in 2 or more chest
leads or >= mm in 2 or more limb leads leads or >= mm in 2 or more limb leads
2 2 Q waves >= 004s Q waves >= 004s
Myocardial Infarction In the presence of Myocardial Infarction In the presence of
BBBs BBBs
RBBB: usual myocardial criteria RBBB: usual myocardial criteria
2 2 LBBB: diminishing R wave forces in the LBBB: diminishing R wave forces in the
precordial leads or Q waves at vS and v6 precordial leads or Q waves at vS and v6
!atterns that may mimic MI: !atterns that may mimic MI:
complete LBBB complete LBBB
2 2 early repolarization pattern early repolarization pattern
3 3 LV aneurysm LV aneurysm
4 4 hyperkalemia hyperkalemia
S S pericarditis pericarditis
6 6 intracranial hemorrhage intracranial hemorrhage
7 7 idiopathic subaortic stenosis idiopathic subaortic stenosis
8 8 WPW syndrome WPW syndrome
9 9 electronic pacing of right ventricle electronic pacing of right ventricle
0 0 pulmonary disorders pulmonary disorders
VI. Miscellaneous LCG indings: VI. Miscellaneous LCG indings:
hypokalemia hypokalemia
U wave as tall or taller than the 1 wave at leads v2 v3 U wave as tall or taller than the 1 wave at leads v2 v3
2 2 hyperkalemia hyperkalemia
in the chest leads, height of 1 waves >0mm in most in the chest leads, height of 1 waves >0mm in most
leads leads
In the limb leads, height of 1 waves > Smm in most In the limb leads, height of 1 waves > Smm in most
leads leads
3 3 hypocalcemia hypocalcemia
prolonged Q1 interval ( normal Q1 interval is less prolonged Q1 interval ( normal Q1 interval is less
than half the RR interval than half the RR interval
4 4 hypercalcemia hypercalcemia
shortened Q1 interval shortened Q1 interval
S S digitalis effect digitalis effect
manifested by prolonged PR interval, scooping of the manifested by prolonged PR interval, scooping of the
S1 segment, and short Q1 interval S1 segment, and short Q1 interval
6 digitalis toxicity 6 digitalis toxicity
all types of arrythmias, usually PVC's or paroxysmal atrial all types of arrythmias, usually PVC's or paroxysmal atrial
tachycardia tachycardia
7 electrical alternans of QRS complex 7 electrical alternans of QRS complex
height of QRS varies from beat to beat height of QRS varies from beat to beat
may be due to cardiac tamponade, large pericardial effusion, low may be due to cardiac tamponade, large pericardial effusion, low
cardiac output, COPD, tension pneumothorax cardiac output, COPD, tension pneumothorax
8 poor R wave progression 8 poor R wave progression
height of the R wave in v3 is < 3mm height of the R wave in v3 is < 3mm
may be due to old anteroseptal wall MI, LVH, normal variant of a may be due to old anteroseptal wall MI, LVH, normal variant of a
heart rotated clockwise, LBBB heart rotated clockwise, LBBB
9 persistent S wave in vS v6 9 persistent S wave in vS v6
prominent S waves in vS and v6 prominent S waves in vS and v6
my be die to RVH, or the heart rotated clockwise my be die to RVH, or the heart rotated clockwise
0 early repolarization changes 0 early repolarization changes
normal variant in young males (S1 segment elevation of 2 normal variant in young males (S1 segment elevation of 2- -3mm in 3mm in
leads v2 leads v2- -v4 usually found in males <40yrs old v4 usually found in males <40yrs old
may be due to Acute anteroseptal wall MI, or acute pericarditis may be due to Acute anteroseptal wall MI, or acute pericarditis
juvenile 1 wave inversion juvenile 1 wave inversion
normal variant in young females (1 wave inversion in v normal variant in young females (1 wave inversion in v- -v3 in v3 in
females <30yrs old females <30yrs old
may be due to acute anteroseptal wall ischemia may be due to acute anteroseptal wall ischemia
2 low voltage QRS complexes 2 low voltage QRS complexes
the amplitude of the entire QRS complex in all the limb leads the amplitude of the entire QRS complex in all the limb leads
is <Smm is <Smm
may be found in normal elderly patients, obese or edematous may be found in normal elderly patients, obese or edematous
patients, cardiac tamponade, large pericardial effusion, patients, cardiac tamponade, large pericardial effusion,
pneumothorax, hypothyroidism, dilated cardiomyopathy pneumothorax, hypothyroidism, dilated cardiomyopathy
3 high voltage QRS complexes 3 high voltage QRS complexes
large QRS complexes large QRS complexes
may be found in patients <3Syrs old, LVH, RVH, LBBB, may be found in patients <3Syrs old, LVH, RVH, LBBB,
RBBB RBBB
4 cerebral 1 waves of intracranial hemorrhage 4 cerebral 1 waves of intracranial hemorrhage
wide, prominent, and deeply inverted 1 waves with a long wide, prominent, and deeply inverted 1 waves with a long
Q1 interval Q1 interval
may be found in intracranial hemorrhage, subendocardial may be found in intracranial hemorrhage, subendocardial
MI, and MI MI, and MI
S wrong lead placement S wrong lead placement
an upright P wave in lead AVR accompanied by a an upright P wave in lead AVR accompanied by a
normal R wave progression in the precordial leads normal R wave progression in the precordial leads
6 wrong speed 6 wrong speed
widened PR and QRS intervals and the patient's widened PR and QRS intervals and the patient's
heart rate does not jive with the LCG heart rate heart rate does not jive with the LCG heart rate
Speed used is S0mm/sec instead of the usual Speed used is S0mm/sec instead of the usual
2Smm/sec 2Smm/sec
7 artifacts 7 artifacts
irregular spikes or undulations on the LCG baseline irregular spikes or undulations on the LCG baseline
are not found in the other segments are not found in the other segments