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The Complete Guide to ECGs, 3rd Ed

The Complete Guide to ECGs, 3rd Ed

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The Complete

Guide to ECGs
Third Edition
James H. O’Keefe, MD, FACC
Professor of Medicine
University of Missouri, Kansas City
Director, Preventive Cardiology
Mid America Heart Institute
St. Lukes Hospital
Kansas City, Missouri
Stephen C. Hammill, MD, FACC, FHRS
Past President, Heart Rhythm Society
Professor of Medicine
Director, Electrocardiography Laboratory
Mayo Clinic
Rochester, Minnesota
Mark S. Freed, MD, FACC
President and Editor-in-Chief
Physicians’ Press
Royal Oak, Michigan
Steven M. Pogwizd, MD, FACC
FeatheringillEndowedProIessorinCardiacArrhythmiaResearch
ProIessoroIMedicine,Physiology&Biophysics,andBiomedicalEngineering
AssociateDirector,CardiacRhythmManagementLaboratory
TheUniversityoIAlabamaatBirmingham
Birmingham,Alabama
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they are not responsible for errors, omissions, or for any outcomes related to the use of the contents
of this book and take no responsibility for the use of the products and procedures described. Treatments
and side effects described in this book may not be applicable to all people; likewise, some people may
require a dose or experience a side effect that is not described herein. Drugs and medical devices are
discussed that may have limited availability controlled by the Food and Drug Administration (FDA)
for use only in a research study or clinical trial. Research, clinical practice, and government regulations
often change the accepted standard in this field. When consideration is being given to use of any drug
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for the product. This is especially important in the case of drugs that are new or seldom used.
6048
ISBN-13: 978-07637-6405-0
Printed in the United States of America
12 11 10 09 10 9 8 7 6 5 4 3 2 13
Dedication
TomyIamily.MyconnectionIromthepast,intotheIuture.TheIoundationthatbrings
joy,meaningandstrengthtomyliIe.
JamesO’KeeIe
TomywiIeKarenandsonsNoel,Eric,Steve,andDanny—thanksIoryourpatience
andsupport.
StephenHammill
Tomymother,Iather,Ralph,Susie,Bradley,Paulie,Jill,andJosephine,thejoysoImy
liIe.
MarkFreed
TomywiIeCindy,andtomychildrenLeahandMike,withlove;andinmemoryoImyIather,
Edward.
StevenPogwizd
JamesO’KeeIe,Jr.,MD StephenHammill,MD MarkFreed,MD StevenPogwizd,MD
Preface
The Complete Guide to ECGs has been developed as a unique and practical means Ior physicians,
physicians-in-training,andothermedicalproIessionalstoimprovetheirECGinterpretationskills.The
highlyinteractiveIormatandcomprehensivescopeoIinIormationarealsoideallysuitedIorphysicians
preparingIortheAmericanBoardoIInternalMedicine(ABIM)CardiovascularDiseaseorInternal
MedicineBoardExams,theAmericanCollegeoICardiologyECGproIiciencytest,andotherexams
requiringECGinterpretation.
ThisThirdEditionincludesmanynewECGcasesandquizzesandcontainsmorethan1000questions
andanswersrelatedtoECGinterpretation.AlsoIeaturedaresectionsonapproachtoECGinterpretation
andECGdiIIerentialdiagnosisandanexpandedIinalsectiononECGcriteria.
WerecommendusingtheanswersheetonmanyotherECGsinadditiontothesampletracingsprovided.
StudygroupsandregulareducationalconIerencesareidealsettingsIorthepresentationoIunknown
ECGsanddiscussionoItheircorrectinterpretation.
WehopeyouenjoyreadingThe Complete Guide to ECGsandIinditapracticalresourceIorpatient
care.
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Table of Contents
GeneralInstructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CommonDilemmasinECGInterpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ApproachtoECGInterpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Heartrate . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Pwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OriginoItherhythm . . . . . . . . . . . . . . . . . 7
PRinterval . . . . . . . . . . . . . . . . . . . . . . . . . 7
QRSwidth . . . . . . . . . . . . . . . . . . . . . . . . . 8
QTinterval . . . . . . . . . . . . . . . . . . . . . . . . . 8
QRSaxis . . . . . . . . . . . . . . . . . . . . . . . . . . 9
QRSvoltage . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
PrecordialRwaveprogression . . . . . . . . . . . . 9
Qwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
STsegment . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Twave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Uwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Pacemakers . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ECGDiIIerentialDiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Pwave . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
PRinterval . . . . . . . . . . . . . . . . . . . . . . . . 16
PRsegment . . . . . . . . . . . . . . . . . . . . . . . 16
QRSduration . . . . . . . . . . . . . . . . . . . . . . 16
QRSamplitude . . . . . . . . . . . . . . . . . . . . 17
QRSaxis . . . . . . . . . . . . . . . . . . . . . . . . . 17
Qwave . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Rwaveprogression . . . . . . . . . . . . . . . . . 18
QRSmorphology . . . . . . . . . . . . . . . . . . . . . . 18
STsegment . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Twave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
QTinterval . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Uwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
PPpause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Groupbeating . . . . . . . . . . . . . . . . . . . . . . . . . 20
ECGCasesandQuizzes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ECGCriteria(seenextpageIorexpandedtableoIcontents) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
IndexoICases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
ECG Criteria (Section 4)
GENERALFEATURE8
01. NormalECG . . . . . . . . . . . . . 525
02. BorderlinenormalECGor
normalvariant . . . . . . . . . . . . 525
03. Incorrectelectrodeplacement 526
04. ArtiIact . . . . . . . . . . . . . . . . . . 526
PWAVEABNORMAL¡T¡E8
05. Rightatrialabnormality . . . . . 527
06. LeItatrialabnormality . . . . . . 527
8UPRAVENTR¡CULARRHYTHM8
07. Sinusrhythm . . . . . . . . . . . . . 527
08. Sinusarrhythmia . . . . . . . . . . 527
09. Sinusbradycardia . . . . . . . . . . 528
10. Sinustachycardia . . . . . . . . . . 528
11. Sinuspauseorarrest . . . . . . . 528
12. Sinoatrialexitblock . . . . . . . . 528
13. Atrialprematurecomplexes . . 529
14. Atrialparasystole . . . . . . . . . . 529
15. Atrialtachycardia . . . . . . . . . . 530
16. Atrialtachycardia,multiIocal . 530
17. Supraventriculartachycardia,
paroxysmal . . . . . . . . . . . . . . . 530
18. AtrialIlutter . . . . . . . . . . . . . . 531
19. AtrialIibrillation . . . . . . . . . . 531
JUNCT¡ONALRHYTHM8
20. AVjunctionalpremature
complexes . . . . . . . . . . . . . . . 532
21. AVjunctionalescapecomplexes 532
22. AVjunctionalrhythm
/tachycardia . . . . . . . . . . . . . . 533
VENTR¡CULAR RHYTHM8
23. Ventricularpremature
complexes . . . . . . . . . . . . . . . 533
24. Ventricularparasystole . . . . . 534
25. Ventriculartachycardia . . . . . 534
26. Acceleratedidioventricular
rhythm . . . . . . . . . . . . . . . . . . 535
27. Ventricularescapecomplexesor
rhythm . . . . . . . . . . . . . . . . . . 535
28. VentricularIibrillation . . . . . . 535
AVCONDUCT¡ON
ABNORMAL¡T¡E8
29. AVblock,1° . . . . . . . . . . . . . 535
30. AVblock,2°-MobitztypeI
(Wenckebach) . . . . . . . . . . . . 536
31. AVblock,2°-MobitztypeII . 536
32. AVblock,2:1 . . . . . . . . . . . . . 537
33. AVblock,3° . . . . . . . . . . . . . 537
34. WolII-Parkinson-Whitepattern 537
35. AVdissociation . . . . . . . . . . . 538
ABNORMAL¡T¡E8OFOR8AX¡8
36. LeItaxisdeviation . . . . . . . . . . 538
37. Rightaxisdeviation . . . . . . . . . 539
38. Electricalalternans . . . . . . . . . . 539
OR8VOLTAGEABNORMAL¡T¡E8
39. Lowvoltage . . . . . . . . . . . . . . . 539
40. LeItventricularhypertrophy . . 539
41. Rightventricularhypertrophy . 540
42. Combinedventricular
hypertrophy . . . . . . . . . . . . . . . 540
¡NTRAVENTR¡CULAR
CONDUCT¡ONABNORMAL¡T¡E8
43. RBBB,complete . . . . . . . . . . . 541
44. RBBB,incomplete . . . . . . . . . . 541
45. LeItanteriorIascicularblock . . 541
46. LeItposteriorIascicularblock . 542
47. LBBB,complete . . . . . . . . . . . . 542
48. LBBB,incomplete . . . . . . . . . . 542
49. NonspeciIicintraventricular
conductiondisturbance . . . . . . 542
50. Functional(rate-related)aberrant
intraventricularconduction . . . 542
O-WAVEMYOCARD¡AL
¡NFARCT¡ON8
51. Anterolateral(recentoracute) . 544
52. Anterolateral(indeterminate
orold) . . . . . . . . . . . . . . . . . . . 544
53. Anteriororanteroseptal(recentor
acute) . . . . . . . . . . . . . . . . . . . . 544
54. Anteriororanteroseptal
(indeterminateorold) . . . . . . . 544
55. Lateral(recentoracute) . . . . . . 544
56. Lateral(indeterminateorold) . 544
57. InIerior(recentoracute) . . . . . 544
58. InIerior(indeterminateorold) . 544
59. Posterior(recentoracute) . . . . 544
60. Posterior(indeterminateorold) 544
REPOLAR¡ZAT¡ON
ABNORMAL¡T¡E8
61. Normalvariant,early
repolarization . . . . . . . . . . . . . . 544
62. Normalvariant,juvenileT
waves . . . . . . . . . . . . . . . . . . . . 545
63. NonspeciIicSTand/orTwave
abnormalities . . . . . . . . . . . . . . 545
64. STand/orTwaveabnormalities
suggestingmyocardialischemia 545
65. STand/orTwaveabnormalities
suggestingmyocardialinjury . . 546
66. STand/orTwaveabnormalities
suggestingelectrolyte
disturbances . . . . . . . . . . . . . . . 546
67. STand/orTwaveabnormalities
secondarytohypertrophy . . . . . 546
68. ProlongedQTinterval . . . . . . . 546
69. ProminentUwaves . . . . . . . . . 547
CL¡N¡CALD¡8ORDER8
70. DigitaliseIIect . . . . . . . . . . . . . 547
71. Digitalistoxicity . . . . . . . . . . . . 547
72. AntiarrhythmicdrugeIIect . . . . 547
73. Antiarrhythmicdrugtoxicity . . 548
74. Hyperkalemia . . . . . . . . . . . . . . 548
75. Hypokalemia . . . . . . . . . . . . . . 548
76. Hypercalcemia . . . . . . . . . . . . . 548
77. Hypocalcemia . . . . . . . . . . . . . . 548
78. AtrialseptaldeIect,secundum . 549
79. AtrialseptaldeIect,primum . . . 549
80. Dextrocardia,mirrorimage . . . 549
81. Chroniclungdisease . . . . . . . . 549
82. Acutecorpulmonaleincluding
pulmonaryembolus . . . . . . . . . 550
83. PericardialeIIusion . . . . . . . . . 550
84. Acutepericarditis . . . . . . . . . . . 550
85. Hypertrophiccardiomyopathy . 551
86. Centralnervoussystemdisorder 551
87. Myxedema . . . . . . . . . . . . . . . . 551
88. Hypothermia . . . . . . . . . . . . . . 551
89. Sicksinussyndrome . . . . . . . . . 552
PACEDRHYTHM8
90. Atrialorcoronarysinuspacing 552
91. Ventriculardemandpacemaker
(VVI),normallyIunctioning . . 552
92. Dual-chamberpacemaker(DDD) 552
93. PacemakermalIunction,not
constantlycapturing(atriumor
ventricle) . . . . . . . . . . . . . . . . . 553
94. PacemakermalIunction,not
constantlysensing(atriumor
ventricle) . . . . . . . . . . . . . . . . . 553
Abbreviations
APC Atrial premature contraction RBBB Right bundle branch block
AV Atrioventricular RVH Right ventricular hypertrophy
COPD Chronic obstructive pulmonary disease SA Sinoatrial
JPC Junctional premature complex SVT Supraventricular tachycardia
LAFB Left anterior fascicular block VA Ventriculoatrial
LBBB Left bundle branch block VF Ventricular fibrillation
LPFB Left posterior fascicular block VPC Ventricular premature contraction
LVH Left ventricular hypertrophy VT Ventricular tachycardia
MI Myocardial infarction WPW Wolff-Parkinson-White
Nomenclature
TherelativeamplitudesoIthecomponentwavesoItheQRScomplexaredescribedusingsmall(lower
case)andlarge(uppercase)letters.Forexample,anrScomplexdescribesaQRSwithasmallRwave
andalargeSwave;aqRscomplexdescribesaQRSwithasmallQwave,alargeRwave,andasmall
S wave; and an RSR’ complex describes a QRS with a large R wave, a large S wave, and a large
secondaryRwave(R’).WhentheQRScomplexconsistssolelyoIaQwave,a“QS”designationis
used.
Acknowledgments
WewishtoacknowledgeMonicaCrowderKauImanIorheroutstandingworkintypingand
Iormattingthisguide,NormLyleIorcoverart,andtheexcellentstaIIatJonesandBartlett
Publishers.Weareindebtedtotheseindividuals,andhopetheireIIortsarewell-received.
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Notice
TheECGinterpretationsandcriteriaexpressedinthisbookrepresentaconsensusamongthe
authorsbasedonpreviouslypublishedliteratureandtheirownexperienceandviewpoints.The
authorsandpublisherdisclaimresponsibilityIoradverseeIIectsresultingIromomissionsor
undetectederrorsoradverseresultsobtainedIromtheuseoIsuchinIormation.Readersare
encouragedtoreviewotherreIerencesonECGinterpretationtoIurtherexpandtheirknowlege
andinterpretationskills.
—1—
General Instructions
R
ead each ECG in a thorough and systematic Iashion, using the answer sheet to record your
Iindings.Beorganized.Becompulsive.BestrictinyourapplicationoItheECGcriteria.And
take your time — even the most experienced electrocardiographers miss important ECG
diagnoseswhenhurryingthroughaninterpretation.BesuretoanalyzetheIollowing14Ieaturesoneach
ECG,asoutlinedhereanddescribedingreaterdetailinSection1:
01. Heartrate
02. Pwavemorphologyandamplitude
03. OriginoItherhythm
04. PRinterval
05. QRSwidth
06. QTinterval
07. QRSaxis
08. QRSvoltage
09. Rwaveprogressionintheprecordialleads
10. AbnormalQwaves
11. STsegment
12. Twave
13. Uwave
14. Electronicpacemaker
OncetheseIeatureshavebeenidentiIied,askyourselItheIollowingquestions:
1. Isanarrhythmiaand/orconductiondisturbancepresent?
2. Ischamberenlargementand/orhypertrophypresent?
3. Isischemia,injury,and/orinIarctionpresent?
4. Areanyclinicaldisorders(items70-89onanswersheet)likelytobepresent?
ItisimportanttoconsidereachECGinthecontextoItheclinicalhistory.Forexample,diIIusemildST
segmentelevationinanasymptomaticpatientislikelytorepresentearlyrepolarizationabnormality,
whereasthesameIindinginapatientwithchestpainandaIrictionrubismorelikelytorepresentacute
pericarditis.
AItercodingthe ECG ontheaccompanyinganswersheet,studythecorrectinterpretation.IIECG
diagnoses were missed or improperly selected, turn to the Iinal section oI the book and review the
appropriatecriteria.TheECGcriteriaexpressedinthisbookrepresentaconsensusamongtheauthors,
basedonpreviouslypublishedliteratureandtheirownexperienceandviewpoints.
Answer the multiple choice and Iill-in-the-blank questions corresponding to each ECG. Cover the
answercolumnasyouworkthroughthe“QuickReviews”and“PopQuizzes”thatIolloweachcase.
Placeacheckmarknexttothequestionsthatwereansweredincorrectly;attheendoIeachreading
sessionandatthestartoIeachnewreadingsession,returntothesequestionsandbesuretheycanbe
answeredcorrectly.OncealltheECGshavebeeninterpretedandthequestionsanswered,reviewthem
againuntiltheyaremastered.
—2—
Common Dilemmas in ECG Interpretation
Q
uestionsIrequentlyariseregarding“optimalcoding”oIECGtracings,sincemanyspeciIicECG
criteria remain controversial and no single ECG reIerence standard exists. The Iollowing
recommendations to some common dilemmas in ECG interpretation represent a consensus
amongtheauthorsbasedonpreviouslypublishedliteratureandtheirexperienceandviewpoints.
Problem 1: QwavesarepresentinleadsV
1
andV
2
only.ShouldamyocardialinIarctionbecoded?
Recommendation:No,itisimportanttoIollowstrictcodingcriteriawheninterpretingECGs.Tocode
ananteroseptalmyocardialinIarction,QwavesmustbepresentinleadsV
1
,V
2
andV
3
.Inday-to-day
clinicalmedicine,QwavesinV
1
and V
2
areoItenreIerredtoas“possible”anteroseptalMIorlow
anteriorIorces.Whilethisdesignationisacceptableinclinicalcardiology,QwavemyocardialinIarction
shouldnotbecodedinstandardizedtestingIormats.
Problem 2: TheECGshowsacutemyocardialinIarction.ShouldanyotherECGdiagnosesbecoded?
Recommendation: Yes, it is important to code item 65 (ST and/or T abnormalities suggesting
myocardial injury) when acute myocardial inIarction with typical ST segment elevation is present.
RemembertoalsousethiscodewhenSTsegmentdepressionispresentinleadsV
1
andV
2
inthesetting
oIposteriorMI.
Problem 3: LeItbundlebranchblockispresent.ShouldacutemyocardialinIarctioneverbecoded?
Recommendation: No (controversial). Most electrocardiographers are reluctant to diagnose acute
myocardial inIarction in the setting oI LBBB. However, three criteria have independent value Ior
diagnosingacutemyocardialinjury(item65):
STelevation~1mmconcordantto(samedirectionas)themajordeIlectionoItheQRS
STdepression~1mminleadV
1
,V
2
,orV
3
STelevation~5mmdiscordantwith(oppositedirectionto)themajordeIlectionoItheQRS.
Problem 4: AcutemyocardialinIarctionispresentwithSTelevationinoneportionoIthetracingand
STsegmentdepressioninanother.IsitnecessarytocodebothST-Tchangessuggestingmyocardial
injuryandST-Tchangessuggestingmyocardialischemia?Recommendation:Manyacutemyocardial
inIarctionshaveSTelevationinsomeleadsandSTdepressioninothers.STsegmentdepressionmay
beduetoreciprocalECGchanges,ischemiaadjacenttoorremoteIromtheinIarctzone,ornon-Q-wave
myocardialinIaction.Item65(STand/orTwaveabnormalitiessuggestingmyocardialinjury)should
be coded in this setting, but not item 64 (ST and/or T wave abnormalities suggesting myocardial
ischemia).Remembertocodeitem59(posteriorMI,agerecentoracute)whenthereisaninitialRwave
0.04secondsinleadV
1
orV
2
withR/Swaveamplitude~1plussigniIicant(usually2mm)ST
segmentdepression,particularlyinthesettingoIacuteinIeriorMI.
—3—
Problem 5: Ischemic-lookingSTsegmentelevationispresentwithoutpathologicalQwavesina
patientwithchestpain.ShouldacutemyocardialinIarctionbecoded?Recommendation:No,convex
upwardSTsegmentelevationwithoutabnormalQwavesinthesettingoIchestpainshouldbecoded
asitem65(STand/orTwaveabnormalitiessuggestingmyocardialinjury).Clinically,thisusually
representstheearlystagesoIacuteinIarction(ortransientcoronaryspasmand/orocclusion),andmost
oIthesepatientsneedurgentpharmacologicormechanicalinterventiontorestorecoronarybloodIlow
tothejeopardizedmyocardium.Nevertheless,intheabsenceoIpathologicalQwaves(orpathological
RwavesinthecaseoIposteriorinIarction),acutemyocardialinIarctionshouldnotbecoded.
Problem 6: WithsomanydiIIerentcriteriaIorthediagnosisoIleItventricularhypertrophy(LVH),
whichshouldbeusedasthe“gold-standard?”Recommendation:TheCornellcriteria(RwaveinaVL
¹ S wave in V
3
~ 28 mm in males or ~ 20 mm in Iemales) is probably the most accurate voltage
criterion.However,manyECGsmeetvoltagecriteriainoneareaoIthetracing,butnotintheothers,
andallcriteriaIorLVHarerelativelyinsensitivewhenconsideredindividually.ThereIore,itisbestto
knowmostoralloIthevariouscriteriaIorLVH(item40).Remembertocodeitem67(STand/orT
waveabnormalitiessecondarytohypertrophy)iIa“strain”patternispresentinassociationwithLVH.
Problem 7: WhatarethemostimportantcriteriaIordiagnosingrightventricularhypertrophy(RVH)?
Recommendation:RVH,likeLVH,isdiIIiculttodiagnosisduetothenumerousdiIIerentcriteriathat
havebeenproposed.NosingleIindingisdiagnosticoIRVH.Importantelementsincluderightaxis
deviationandadominantRwavewithsecondarySTand/orTwavechangesinleadsV
1
andV
2
.Right
atrialabnormalityisalsocommon.IIrepolarizationabnormalitiesarepresent,remembertocodeitem
67(STand/orTwaveabnormalitiessecondarytohypertrophy).
Problem 8: Second-degreeorthird-degreeAVblockispresent.ShouldIirst-degreeAVblockalso
becodediIthePRintervalexceeds0.20seconds?Recommendation:No.Itisnotnecessarytocode
Iirst-degreeAVblockwhenhigherlevelsoIAVblockarepresent.
Problem 9: Ajunctionalorventricularrhythmispresent.Isitnecessarytocodetheunderlyingatrial
rhythm iI one is present? Recommendation: Yes. II an atrial rhythm is present in addition to a
dominantjunctionalorventricularrhythm,theatrialrhythm(andAVblock,iIpresent)shouldalsobe
coded(e.g.,ventricularescaperhythmandsinusrhythmwiththird-degreeAVblock).
Problem 10: Should leIt axis deviation be coded when leIt anterior Iascicular block (LAFB) is
present?Similarly,shouldrightaxisdeviationbecodedwhenleItposteriorIascicularblock(LPFB)is
present?Recommendation:No.AdescriptionoItheaxisinLAFBorLPFBisredundant.
Problem 11: WolII-Parkinson-White(WPW)patternispresent.WhenshouldmyocardialinIarction
becoded?Recommendation:AcuteMIshouldnotbediagnosedinthepresenceoIWPWsincemost
“Q”wavesareactuallynegativedeltawaves,resultinginapseudoinIarctpattern.
—4—
Problem 12: AtrialIibrillationispresentwithintermittentepisodesoIatrialIlutter(i.e.,“Iib/Ilutter).
ShouldatrialIibrillationoratrialIlutterbecoded?Recommendation:Thebeststrategyinthissetting
istocodeatrialIibrillation.AtrialIluttershouldbereservedIortracingsthatshowcontinuousatrial
IlutterwithoutinterspersedepisodesoIIibrillation.
Problem 13: LeIt ventricular hypertrophy with a “strain” pattern (ST depression with T wave
inversion)isevidentinthelateralleads.Shoulditem64,“STand/orTwaveabnormalitiessuggesting
myocardialischemia,”becoded?Recommendation:No.WhenLVHwithstrainispresent,items40
(leItventricularhypertrophy)and67(STand/orTwaveabnormalitiessecondarytohypertrophy)should
becoded.
Problem 14:AnarrowQRStachycardiawithoutPwavesispresentthroughouttheECGtracing.
Shoulditem15(atrialtachycardia)oritem17(supraventriculartachycardia,paroxysmal)becoded?
Recommendation: Paroxysmal SVT (item 17) should be coded, even iI the arrhythmia persists
throughoutthetracing.Atrialtachycardia(item15)shouldbereservedIornarrowcomplextachycardias
withidentiIiableectopicPwaves;ashortPRintervalisoItenbutnotalwayspresent.
Problem 15: ApatientwithatrialIibrillationorchronicheartIailuredemonstratessaggingSTsegment
depression,paroxysmalatrialtachycardia(PAT)withblock,orcompleteheartblockwithaccelerated
junctionalrhythmonECG.Shoulditem70(digitaliseIIect)oritem71(digitalistoxicity)becodediI
theclinicalhistorydoesnotspeciIicallystatethepatientisreceivingdigoxin.Recommendation:Yes.
ItisappropriatetocodedigitaliseIIectortoxicityIorclassicIindingsinapatientlikelytobereceiving
digoxintherapy.
—5—
— Section 1 —
APPROACH TO
ECG INTERPRETATION
EachECGshouldbereadinathoroughandsystematicIashion.
It is important to be organized, compulsive, and strict in your
applicationoItheECGcriteria.AnalyzetheIollowingIeatures
oneveryECG:
1. Heartrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. Pwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3. OriginoItherhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4. PRinterval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5. QRSduration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
6. QTinterval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
7. QRSaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
8. QRSvoltage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
9. PrecordialRwaveprogression . . . . . . . . . . . . . . . . . . . . 9
10. AbnormalQwaves . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11. STsegment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
12. Twave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
13. Uwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
14. Electronicpacemaker . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Once these Ieatures have been identiIied, ask the Iollowing
questions:
1. Isanarrhythmiaorconductiondisturbancepresent?
2. Ischamberenlargementorhypertrophypresent?
3. Isischemia,injury,orinIarctionpresent?
4. Is a clinical disorder present (see items 70-89 on answer
sheet)?
Be sure to consider each ECG in the context oI the clinical
history. For example, diIIuse mild ST segment elevation in a
young,asymptomaticpatientwithoutpreviouscardiachistoryis
likelytorepresentearlyrepolarizationabnormality,whereasthe
same Iinding in a patient with chest pain and a Iriction rub is
morelikelytorepresentacutepericarditis.
1. Heart Rate
The Iollowing method can be used to determine heart rate
(assumesastandardpaperspeedoI25mm/sec)
Regular Rhythm
• CountthenumberoIlargeboxesbetweenPwaves(atrialrate),
Rwaves(ventricularrate),orpacerspikes(pacemakerrate)
• Beatsperminute÷300dividedbythenumberoIlargeboxes
Note: It is easier to memorize the heart rates associated with
each oI the large boxes, rather than count the number oI large
boxes(1,2,3,etc)anddivideinto300:
P
R
T P
R
T
Heart Rate = 300 ∏no. large boxes between
“R” Waves = 300 ∏3 = 100 bpm
3 LARGE BOXES
300 150 100 75 60 50 43 37 33
Heart Rate = 75 bpm
The Complete Guide to ECGs
—6—
Note:IIthenumberoIlargeboxesisnotawholenumber,either
estimatetherate(thisisroutinepractice)ordivide1500bythe
numberoIsmallboxesbetweenPwaves(atrialrate),Rwaves
(ventricularrate),orpacerspikes(pacemakerrate):
Note: For tachycardias, it is helpIul to memorize the rates
between150and300BPM:
Slow or Irregular Rhythm
• IdentiIythe3-secondmarkersattoporbottomoIECGtracing
• Count the number oI QRS complexes (or P waves or pacer
spikes) that appear in 6 seconds (i.e., two consecutive 3-
secondmarkers)
• Multiplyby10toobtainrateinBPM
2. P Wave
What It Represents
The P wave represents electrical Iorces generated Irom atrial
activation.TheIirstandsecondhalvesoI the P waveroughly
correspondtorightandleItatrialactivation,respectively.
What to Measure
• Duration (seconds): Measured Irom the beginning oI the P
wavetotheendoIPwave.
• Amplitude(mm):MeasuredIrombaselinetotop(orbottom)
oIPwave.PositiveandnegativedeIlectionsaredetermined
separately.Onesmallbox÷1mmonstandardscaleECGs
(i.e.,10mm÷1mV)
• Morphology:
P Wave Characteristics
• NormalPwaveduration:0.08-0.11seconds
• NormalPwaveaxis:0-75
o
• NormalPwavemorphology:UprightinI,II,aVF;uprightor
biphasicinIII,aVL,V
1
,V
2
.Smallnotchingmaybepresent
• NormalPwaveamplitude:Limbleads:·2.5mm;V
1
:positive
deIlection·1.5mmandnegativedeIlection·1mm
300 150 100 75
ESTIMATED Heart Rate = halfway between 100 and
75 = 87 bpm (or 1500 ÷ 17.5 small boxes)
3
0
0
2
5
0
2
1
4
1
8
8
1
6
7
1
5
0
Heart Rate = 188 bpm
ESTIMATED Heart Rate = number of QRS complexes in
6 seconds x 10 = 6 x 10 = 60 bpm
3 seconds 3 seconds
1 2 3 4 5 6
P
R
0
1
1
2
2
3
4
(
m
m
)
UPWARD DEFLECTION
Duration = 1.5 small boxes
= 1.5 x 0.04 sec. = 0.06 sec.
Amplitude = 2 mm
DOWNWARD DEFLECTION
Duration = 1.5 small boxes
= 1.5 x 0.04 sec. = 0.06 sec.
Amplitude = 1 mm
UPRIGHT BIPHASIC INVERTED
FLUTTER (F) FIBRILLATION (f) DOME & DART
Section 1. Approach to ECG Interpretation
—7—
3. Origin of the Rhythm
RhythmidentiIicationisoneoIthemostdiIIicultandcomplex
aspects oI ECG interpretation, and one oI the most common
mistakes made by computer ECG interpretation programs.
ProperrhythminterpretationrequiresintegrationoIheartrate,RR
regularity,Pwavemorphology,PRinterval,QRSwidth,andthe
P:QRSrelationship.Nosinglealgorithmcansimplydescribeall
the various permutations; however the Iollowing rhythm-
recognitiontables,basedinitiallyontheP:QRSrelationshipand
heartrate,provideauseIulIrameoIreIerence:
— P:QRS Relationships —
P:QRS < 1:Junctionalorventricularprematurecomplexesorrhythms
(escape,accelerated,tachycardia)
P:QRS = 1
• P wave preceeds QRS: Sinus rhythm; ectopic atrial rhythm;
multiIocalatrialtachycardia;wanderingatrialpacemaker;SVT(sinus
nodereentrytachycardia,automaticatrialtachycardia);sinoatrialexit
block,2
o
;conductedAPCswithanyoItheabove
• P wave follows QRS; SVT (AV nodal reentry tachycardia,
orthodromic SVT); junctional / ventricular rhythm with 1:1
retrogradeatrialactivation
No P Waves: Atrial Iibrillation; atrial Ilutter; sinus arrest with
junctional or ventricular escape rhythm; SVT (AV nodal reentry
tachycardia,AVreentrytachycardia),junctionaltachycardiaorVTwith
PwaveburiedinQRS;VF
— Heart Rate < 100 BPM —
Narrow QRS (< 0.12 sec) - Regular R-R
• SinusP;rate60-100:Sinus rhythm
• SinusP;rate·60:Sinus bradycardia
• NonsinusP;PR0.12: Ectopic atrial rhythm
• NonsinusP;PR·0.12:Junctional or low atrial rhythm
• SawtoothIlutterwaves:Atrial flutter, usually with 4:1 AV block
• NoP;rate·60: Junctional rhythm
• NoP;rate60-100:Accelerated junctional rhythm
Narrow QRS - Irregular R-R
• SinusP,P-Pvarying~0.16seconds:Sinus arrhythmia
• SinusandnonsinusP:Wandering atrial pacemaker
• Any regular rhythm with 2
o
/ 3
o
AV block or premature beats
• Fine or coarse baseline oscillations: Atrial fibrillation with slow
ventricular response
• SawtoothIlutterwaves:Atrial flutter, usually with variable AV block
• P:QRSratio~1:2
o
or 3
o
AV block or blocked APCs
• P:QRS ratio · 1: Junctional or ventricular premature beats or
escape rhythm
Wide QRS ( 0.12 seconds)
• SinusornonsinusP:Any supraventricular rhythm with a preexisting
IVCD (e.g. bundle branch block) or aberrancy
• NoP†;rate·60:Idioventricular rhythm
• NoP†;rate60-100:Accelerated idioventricular rhythm
†AVdissociationmaybepresent
— Heart Rate > 100 BPM —
Narrow QRS (< 0.12 sec) - Regular R-R
• SinusP:Sinus tachycardia
• Flutterwaves:Atrial flutter
• No P: AV nodal reentrant tachycardia (AVNRT), junctional
tachycardia
• ShortR-P(R-P·50°oIR-Rinterval):AVNRT, orthodromic SVT
(AVRT), atrial tachycardia with 1
o
AV block, junctional tachycardia
with 1:1 retrograde atrial activation
• LongR-P(R-P~50°oIR-Rinterval):Atrial tachycardia, sinus
node reentrant tachycardia, atypical AVNRT, orthodromic SVT with
prolonged V-A conduction
Narrow QRS - Irregular R-R
• NonsinusP;~3morphologies:Multifocal atrial tachycardia
• Fineorcoarsebaselineoscillations:Atrial fibrillation
• Flutterwaves:Atrial flutter
• Any regular rhythm with 2
o
/3
o
AV block or premature beats
Wide QRS ( 0.12 seconds)
• Sinus or nonsinus P: Any regular or irregular supraventricular
rhythm with a preexisting IVCD or aberrancy
• NoP;rate100-110:Accelerated idioventricular rhythm
• NoP,rate110-250:VT, SVT with aberrancy
• Irregular,polymorphic,alternatingpolarity: Torsade de Pointes
• Chaotic irregular oscillations; no discrete QRS: Ventricular
fibrillation
4. PR Interval & Segment
What it Represents
• PRintervalrepresentsconductiontimeIromtheonsetoIatrial
depolarization to the onset oI ventricular repolarization. It
doesnotreIlectconductionIromthesinusnodetotheatrium.
• PRsegmentrepresentsatrialrepolarization.
How to Measure
• PRinterval(seconds):FromthebeginningoIthePwaveto
theIirstdeIlectionoItheQRScomplex.MeasurelongestPR
seen.
P
R
T
PR
Interval
PR INTERVAL = 4 small boxes =
4 x 0.04 = 0.16 sec.
The Complete Guide to ECGs
—8—
• PRsegment(mm):AmountoIelevationordepressionrelative
totheTPsegment(endoItheTwavetothebeginningoIthe
Pwave).
Definitions
PR Interval
• NormalPRinterval:0.12-0.20seconds
• ProlongedPRinterval:~0.20seconds
• ShortPRinterval:·0.12seconds
PR Segment
• NormalPRsegment:Usuallyisoelectric.Maybedisplaced
inadirectionoppositetothePwave.Elevationisusually·
0.5 mm; depression is usually ·0.8mm
• PRsegmentelevation:Usually0.5mm
• PRsegmentdepression:Usually0.8mm
5. QRS Duration
What it Represents
DurationoIventricularactivation
How to Measure
Inseconds,Iromthebeginningtotheend oI theQRS(orQS)
complex
Definitions
• NormalQRSduration:·0.10seconds
• IncreasedQRSduration:0.10seconds
Note:ForthepurposesoIestablishingadiIIerentialdiagnosis,
itisoItenuseIultodistinguishmoderateprolongationoIthe
QRS(0.10to0.12seconds)IrommarkedprolongationoIthe
QRS(~0.12seconds)
6. QT Interval
What it Represents
Total duration oI ventricular systole, i.e., ventricular
depolarization(QRScomplex)andrepolarization(Twave)
How To Measure
• QTinterval:Inseconds,IromthebeginningoItheQRS(or
QS)complextotheendoItheTwave.Itisbestusealead
with alargeT waveand distincttermination
• CorrectedQTinterval(QTc):SincethenormalQTinterval
variesinverselywithheartrate,theQTc,whichcorrectsIor
heartrate,isusuallydetermined
QTc(sec)÷QTinterval(sec)dividedbythesquarerootoI
theprecedingRRinterval(sec).Example:ForheartrateoI
50 BPM, RR interval ÷ 1.2 seconds, and QTc ÷ QT
squarerootoI1.2÷QT1.1
Alternative method: Use 0.40 seconds as the normal QT
interval Ior a heart rate oI 70 BPM. For every 10 BPM
changeinheartrateabove(orbelow)70,subtract(oradd)
0.02seconds.Themeasuredvalueshouldbewithin+0.04
seconds oI the calculated normal. Example: For a heart
rate oI 100 BPM, the calculated “normal” QT interval ÷
0.40seconds—(3x0.02seconds)÷0.34+0.04seconds.
For a heart rate oI 50 BPM, the calculated “normal” QT
interval ÷0.40seconds ¹(2x 0.02 seconds)÷0.44+ 0.04
seconds.
Definitions
• Normal QTc: 0.35-0.43 seconds Ior heart rates oI 60-100
BPM.ThenormalQTshouldbe·50°oItheRRinterval
• ProlongedQTc:0.44seconds
• ShortQTc:·0.35secondsIorheartratesoI60-100BPM
QS S
R
q
R′
r
R
QRS duration = 1.5 small boxes = 0.06 sec.
R
T
QT interval = 8 small boxes =
8 x 0.04 sec. = 0.32 sec.
QT Interval
Section 1. Approach to ECG Interpretation
—9—
7. QRS Axis
What It Represents
ThemajorvectoroIventricularactivation
How to Determine
• Determine iI “net QRS voltage” (upward minus downward
QRSdeIlection)ispositive(~0)ornegative(·0)inleadsI,
II,aVF:
• Determineaxiscategoryaccordingtothechartbelow:
Axis
Net QRS Voltage
Lead I aVF Lead II
Normalaxis(0
o
to90
o
) + +
Normalvariant(0
o
to-30
o
) + - +
LeItaxisdeviation
(-30
o
to-90
o
)
+ - -
Rightaxisdeviation(~100
o
) - +
Rightsuperioraxis
(-90
o
to¹180
o
)
- -
“¹”representspositive(~0)netQRSvoltage
“–“representsnegative(·0)netQRSvoltage
8. QRS Voltage
How to Measure
Inmillimeters,IrombaselinetothepeakoItheRwave(Rwave
voltage)orSwave(Swavevoltage)(seeQRSaxis,above)
Definitions
• Normalvoltage:AmplitudeoItheQRShasawiderangeoI
normallimits,dependingonthelead,ageoItheindividual,and
otherIactors
• Lowvoltage(IrompeakoIRwavetopeakoISwave):Total
QRSamplitude(R¹S)·5mminalllimbleadsand·10mm
inallprecordialleads
• Increased voltage: See LVH (item 40, Section 4) and RVH
(item41,Section4)
9. R Wave Progression
How to Identify
Determine the precordial transition zone, i.e., the lead with
equalRandSwavevoltage(R/S÷1)
Definitions
• Normal R wave progression: Transition zone ÷ V
2
-V
4
, with
increasing R wave amplitude across the precordial leads.
(Exception:RwaveinV
5
oItenexceedsRwaveinV
6
.)
• PoorRwaveprogression:Transitionzone÷V
5
orV
6
• ReverseRwaveprogression:DecreasingRwaveamplitude
acrosstheprecordialleads
10. Q Waves
How to Identify
A Q wave is present when the Iirst deIlection oI the QRS is
negative. II the QRS consists exclusively oI a negative
0
1
1
2
2
3
4
3
4
(
m
m
)
NET QRS VOLTAGE =
upward – downward deflection (mm)
= a – b = 3 – 2 = 1 (positive)
a
b
V1
V2
V3
V4
V5
V6
PRECORDIAL
TRANSITION ZONE
(R = S) =V4
The Complete Guide to ECGs
—10—
deIlection,thatdeIectionisconsideredaQwave,butthecomplex
isreIerredtoasa“QS”complex
What to Measure
Duration,inseconds,Iromthebeginningtotheend(i.e.,whenit
returns to baseline) oI the Q wave. When the QRS complex
consistssolelyoIaQwave,a“QS”designationisused
Definitions
• NormalQwaves:SmallQwaves(duration·0.03seconds)
arecommoninmostleads,exceptaVR,V
1
-V
3
• AbnormalQwaves:AnyQwaveinleadsV
1
-V
3
.Qwave
0.03secondsinleadsI,II,aVL,aVF,V
4
,V
5
,orV
6
.Note:For
Q-wave myocardial inIarction, Q wave changes must be
presentinatleast2continguousleadsandmustbe1mmin
depth.
11. ST Segment
What it Represents
The ST segment represents the interval between the end oI
ventriculardepolarization(QRScomplex)andthebeginningoI
repolarization(Twave).ItisidentiIiedasthesegmentbetween
theendoItheQRScomplexandthebeginningoItheTwave.
What to Identify
• AmountoIelevationordepression,inmillimeters,relativeto
theTPsegment(endoItheTwavetothebeginningoItheP
wave)
• STsegmentmorphology
Definitions
• NormalSTsegment:Usuallyisoelectric,butmayvaryIrom
0.5mmbelowto1mmabovebaselineinlimbleads,andupto
3mmconcaveupwardelevationmaybeseenintheprecordial
leadsinearlyrepolarization(seeitem61,Section4).
Note:WhilesomeSTsegmentdepressionandelevationcan
beseeninnormals,itmayalsoindicatemyocardialinIarction,
injury, or some other pathological process. It is especially
importanttoconsidertheclinicalpresentationandcompareit
topreviousECGs(iIavailable)whenSTsegmentdepression
orelevationisidentiIied.
• NonspeciIic ST segment: Slight (· 1 mm) ST segment
depressionorelevation.
QS
Q wave duration = 1 small box
= 0.04 seconds
R
q
0
1
1
2
2
3
3
m
m
T
S
S
T
P
ST elevation = 1.5 mm ST depression = 2 mm
Concave Upward Convex Upward
Horizontal Upsloping
Downsloping
ST ELEVATION:
ST DEPRESSION:
Section 1. Approach to ECG Interpretation
—11—
12. T Wave
What it Represents
TheelectricalIorcesgeneratedIromventricularrepolarization
What to Identify
• Amplitude:Inmillimeters,IrombaselinetopeakorvalleyoI
theTwave:
• Morphology:
Definitions
• NormalTwavemorphology:UprightinI,II,V
3
-V
6
;inverted
inaVR,V
1
;maybeupright,IlatorbiphasicinIII,aVL,aVF,
V
1
,V
2
.TwaveinversionmaybepresentinV
1
-V
3
inhealthy
youngadults(juvenileTwaves,seeitem62,Section4)
• NormalTwaveamplitude:Usually·6mminlimbleadsand
10mminprecordialleads
• TallTwaves:Amplitude~6mminlimbleadsor~10mmin
precordialleads
• NonspeciIicTwaves:Flatorslightlyinverted
13. U Wave
What it Represents
Controversial: AIterpotentials oI ventricular muscle vs.
repolarizationoIPurkinjeIibers.
How to Identify
Whenpresent,theUwavemaniIestsasasmall(usuallypositive)
deIlectionIollowingtheTwave.AtIasterheartrates,theUwave
maybesuperimposedonthepreceedingTwave.
What to Determine
• Morphology:upright,inverted,orabsent
• Height,inmillimeters,Irombaselinetopeakorvalley
Definitions
• NormalUwave:Notalwayspresent.Morphologyisupright
inallleadsexceptaVR.Amplitudeis5-25°theheightoIthe
T wave (usually · 1.5 mm). U waves are typically most
prominentinleadsV
2
,V
3
• ProminentUwave:Amplitude~1.5mm
14. Pacemakers
Overview
Pacemakersaredescribedbya4lettercode:
First letter: ReIers to the chamber(s) PACED (Atrial,
Ventricular,orDual)
Secondletter:ReIerstothechamberSENSED(A, VorD)
Third letter: ReIers to the pacemaker MODE (Inhibited,
Triggered,Dual).
Fourthletter:ReIerstothepresence(R)orabsence(noletter)
oI RATE RESPONSIVENESS. Rate-responsive (or rate-
adaptive)pacemakerscanvarytheirrateinresponsetosensed
motion or physiologic alterations (e.g., QT interval,
temperature)producedbyexercisebyincreasingtheirrateoI
0
1
1
2
2
(
m
m
)
P
R
T
T wave amplitude = 2 mm
UPRIGHT PEAKED
NOTCHED BIPHASIC
INVERTED
P
R
S
T P
U
P
R
S
T P
U
UPRIGHT
INVERTED
0
1
1
2
3
3
2
(
m
m
)
U wave amplitude = 0.3 mm
The Complete Guide to ECGs
—12—
pacing.
Forexample,aVVIRpacemakerPACEStheVentricle,SENSES
theVentricle,isINHIBITEDbyasensedQRScomplex,andis
Rateresponsive.ADDDpacemakerPACESandSENSESthe
atriaandventricle;theDUALMODEindicatesthatsensedatrial
activitywillinhibitatrialoutputandtriggeraventricularoutput
aIter a designated “AV interval,” and that sensed ventricular
activitywillinhibitventricularoutput.
TypicalsinglechamberpacemakersincludeVVIandAAI
TypicaldualchamberpacemakersincludeDVIandDDD
— Approach to Pacemaker Evaluation —
Step 1. Assess underlying rhythm. Determine iI the
rhythmis100°pacedorwhetherthereisanon-pacedintrinsic
rhythmwithapacemakerIunctioningindemandmode.
• 100°ventricularpaced
• Ventricularpacingindemandmode(inconstantventricular
pacingIromoutputinhibitionbyintrinsicsinusrhythm)
Step 2. Determine the chamber(s) PACED
DeterminetherelationshipoIpacingspikestoPwavesandQRS
complexes:AspikeprecedingthePwavetypicallyrepresents
atrial pacing; a spike preceding the QRS complex typically
representsventricularpacing.
• Atrial(A)pacedbeat
• Ventricular(V)pacedbeat
• Atrial(A)andventricular(V)pacedbeat
Step 3. Determine timing intervalsIrom2consecutively
pacedbeats:
• Foratrialpacing,determinetheA-Ainterval
PACER SPIKE
SINUS SINUS PACED PACED
A–A
Section 1. Approach to ECG Interpretation
—13—
• Forventricularpacing,determinetheV-Vinterval
• Fordualchamberpacing,determinetheA-VandV-Aintervals
Step 4. Determine the chamber(s) SENSED
• Atrial pacemaker: Proper atrial sensing is present when
intrinsicatrialactivation(nativePwave)isIollowedby:(1)a
native P wave that occurs at an interval less than the A-A
interval;or(2)anatrial-pacedbeatthatoccursaIteraninterval
equaltotheA-Ainterval
• Ventricular pacemaker: Proper ventricular sensing is
present when intrinsic ventricular activation (native QRS
complex) is always Iollowed by: (1) a native QRS complex
thatoccursatanintervallessthantheV-Vinterval;or(2)a
ventricular-pacedbeatthatoccursaIteranintervalequaltothe
V-Vinterval
• Dual chamber pacemaker:
Atrial sensing is evident when intrinsic atrial activation
(native P wave) is always Iollowed by: (1) a native QRS
complex that occurs at an interval less than the A-V
interval; or (2) a ventricular-paced beat that occurs at an
intervalequaltotheA-Vinterval
Ventricular sensing is evident when intrinsic ventricular
activation(nativeQRScomplex)isalwaysIollowedby:(1)
anativePwavethatoccursatanintervallessthantheV-A
interval;or(2)anatrial-pacedbeatthatoccursataninterval
equaltotheV-Ainterval
V–V
V–A A–V
<A–A A–A
1 2
<V–V V–V
1 2
A–V
<AV
1 2
V–A <V–A
1 2
The Complete Guide to ECGs
—14—
Step 5. Determine the sequence of complexes
representingnormalpacingIunction.Keepinmindthatsingle
chamber pacing on the surIace ECG does not exclude the
possibility that a dual chamber pacemaker is present —
ventricular-paced beats may be due to a single chamber
ventricular pacemaker or a dual chamber pacemaker in which
ventricularspikesaretimedtoIollowPwaves(DDDpacemaker)
Pacing mode
Atrial
pacing spike
Ventricular
pacing spike
Atrialpacing ¹ -
Ventricularpacing - ¹
Dual-chamber
(DDD)pacing
¹
¹
-
-
¹
-
¹
-
¹ PacingspikepresentonsurIaceECG
- PacingspikeabsentonsurIaceECG
Step 6. Look for pacemaker malfunction
A. Failure to Capture (see item 93, Section 4): Are any
pacingspikesnotIollowedbyadepolarization?
B. Sensing Abnormalities
• Undersensing: Based on timing intervals, are there
pacingspikesthatshouldhavebeeninhibitedbyanative
PwaveorQRScomplexbutwerenot?Thisresultsina
pacedbeatthatappearsearlierthanexpected.
Example: For ventricular pacing, undersensing is
evidentwhenanativeQRScomplexisIollowedbya
ventricular-pacedbeatataninterval·V-Vinterval.
• Oversensing:Basedontimingintervals,aretherepacing
spikes that should have been initiated aIter a native P
waveorQRScomplexbutwerenot?Thisresultsina
paced beat that appears later than expected. For
ventricular pacing, oversensing occurs when a native
QRS is Iollowed by a ventricular-paced beat at an
intervalmuchgreaterthantheV-Vinterval.
• Oversensing oI the T wave, in which the T wave is
sensedas(mistakenIor)aQRScomplex:
• OversensingoImusclecontractions(myopotential
inhibition),inwhichamyopotentialissensedas
(mistakenIor)aQRScomplex:
C. Other Causes of Pacemaker Malfunction:Lesscommon
types oI pacemaker malIunction include pacemaker not
Iiring, pacemaker slowing, and pacemaker-mediated
tachycardia.
V–V V–V V–V
V–V
PACEMAKER
FIRES EARLY
V–V
T WAVE
SENSED
V–V
V–V V–V
MYOPOTENTIAL
SENSED
—15—
— Section 2 —
ECG DIFFERENTIAL DIAGNOSIS
(Item Numbers in Parentheses Correspond
to Criteria in Section 4)
1. Pwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2. PRinterval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3. PRsegment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4. QRSduration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
5. QRSamplitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
6. QRSaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
7. Qwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
8. Rwaveprogression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
9. QRSmorphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
10. STsegment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
11. Twave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
12. QTinterval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
13. Uwave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
14. PPpause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
15. Groupbeating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
P Wave
— LEAD I —
Inverted P wave
• Ectopicatrialprematurebeat(item13)orrhythm(items15,
17)
• AVjunctional/ventricularprematurecomplex(items20,23)or
rhythmwithretrogradeatrialactivation
• Dextrocardia(item80):InvertedP-QRS-TinleadsIandaVL
with reverseRwaveprogressionintheprecordialleads
• Reversal oI right and leIt arm leads (item 03): Inverted P-
QRS-TinleadsIandaVLwithnormalRwaveprogressionin
theprecordialleads
— LEAD II —
Tall peaked P wave
• Rightatrialabnormality/enlargement(item05)
• Bi-atrialabnormality
Bifid P wave with peak-to-peak interval < 0.03 sec.
• Normal
Bifid P wave with peak-to-peak interval > 0.03 sec. and
P wave duration > 0.12 sec.
• LeItatrialabnormality/enlargement(item06)
Inverted P wave
• Ectopicatrialprematurebeat(item13)orrhythm(items15,
17)
• AVjunctional/ventricularprematurecomplex(items20,23)or
rhythmwithretrogradeatrialactivation
Sawtooth regular P waves
• AtrialIlutter(item18)
• ArtiIact due to tremor (e.g., Parkinson’s disease, shivering)
(item04)
Irregularly irregular baseline
• AtrialIibrillation(item19)
• ArtiIactduetotremor(item04)
• MultiIocalatrialtachycardia(item16)
Multiple P wave morphologies
• Wanderingatrialpacemaker(rate·100bpm)
• MultiIocalatrialtachycardia(rate~100bpm)(item16)
• Sinus or atrial rhythm with multiple atrial premature
complexes
The Complete Guide to ECGs
—16—
— LEAD V
1

Tall upright P wave
• Rightatrialabnormality/enlargement(item05)
Deep inverted P waves
• LeItatrialabnormality/enlargement(item06)
Dome and dart P wave
• Ectopicatrialrhythm(item15)
— NO P WAVES —
P Waves present but hidden
• EctopicatrialrhythmorAPCs(Pwaveshiddeninpreceding
Twave)
• JunctionalrhythmorSVT(PwaveburiedinQRS)
• SupraventricularrhythmwithmarkedIirst-degreeAVblock(P
wavehiddeninprecedingTwave)
P Waves not present
• Sinoventricularconductionduetohyperkalemia(item74)
• Marked sinoatrial exit block or sinus bradycardia with
junctionalorventricularrhythm(escapeoraccelerated)
• Sinuspauseorarrest(item11)
PR Interval
Prolonged (> 0.20 seconds) PR interval
• First-degreeAVblock(item29)
• Complete heart block (item 33): PR interval varies, has no
constant relationship to the QRS, and may intermittently
exceed0.20seconds
• Supraventricular or junctional rhythm with retrograde atrial
activation:PwaveinvertedinleadII
• Atrialprematurecomplex(item13)
Short (< 0.12 seconds) PR interval
• ShortPRwithsinusrhythmandnormalQRS
• WolII-Parkinson-Whitepattern(item34):Deltawave,wide
QRS,ST-TchangesinadirectionoppositetomaindeIlection
oIQRS
• Lowectopicatrialrhythm:PRintervalusually~0.11seconds;
PwaveinvertedinleadII
• Ectopic junctional beat or rhythm with retrograde atrial
activation: PR interval usually · 0.11 seconds; P wave
invertedinleadII
PR Segment
PR segment depression
• Normals:·0.8mm
• Pericarditis(item84)
• PseudodepressionduetoatrialIlutter(item18)orParkinson’s
tremor(item04)
• Atrial inIarction: Reciprocal elevation in opposite leads;
inIeriorMIusuallyevident
PR segment elevation
• Normals:·0.5mm
• Pericarditis(item84):LeadaVRonly
• AtrialinIarction:Reciprocaldepressioninoppositeleads
QRS Duration
Increased QRS duration 0.10 to < 0.12 seconds
• LeItanteriorIascicularblock(item45)
• LeItposteriorIascicularblock(item46)
• IncompleteLBBB(item48)
• IncompleteRBBB(item44)
• NonspeciIicIVCD(item49)
• LVH(item40)
• RVH(item41)
• Supraventricularbeatorrhythmwithaberrantintraventricular
conduction(item50)
• Fusionbeats
• WolII-Parkinson-Whitepattern(item34)
• VPCs originating near the bundle oI His (i.e., high in the
interventricularseptum)
Increased QRS duration > 0.12 seconds
• RBBB(item43)
• LBBB(item47)
• Supraventricularbeatorrhythmwithaberrantintraventricular
conduction(item50)
• Fusionbeats
• WolII-Parkinson-Whitepattern(item34)
• Ventricularprematurecomplexes(item23)
• Ventricularrhythm(items24-27)
• NonspeciIicIVCD(item49)
• Pacedbeat
Section 2. ECG Differential Diagnosis
—17—
QRS Amplitude
Low voltage QRS
• Chroniclungdisease(item81)
• PericardialeIIusion(item83)
• Myxedema(item87)
• Obesity
• PleuraleIIusion
• RestrictiveorinIiltrativecardiomyopathy
• DiIIusecoronaryarterydisease
Tall QRS
• LVH(item40)
• Hypertrophiccardiomyopathy(item85)
• LBBB(item47)
• WolII-ParkinsonWhitepattern(item34)
• Normalpersonswiththinbodyhabitus
Prominent R wave in lead V
1
• RVH(item41)
• PosteriorwallMI(items59,60)
• Incorrectleadplacement:ElectrodeIorleadV
1
placedin3
rd
insteadoI4
th
intercostalspace
• SkeletaldeIormities(e.g.,pectusexcavatum)
• RBBB(item43)
• WolII-Parkinson-Whitepattern(item34)
• Duchenne’smusculardystrophy
Alternation in QRS amplitude
• Electricalalternans(item38)
QRS Axis
Left axis deviation
• LeItanteriorIascicularblock(iIaxis~-45°,item45)
• InIeriorwallMI(items57,58)
• LBBB(item47)
• LVH(item40)
• OstiumprimumASD(item79)
• Chroniclungdisease(item81)
• Hyperkalemia(item74)
Right axis deviation
• RVH(item41)
• Verticalheart
• Chroniclungdisease(item81)
• Pulmonaryembolus(item82)
• LeItposteriorIascicularblock(item46)
• LateralwallMI(items55,56)
• Dextrocardia(item80)
• Leadreversal(item03)
• OstiumsecundumASD(item78)
Q Wave
Q wave myocardial infarction (see items 51-60)
• AnterolateralMI:AbnormalQwavesinleadsV
4
-V
6
• AnteriorMI:AbnormalQwavesinatleasttwoconsecutive
leadsinV
2
-V
4
• Anteroseptal MI: Abnormal Q waves in leads V
1
-V
3
(and
sometimesV
4
)
• LateralMI:AbnormalQwavesinleadsIandaVL
• InIeriorMI:AbnormalQwavesinatleasttwooIleadsII,III,
andaVF
Pseudoinfarcts (Q waves in absence of MI)
• WolII-Parkinson-White (item 34): Negative delta waves
mimicQwaves
• Hypertrophiccardiomyopathy(item85):QwavesinI,aVL,
V
4
-V
6
duetoseptalhypertrophy
• LVH(item40):PoorRwaveprogression,attimeswithST
elevation in V
1
-V
3
, can mimic anteroseptal MI. InIerior Q
wavesmaybepresentandcanmimicinIeriorMI
• LBBB(item47):QSpatterninV
1
-V
4
mimicsanteroseptalMI.
Lesscommonly,QwavesinIIIandaVFmimicinIeriorMI
• RVH(item41)
• LeItanteriorIascicularblock(item46)
• Chronic lung disease (item 81): Q waves appear in inIerior
and/orrightandmid-precordialleads
• Amyloid, sarcoid, and other inIiltrative cardiomyopathic
diseases:Electricallyactivetissuereplacedbyinertsubstance
• Cardiomyopathy
• ChestdeIormity(e.g.,pectusexcavatum)
• Pulmonary embolism (item 82): Q wave in lead III and
sometimesaVF,butQwavesinIIarerare
• Myocarditis
• Myocardialtumors
• Hyperkalemia(item74)
• Pneumothorax:QScomplexinrightprecordialleads
• Pancreatitis
The Complete Guide to ECGs
—18—
• Leadreversal(item03)
• Correctedtransposition
• Musculardystrophy
• Mitralvalveprolapse:RareQwaveinIIIandaVF
• Myocardial contusion: Q waves in areas oI intramyocardial
hemorrhageandedema
• LeIt/rightatrialenlargement:Prominentatrialrepolarization
wave(Ta)candepressthePRsegmentandmimicQwaves
• Atrial Ilutter (item 18): Flutter waves may deIorm the PR
segmentandsimulateQwaves
• Dextrocardia(item80)
R Wave Progression (Precordial Leads)
Early R wave progression (tall R wave in V
1
, V
2
; R/S > 1)
• RVH(item41)
• PosteriorMI(items59,60)
• RBBB(item43)
• WolII-Parkinson-Whitepattern(item34)
• Normals
• Duchenne’smusculardystrophy
Poor R wave progression (first precordial lead where R
wave amplitude S wave amplitude = V
5
or V
6
)
• Normals(abnormalleadplacement)
• AnteriororanteroseptalMI(items53,54)
• Dilatedorhypertrophiccardiomyopathy
• LVH(item40)
• Chroniclungdisease(item81)
• Corpulmonale(item82)
• RVH(item41)
• LeItanteriorIascicularblock(item45)
Reverse R wave progression (decreasing R wave
amplitude across precordial leads)
• AnteriorMI(items53,54)
• Dextrocardia(item80)
QRS Morphology
Initial slurring of R wave (delta wave)
• WolII-Parkinson-Whitepattern(item34)
Terminal notching (of R or S wave)
• Hypothermia(Osbornewave;item88)
• Earlyrepolarization(item61)
• Pacemakerspike(Iailuretosense;item94)
• AtrialIlutter(item18):Flutterwavesmaybesuperimposedon
QRS
ST Segment
ST segment elevation
• Myocardial injury (item 65): Convex upward ST elevation
localized to a few leads and terminates with an inverted T
(unlesshyperacutepeakedTwave).ReciprocalSTdepression
evidentinotherleads.QwavesIrequentlypresent.ST&T
wavechangesevolve,andTwavebecomesinvertedbefore ST
segmentreturnstobaseline
• Acutepericarditis(item84):WidespreadSTelevation(I-III,
aVF,V
3
-V
6
) without reciprocalSTdepressioninotherleads
except aVR. No Q wave. PR segment depression is
sometimespresent.ST-Twavechangesevolve;TwaveoIten
becomesinvertedafter STsegmentreturnstobaseline.Note:
Pericarditis(andSTelevation)maybeIocal
• Ventricularaneurysm:STelevationusuallywithdeepQwave
or QS in same leads; ST & T wave changes persist and are
stable overalongperiodoItime
• Earlyrepolarization(item61):ConcaveupwardSTelevation
that ends with an upward T wave, with notching on the
downstroke oI the R wave. T waves are usually large and
symmetrical.ST-Twavechangesarestableoveralongtime
period
• LVH(item40)
• Bundlebranchblock(items43,47)
• Centralnervoussystemdisease(item86)
• Apicalhypertrophiccardiomyopathy(item85)
• Hyperkalemia(item74)
• Acutecorpulmonale(item82)
• Myocarditis
• Myocardialtumor
ST segment depression
• Myocardialischemia(item64):horizontalordownsloping
• Repolarizationchangessecondarytoventricularhypertrophy
(item67)orbundlebranchblock(items43,47)
• DigitaliseIIect(item70)
• “Pseudodepression” due to superimposition oI atrial Ilutter
wavesorprominentatrialrepolarization wave(asseenwith
atrial enlargement, pericarditis, atrial inIarction) on the ST
segment
• Centralnervoussystemdisorder(item86)
Section 2. ECG Differential Diagnosis
—19—
• Hypokalemia(item75)
• AntiarrhythmicdrugeIIect(item72)
• Mitralvalveprolapse
Nonspecific ST segment changes
• Organicheartdisease
• Drugs(e.g.,quinidine)
• Electrolytedisorders(e.g.,hypokalemia,item75)
• Hyperventilation
• Myxedema(item87)
• Stress
• Pancreatitis
• Pericarditis(item84)
• Centralnervoussystemdisorders(item86)
• LVH(item40)
• RVH(item41)
• Bundlebranchblock(items43,44,47,48)
• Healthyadults(normalvariant)(item02)
TT Wave
Tall peaked T waves
• HyperacuteMI
• Anginapectoris
• Normalvariant(item02):UsuallyeIIectsmid-precordialleads
• Hyperkalemia (item 74): More common when the rise in
serumpotassiumisacute
• Intracranialbleeding(item86)
• LVH(item40)
• RVH(item41)
• LBBB(item47)
• SuperimposedPwaveIromAPC,sinusrhythmwithmarked
Iirst-degreeAVblock,completeheartblock,etc.
• Anemia
Deeply inverted T waves
• Myocardialischemia(item64)
• LVH(items40,67)
• RVH(items41,67)
• Centralnervoussystemdisorder(item86)
• WolII-Parkinson-Whitepattern(item34)
Nonspecific T waves
• Persistentjuvenilepattern:TwaveinversioninV
1
-V
3
inyoung
adults
• Organicheartdisease
• Drugs(e.g.,quinidine)
• Electrolytedisorders(e.g.,hypokalemia,item75)
• Hyperventilation
• Myxedema(item87)
• Stress
• Pancreatitis
• Pericarditis(item84)
• Centralnervoussystemdisorders(item86)
• LVH(item40)
• RVH(item41)
• Bundlebranchblock(items43,44,47,48)
• Healthyadults(normalvariant)(item02)
QT Interval
Long QT interval
• Acquired conditions
• Drugs(quinidine,procainamide,disopyramide,amiodarone,
sotalol, doIetilide, azimilide, phenothiazines, tricyclics,
lithium)
• Hypomagnesemia
• Hypocalcemia(item77)
• Markedbradyarrhythmias
• Intracranialhemorrhage(item86)
• Myocarditis
• Mitralvalveprolapse
• Myxedema(item87)
• Hypothermia(item88)
• Liquidproteindiets
• Congenital disorders
• Romano-Wardsyndrome(normalhearing)
• JervellandLange-Nielsonsyndrome(deaIness)
Short QT interval
• Hypercalcemia(item76)
• Hyperkalemia(item74)
• DigitaliseIIect(item70)
• Acidosis
• Vagalstimulation
• Hyperthyroidism
• Hyperthermia
The Complete Guide to ECGs
—20—
U Wave
Prominent U wave
• Hypokalemia(item75)
• Bradyarrhythmias
• Hypothermia(item88)
• LVH(item40)
• Coronaryarterydisease
• Drugs(digitalis,quinidine,amiodarone,isoproterenol)
Inverted U wave
• LVH(item40)
• SevereRVH(item41)
• Myocardialischemia
PP Pause > 2.0 seconds
• Sinus pause or arrest (item 11): Due to transient Iailure oI
impulseIormationattheSAnode.Sinusrhythmresumesata
PPintervalthatisnotamultipleoIthebasicsinusPPinterval
• Sinus arrhythmia (item 08): Phasic gradual change in PP
interval
• Second-degreesinoatrialexitblock,MobitzI(Wenckebach)
(item12):ProgressiveshorteningoIPPintervaluntilaPwave
Iailstoappear
• Second-degree sinoatrial exit block, Mobitz II (item 12):
PauseIollowedbyresumptionoIsinusrhythmataPPinterval
thatisamultiple(e.g.,2x,3x,etc.)oIthebasicsinusrhythm
• Third-degreesinoatrialexitblock(item12):CompleteIailure
oI sinoatrial conduction; cannot be diIIerentiated Irom
completesinusarrestonsurIaceECG
• Abruptchangeinautonomictone
• “Pseudo”sinuspauseduetononconductedAPCs(item13):
P wave appears to be absent but is actually buried in the T
wave—lookIorsubtledeIormityoItheTwavejustpreceding
thepausetodetectnonconductedAPCs
Group Beating
• MobitzTypeI,second-degreeAVblock(item30)
• MobitzTypeII,second-degreeAVblock(item31)
• BlockedAPCs(item13)
• ConcealedHis-bundledepolarizations
—21—
— Section 3 —
ECG CASES AND QUIZZES
(See p. 555 for index of cases by diagnosis)
ECG 1. 71-year-old male with acute shortness of
breath:
—22—
23
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—24—
ECG1wasobtainedIroma71-year-oldmalewithacuteshortnessoIbreathimmediatelyuponarrivaltotheemergencydepartment.TheECG
showssinustachycardiaat111beats/minute,RBBB(widenedrsR’complexinleadV
1
withwideSwavesinleadsI,V
5
,V
6
;arrows),andleIt
posteriorIascicularblock(axis~¹100o).StrikingSTsegmentelevation(arrowheads)withassociatedQwavesarepresentinleadsV
2
-V
4
,II,
IIIandaVF,diagnosticoIacuteanteriormyocardialinIarctionandacuteinIeriormyocardialinIarction.AcuteocclusionoIalargeleItanterior
descendingcoronaryarterythat“wrapsaround”theleItventricularapexandsuppliesasubstantialportionoItheinIeriorwallcanproducethe
appearanceoIsimultaneousacuteanteriorandinIeriorinIarctions.
Codes: 10 Sinustachycardia
43 RBBB,complete
46 LeItposteriorIascicularblock
53 AnteriororanteroseptalQwaveMI(agerecentoracute)
57 InIeriorQwaveMI(agerecentoracute)
65 STand/orTwaveabnormalitiessuggestingmyocardialinjury
25
Ouestions: ECG 1
1. SigniIicant ST segment elevation consistent with myocardial
injury or inIarction is deIined as:
a. 1 mm ST elevation in leads V
1
, V
2
, or V
3
b. 2 mm ST elevation in leads V
1
, V
2
, or V
3
c. 2 mm ST elevation in other leads
d. 1 mm ST in other leads
2. Repolarization abnormalities that suggest acute or recent
myocardial inIarction include:
a. Peaked T waves Iollowed by T wave inversion
b. ST-elevation Iollowed by peaked T waves
c. Deeply inverted T waves
d. Dominant R wave and ST depression in leads V
1
- V
3
3. Match the Iollowing types oI acute myocardial inIarction with
their associated ST segment changes:
a. Anterolateral MI 1. ST elevation in I, aVL
b. Lateral MI 2. ST elevation in V
1
- V
3
c. Anterior MI 3. ST elevation in V
4
- V
6
d. Posterior MI 4. ST depression in V
1
- V
3
4. Which parameters on initial ECG obtained independently predict
30-day all-cause mortality in acute myocardial inIarction:
a. Sinus tachycardia
b. Sum oI absolute ST segment deviations (elevation and/or
depression)
c. QRS duration ~ 100 msec
d. Rightward axis
Answers: ECG 1

1. SigniIicant ST elevation consistent with myocardial
injury/inIarction requires the presence oI ST elevation at the J-
point in two or more contiguous leads, including ≥ 2 mm in
leads V
1
, V
2
, or V
3
, and ≥ 1 mm in other leads. The ST
conIiguration oI myocardial injury/inIarction is classically
described as FRQYH[ upward ('outpouching¨). In contrast, the ST
conIiguration oI acute pericarditis or normal variant early
repolarization is FRQFDYH upward. (Answer: b, d)
2. The repolarization abnormalities oI acute injury/inIarction occur
in a predictable sequence. Hyperacute T waves tall peaked T
waves in the region oI the inIarct are seen in the Iirst Iew
minutes oI the event. ST-elevation appears next, and generally
lasts Ior several hours or until the inIarct artery is opened. The
repolarization abnormalities oIten evolve into inverted T waves
in the aIIected leads within several hours to days. Instead oI Q
waves and ST elevation, acute posterior MI presents with
mirror-image changes in the anterior precordial leads (V
1
- V
3
),
including dominant R waves (mirror-image oI abnormal Q
waves) and horizontal ST segment depression (mirror-image oI
26
ST elevation). (Answer: a, c, d)
3. (Answer: a-3, b-1, c-2, d-4)
4. A large study evaluating the initial ECG as a predictor Ior 30-
day all cause mortality in acute myocardial inIarction Iound that
sinus tachycardia and the sum oI absolute ST segment deviations
were the most powerIul predictors oI outcome. A QRS duration
~ 100 msec was also shown to be an independent adverse
prognostic Iactor. QRS axis did not aIIect outcome. (Hathaway,
WR, et al. JAMA, 1996, 273:387-391.) (Answer: a, b, c)
- («:·/ k:.::« 1 - - («:·/ k:.::« 1 - - («:·/ k:.::« 1 - - («:·/ k:.::« 1 -
8inus tachycardia
· Rate ~ per minute
· P wave amplitude oIten (increases/decreases) and
PR interval oIten (increases/decreases) with
increasing heart rate
100
increases
decreases
RBBB, complete
· QRS duration seconds
· Secondary R wave (R) in lead is usually
(shorter/taller) than the initial R wave
· Onset oI intrinsicoid deIlection in leads V
1
and V
2
~ seconds
· ST segment and T wave
in V
1,
V
2
· Wide slurred S wave in leads
· QRS axis is usually (normal/leItward/rightward)
· RBBB (does/does not) interIere with the ECG
diagnosis oI ventricular hypertrophy or Q wave
MI
0.12
V
1
taller
0.05
depression
inversion
I, V
5
, V
6
normal
does not
- («:·/ k:.::« 1 - - («:·/ k:.::« 1 - - («:·/ k:.::« 1 - - («:·/ k:.::« 1 -
Left posterior fascicular block
· (LeIt/right) axis deviation with mean QRS axis
between and degrees
· QRS duration between and seconds
· No other Iactor responsible Ior axis deviation
right
100, 180
0.08, 0.10
right
Anteroseptal M¡, probably acute or
recent
· Abnormal Q or QS deIlection and ST elevation in
leads (and sometimes V
4
)
· The presence oI a Q wave in lead
distinguishes anteroseptal Irom anterior inIarction
V
1
-V
3

V
1
¡nferior M¡, probably acute or recent
· Abnormal Q waves and ST elevation in at least
two oI leads
· Associated ST depression is usually evident in
leads I, aVL, V
1
-V
3
(true/Ialse)
II, III, aVF
true
—27—
—POPOU¡Z—
RhythmRecognItIon:HR<100;ReguIarRRIntervaI
Instructions:DeterminethecardiacrhythmIoreachoItheIollowingECGs.
ECG Diagnosis
Answer:AcceleratedAVjunctionalrhythm.Description:Regularrhythm
withjunctionalQRScomplexes(typicallynarrow)occurringatarateoI~60
perminute.PwavesmayprecedetheQRSby0.11seconds(retrograde
atrialactivation),maybeburiedintheQRS(andnotvisualized),ormay
IollowtheQRScomplex(lookIordeIormityinSTsegment).AVjunctional
rhythmsareoItenassociatedwithisorhythmicAVdissociationandretrograde
atrialactivation(notapparentinthisECG).
Answer:Atrialtachycardiawithblock.Description:Regularectopicatrial
(nonsinus)rhythmusuallyatarateoI150-240perminute(canbeaslowas
100perminute)withoccasionalnonconductedPwaves.Isoelectricintervals
arepresentbetweenallPwavesinallleads(unlikeatrialIlutter).Primary
causesincludedigoxintoxicity(75°)andorganicheartdisease(25°).
Answer:Acceleratedidioventricularrhythm(AIVR).Description:Regular
orslightlyirregularventricular(wideQRScomplex)rhythmatarateoI60-
110perminute.QRSmorphologyissimilartoventricularpremature
complexes(VPCs).Competitionbetweennormalsinusandectopic
ventricularrhythmsoItenresultsinAVdissociation,ventricularcapture
complexes,andIusionbeats.AIVRisseeninmyocardialischemia,digitalis
toxicity,IollowingcoronaryreperIusion,andoccasionallyinnormals.
28
ECG 2. 73-year-old female 24 hours after elective hip
surgery:
29
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—30—
ECG2wasobtainedina73-year-oldIemale24hoursaIterelectivehipsurgery.TheECGshowsarapidwide-complextachycardiaatarate
oI138beats/minute.Onacloserinspection,sinusPwaves(arrows)andleItbundlebranchblock(broadmonophasicRwaveinleadV
1
;QRS
duration134msec)arepresent.ThePwavesinleadV
1
(arrowhead)meetcriteriaIorleItatrialenlargement.LeItaxisdeviation(QRSaxis–54o
isalsopresent.
Codes: 06 LeItatrialabnormality/enlargement
10 Sinustachycardia
36 LeItaxisdeviation(~–30o
47 LBBB,complete
—31—
Ouestions:ECG2
1. AQRSduration≥secondsisnecessaryIorthediagnosisoI
completeLBBB:
a. 0.10
b. 0.11
c. 0.12
d. 0.13
2. LBBBiscommonlyseenin normalhearts:
a. True
b. False
3. Non-voltage related changes oIten associated with leIt
ventricularhypertrophyincludealltheIollowingexcept:
a. LeItatrialenlargement/abnormality
b. LeItaxisdeviation
c. Intraventricularconductiondisturbance
d. ProminentUwaves
e. Sinusarrhythmia
4. LBBBinterIereswiththeECGdiagnosisoI:
a. QRSaxis
b. LeItventricularhypertrophy
c. Rightventricularhypertrophy
d. AcuteMI
Answers:ECG2
1. LeItbundlebranchblockisdiagnosedwhentheQRSduration
is ≥ 0.12 seconds(120msec)andtypicalQRSmorphologyis
present. When LBBB morphology is present and the QRS
duration measures ~ 0.10 seconds but · 0.12 seconds,
incompleteLBBBshouldbecoded.(Answer:c)
2. LBBB oIten occurs in various Iorms oI organic heart disease,
includingischemicandnon-ischemiccardiomyopathy,valvular
heart disease, LVH, and congenital heart disease. It is rarely
seeninnormalhearts.(Answer:False)
3. Non-voltage ECG changes associated with LVH include leIt
atrialabnormality/enlargement,leItaxisdeviation,IVCD,QRS
prolongation,abnormalQwavesinleadsIII andaVF,leItaxis
deviation,prominentUwaves,andrepolarizationabnormalities.
Sinus arrhythmia (longest and shortest PP intervals vary by ~
0.16secondsor10°)isacommonIindingonnormal ECG’s
thattendstooccurinyoungerandhealthierindividualsandis
notassociatedwithLVH.(Answer:e)
4. LBBB interIeres with determination oI QRS axis and
identiIicationoIventricularhypertrophyandacuteMI.Although
theIormaldiagnosisoILVHshouldnotbemadeinthesetting
LBBB,echocardiographicandpathologicalstudiesshowthat~
80°patientswithLBBBhaveabnormallyincreasedLVmass.
(Answer:all)
32
- («:·/ k:.::« z - - («:·/ k:.::« z - - («:·/ k:.::« z - - («:·/ k:.::« z -
Left atrial abnormality
· Notched P wave with a duration seconds in
leads II, III or aVF, RU
· Terminal negative portion oI the P wave in lead V
1
1 mm deep and seconds in duration
0.12
0.04
Left axis deviation {> -30°}
· Mean QRS axis between and degrees -30, -90
LBBB, complete with 8T-T waves
suggestive of acute myocardial in]ury
or infarction
· ST elevation mm concordant to (same
direction as) the major deIlection oI the QRS
· ST depression mm in V
1
, V
2
, or V
3
· ST elevation mm discordant with (opposite
direction to) the major deIlection oI the QRS
1
1
5
33
—POPOU¡Z—
RhythmRecognItIon:WIdeQRSTachycardIa
Instructions:DeterminethecardiacrhythmIoreachoItheIollowingECGs.
ECG Diagnosis
Answer:Torsadedepointes(“twistingoIthepoints”).Description:
PolymorphicwideQRScomplextachycardiawithcyclesoIthreeormore
beatsoccurringwithalternatingpolarityinasinusoidalpattern.Occursinthe
settingoIaprolongedQTinterval,andisoItenprecededbylong-shortR-R
cycles.CandegenerateintoventricularIibrillation.Ventriculartachycardia
(VT) oI similar morphology but withoutQT prolongation iscalled
“polymorphicVT,”nottorsadedepointes.
Answer:VentricularIibrillation.Description:Extremelyrapidandirregular
ventricularrhythmdemonstratingchaotic,irregulardeIlectionsoIvarying
amplitudeandcontour,withoutdistinctPwaves,QRScomplexes,orT
waves.LethalrhythmrequiringimmediatedeIibrillation.
Patientbrushingteeth;asymptomatic
Answer:ArtiIact.Description:Rapidarmmotionorleadmovement(e.g.,
toothbrushing,hairbrushing)cansimulateVPCsorventriculartachycardia,
andcommonlyIoolstelemetrytechniciansandsetsoIImonitoralarms.Other
causesoIartiIactincludeACelectricalinterIerence(60cyclespersecond),
wanderingbaseline,skeletalmuscleIasciculations/shivering(cansimulate
atrialIibrillation),tremor(cansimulateatrialIlutter),electrocautery,andIV
inIusionpump(cangiveappearanceoIrapidPwaves).
34
ECG 3. 61-year-old female with light-headedness:
35
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—36—
ECG3wasobtainedina61-year-oldIemalewithlight-headedness.AtIirstglance,theECGappearstodemonstrateextremesinusbradycardia
atarateoI30beats/minute.Oncloserinspection,theunusually-shapedTwavesareactuallydeIormedbysuperimposedPwaves(arrows);these
atrial premature contractions (APCs), which occur in a bigeminal pattern, are blocked in the AV node and do not conduct to theventricle.
Nonconducted APCs are the most common cause oI sinus pauses on the ECG. When a sinus pause is present, it is important to look Ior a
deIormedTwaveimmediatelyprecedingthepausetoidentiIythepresenceoIanonconductedAPC.Sinusbradycardiashouldnotbecodedsince
theslowrhythmisduetotheblockedAPC’s.
Codes: 07 Sinusrhythm
13 Atrialprematurecomplexes
37
Ouestions: ECG 3
1. Nonconducted APCs are usually associated with a:
a. Compensatory pause
b. Noncompensatory pause
2. The QRS morphology oI aberrantly conducted APCs is most
oIten:
a. Similar to QRS complex during sinus rhythm
b. RBBB pattern
c. LBBB pattern
Answers: ECG 3
1. A nonconducted APC maniIests as a premature P wave with
abnormal morphology that is not Iollowed by a QRS-T complex.
It occurs when the APC arrives at an AV node that is reIractory
to conduction. The P wave is oIten hidden in the preceding T
wave when you see an RR pause, look Ior a deIormed T
wave immediately preceding the pause to identiIy the presence
oI a nonconducted APC. The sinus node is usually depolarized
and reset so that the next P wave occurs one cycle length aIter
the nonconducted P wave. The resulting 'noncompensatory
pause¨ maniIests as a premature P wave to subsequent P wave
interval equal to one normal PP interval. Uncommonly, a
compensatory pause may occur when sinoatrial (SA) 'entrance
block¨ is present and the SA node is not reset. (Answer: b)
2. The QRS morphology oI aberrantly conducted APC`s is most
oIten RBBB pattern, but can maniIest as LBBB pattern or
variable widening/distortion oI the QRS. The longer reIractory
period oI the right bundle (compared to the leIt bundle)
increases the likelihood that an APC will conduct down the leIt
bundle while the right bundle is still reIractory. (Answer: b)
- («:·/ k:.::« ; - - («:·/ k:.::« ; - - («:·/ k:.::« ; - - («:·/ k:.::« ; -
Atrial premature complexes
· P wave is (normal/abnormal) in conIiguration
· QRS complex is (similar/diIIerent) in morphology
to the QRS complex present during sinus rhythm
· PR interval may be normal, increased, or
decreased (true/Ialse)
· The post-extrasystolic pause is usually
(compensatory/noncompensatory)
abnormal
similar
true
noncompensatory
— 38 —
A.
B.
C.
D.
Answer: Tracings A, B, and D show atrial futter. Tracing A represents atrial futter with 2:1 AV block, evident from the deeply in-
verted futter waves preceding each QRS complex in lead II along with a similar futter waves superimposed on the ST segments of
the preceding beats. The use of calipers will help to verify an atrial futter rate just less than 300 beats per minute. In tracings B and D,
futter waves are evident between QRS complexes. Tracing C shows sinus tachycardia and is the imposter. While the T wave and the
tall sinus P wave suggest atrial futter, placing calipers to determine the interval between and T wave and P wave and then marching
this interval through the tracing fails to show the regularity seen with atrial futter.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
—39—
—POPOU¡Z—
Make The Diagnosis
Instructions:DeterminetheECGdiagnosisthatbestcorrespondstotheECG
Ieatureslistedbelow(seescoresheetIoroptions)
ECG Features Diagnosis
• Non-sinusPwave
• Rate·100perminute
• PRinterval~0.11seconds
Ectopicatrialrhythm
• Rate·100perminute
• Pwaveswith3morphologies
• PR,RR,andRPintervalsvary
Wanderingatrial
pacemaker
• ResultantECGmimicsdextrocardiawithinversionoI
theP-QRS-TinleadsIandaVL
Incorrectlead
placement
• SinusPwave
• LongestandshortestPPintervalsvaryby~0.16seconds
or10°
Sinusarrhythmia
• PPinterval~1.6-2.0seconds
• ResumptionoIsinusrhythmataPPintervalthatisnota
multipleoIthebasicsinusPPinterval
Sinuspauseorarrest
• SinusPwave
• SomesinusimpulsesIailtoreachtheatria
• “Groupbeating”with:
(1) ShorteningoIthePPintervalpriortoabsentP
wave
(2) ConstantPRinterval
(3) PPpauselessthantwicethenormalPPinterval
MobitzTypeI,
second-degree
sinoatrialexitblock
• SinusPwave
• SomesinusimpulsesIailtoreachtheatria
• ConstantPPintervalIollowedbyapausethatisa
multiple(2x,3x,etc.)oIthenormalPPinterval
MobitzTypeII,
second-degree
sinoatrialexitblock
40
ECG 4. 82-year-old female with chest pain:
41
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
42
ECG 4 was obtained Irom an 82-year-old Iemale with chest pain. The ECG shows a regular, wide QRS complex rhythm at a rate oI 94
beats/minute, consistent with accelerated idioventricular rhythm. Sinus bradycardia is also present at a rate oI 56 beats/minute (arrows mark
P waves, which are sometimes hidden in the QRS complex |arrowheads| but march through the tracing). The sinus rhythm and AIVR are
independent oI each other, resulting in AV dissociation. LBBB pattern represents electrical activation Irom the idioventricular rhythm, not true
bundle branch block. Marked ST segment elevation is evident in the anterolateral leads (asterisks), consistent with acute myocardial injury; the
presence oI LBBB pattern makes it diIIicult to diagnose acute myocardial inIarction in a speciIic location.
Codes: 09 Sinus bradycardia
26 Accelerated idioventricular rhythm
35 AV dissociation
65 ST and/or T wave abnormalities suggesting myocardial injury
*
*
*
*
*
43
Ouestions: ECG 4
1. Accelerated idioventricular rhythm (AIVR) presents with:
a. Rates up to but not exceeding 100 BPM
b. Wide QRS complexes
c. Occasional Iusion beats when there is a competing sinus
rhythm
2. ST segment elevation can be due to:
a. Pericarditis
b. Acute myocardial inIarction
c. Digitalis
d. Hyperkalemia
e. LeIt ventricular hypertrophy
I. Intracerebral hemorrhage
g. Acute cor pulmonale
h. Hypocalcemia
i. Early repolarization
Answers: ECG 4
1. AIVR tends to occur at rates between 60-100 BPM, but can
occur at rates up to 110 BPM. When AIVR competes with sinus
rhythm, Iusion beats (QRS complexes intermediate in
morphology between the two rhythms) sometimes occur.
(Answer: b, c)
2. There are numerous causes oI ST segment elevation, including
acute myocardial inIarction, pericarditis, early repolarization,
ventricular aneurysm, myocarditis, LVH, acute cor pulmonale,
LBBB, hypertrophic cardiomyopathy, intracerebral hemorrhage,
and neoplastic invasion oI the heart. Digitalis causes sagging ST
segment depression, not ST elevation. Hypocalcemia can
lengthen the ST segment, but does not cause ST elevation or
depression. (Answer: all except c, h)
- («:·/ k:.::« ; - - («:·/ k:.::« ; - - («:·/ k:.::« ; - - («:·/ k:.::« ; -
Accelerated idioventricular rhythm
· Highly irregular ventricular rhythm (true/Ialse)
· Ventricular rate oI per minute
· QRS morphology is similar to
· Ventricular complexes, beats, and
AV are common
Ialse
60-120
VPCs
capture, Iusion
dissociation
AV dissociation
· Atrial and ventricular rhythms are oI each
other
· Ventricular rate is (·/~) than the atrial rate
independent
~
44
—POPOU¡Z—
PatternRecognItIon:CIInIcaIDIsorders
Instructions:DeterminetheclinicaldiagnosisassociatedwitheachoItheIollowingECGs.
ECG Diagnosis Answer
a. AtrialseptaldeIect,primum
b. AtrialseptaldeIect,secundum
c. Dextrocardia
d. Intracerebralhemorrhage
e. Limbleadreversal
I. Precordialleadreversal
g. DigitaliseIIect
h. Hypothermia
i. PericardialeIIusion
Ostium secundum atrial septal defect (ASD)represents70°
oIallASDs,andresultsIromdeIicienttissueintheregionoI
theIossaovalis.ThediagnosisissuggestedbyanRSR’or
rSR’complexwithaQRSduration·0.11secondsinV
1
,
incompleteRBBB,rightaxisdeviation+rightventricular
hypertrophy.Rightatrialabnormalityispresentin30°,and
AVblockdevelopsin·20°.(Answer:b)
NormalRwaveprogression
Reversal of right and left arm leadsresultsininversionoIthe
P-QRS-TinleadsIandaVL(mimickingdextrocardiainlimb
leads),transpositionoIleadsIIandIII,andtranspositionoI
leadsaVRandaVL.PrecordialRwaveprogressioncanbe
usedtodistinguishlimbleadreversalIromdextrocardia:
LimbleadreversalisassociatedwithnormalRwave
progression;dextrocardiaisassociatedwithreverseRwave
progression(diminshingRwaveamplitudeIromV
1
-V
6
).
(Answer:e)
HypothermiaresultsinsinusbradycardiawithwideningoI
theQRS,prolongationoIPRandQTintervals,andOsborne
(“J”)waves,whicharelateuprightterminaldeIlectionsoIthe
QRScomplex(“camelhump”sign).AtrialIibrillationis
common,andAVjunctionalrhythm,ventriculartachycardia,
orventricularIibrillationmayalsooccur.(Note:Shivering
sometimescausesbaselineartiIactmimickingatrial
Iibrillation,andnotchingsimulatinganOsbornewavemay
beseeninearlyrepolarization.)(Answer:h)
45
- POP OU¡Z -
Make The DIagnosIs
,QVWUXFWLRQV Determine the ECG diagnosis that best corresponds to the
ECG Ieatures listed below (see answer sheet Ior options)
(&*)HDWXUHV $QVZHU
· Ventricular rate oI 30-40 per minute
· QRS morphology is similar to VPCs
· QRS complex occurs as a secondary phenomenon in
response to decreased sinus impulse Iormation or
conduction, or high-degree AV block
Ventricular
escape beats or
rhythm
· Ventricular rate oI 40-60 per minute
· QRS morphology similar to sinus/supraventricular impulse
· QRS complex occurs in response to decreased sinus
impulse Iormation or conduction, or high-degree AV
block; the atrial mechanism may be sinus rhythm,
paroxysmal atrial tachycardia, atrial Ilutter, or atrial
Iibrillation
AV junctional
escape complex
· Ventricular ectopic beats occur at a rate oI 30-50 per
minute (can range Irom 20-400 per minute)
· VPCs show nonIixed coupling
· Fusion complexes may be present
· All interectopic intervals are a multiple oI the shortest
interectopic interval
Ventricular
parasystole
· Regular ventricular rhythm at a rate oI 60-110 bpm
· QRS morphology is similar to VPCs
· Ventricular capture complexes, Iusion beats, and
AV dissociation are common
Accelerated
idioventricular
rhythm
—46—
ECG5. 46-year-oldmalefouryearsstatus-post
cardiactransplantation:
47
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
48
ECG 5 was obtained Irom a 46-year-old male who is Iour years status-post cardiac transplantation. The tracing shows a narrow complex
tachycardia. Atrial Ilutter waves (arrowheads) are apparent in the inIerior leads and in lead V
1
. Every other Ilutter wave is buried in the QRS
complex, so 2:1 AV block should be coded. Flutter waves deIorm the ST segment in the inIerior leads to simulate myocardial ischemia and
deIorm the QRS complex in lead V
1.
to simulate an abnormal Q waves. Right axis deviation is also present.
Codes: 18 Atrial Ilutter
32 AV block, 2:1
37 Right axis deviation (~ ¹100
1
)
49
Ouestions: ECG 5
1. Right axis deviation is associated with all oI the Iollowing
conditions except:
a. Chronic lung disease
b. Right ventricular hypertrophy (RVH)
c. Right bundle branch block (RBBB)
d. Anterior MI
e. Lateral MI
I. LeIt anterior Iascicular block
g. LeIt posterior Iascicular block
h. Dextrocardia
i. Lead reversal
2. The typical response oI atrial Ilutter to carotid sinus massage is:
a. No eIIect
b. Slowing oI Ilutter rate; no change in ventricular response
c. No change in Ilutter rate; transient increase in AV block
d. Conversion to normal sinus rhythm
Answers: ECG 5
1. Right axis deviation is deIined by mean QRS axis between 100°
and 270°. Among the conditions listed, right axis deviation can
be seen in chronic lung disease (e.g., emphysema), RVH, lateral
wall MI, leIt posterior Iascicular block, dextrocardia, and limb
lead reversal. Other causes include vertical heart, pulmonary
embolus, and ostium secundum ASD. Mean QRS axis is usually
normal in RBBB and anterior MI, and is leItward in leIt anterior
Iascicular block. (Answer: c, d, I)
2. In patients with atrial Ilutter, carotid sinus massage typically
causes a transient increase in AV block and slowing oI the
ventricular response without a change in Ilutter rate; less
commonly, no eIIect is seen. When 2:1 AV block is present and
atrial Ilutter is suspected, carotid sinus massage may unmask
Ilutter waves and help conIirm the diagnosis. Upon
discontinuation oI carotid sinus massage, the usual response is
return to the original ventricular rate. (Answer: c)
50
- («:·/ k:.::« , - - («:·/ k:.::« , - - («:·/ k:.::« , - - («:·/ k:.::« , -
Atrial flutter
· Rapid (regular/irregular) atrial undulations ('F¨
waves) at a rate oI per minute
· Flutter rate may (increase/decrease) in the presence
oI Types IA, IC or III antiarrhythmic drugs
· Flutter waves in leads II, III, AVF are typically
(inverted/upright) (with/without) an isoelectric
baseline
· Flutter waves in lead V
1
are typically small
(positive/negative) deIlections (with/without) a
distinct isoelectric baseline
· QRS complex may be normal or aberrant
(true/Ialse)
· AV conduction ratio (ratio oI Ilutter waves to QRS
complexes) is usually (Iixed/variable)
Conduction ratios oI 1:1 and 3:1 are
(common/uncommon)
In untreated patients, AV block ~ suggests
the coexistence oI AV conduction disease
regular
240-340
decrease
inverted, without
positive, with
true
Iixed
uncommon
4:1
Right axis deviation
· Mean QRS axis between and degrees 101, 270
51
Common Dilemmas
in ECG ¡nterpretation
Problem
LeIt bundle branch block is present. Should acute
myocardial inIarction ever be coded?
Recommendation
No (controversial). Most electrocardiographers are reluctant
to diagnose acute myocardial inIarction in the setting oI
LBBB. However, three criteria have independent value Ior
diagnosing acute myocardial injury:
ST elevation ~ 1 mm concordant to (same direction as)
the major deIlection oI the QRS
ST depression ~ 1 mm in V
1
, V
2
, or V
3
ST elevation ~ 5 mm discordant with (opposite direction
to) the major deIlection oI the QRS
52
ECG 6. 85-year-old female with recent onset of chest
pain:
53
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
54
ECG 6 was obtained in an 85-year-old Iemale with recent onset oI chest pain. The ECG shows sinus rhythm and Mobitz Type II second-degree
AV block with 3:2 AV conduction (3 P waves |arrows| Ior every 2 QRS complexes |asterisks|). Also noted are right bundle branch block, leIt
atrial enlargement, leIt ventricular hypertrophy (R wave in aVL ~ 12mm), and acute or recent anteroseptal myocardial inIarction (arrowheads)
with ST and T wave abnormalities suggesting myocardial injury. The T wave inversions in the lateral leads (I, aVL, V
5
, V
6
) are consistent with
repolarization abnormality secondary to LVH; however, in the setting oI evolving myocardial inIarction, they are most likely due to myocardial
ischemia.
Codes: 06 LeIt atrial abnormality/enlargement
07 Sinus rhythm
31 AV block, 2
o
- Mobitz Type II
40 LeIt ventricular hypertrophy
43 RBBB, complete
53 Anterior or anteroseptal myocardial inIarction (age recent or acute)
64 ST and/or T wave abnormalities suggesting myocardial ischemia
65 ST and/or T wave abnormalities suggesting myocardial injury
* *
55
Ouestions: ECG 6
1. Features consistent with Mobitz Type II second-degree AV
block include all oI the Iollowing except:
a. Constant PR interval in the conducted beats
b. Intermittently nonconducted P waves without evidence oI
atrial prematurity
c. RR interval containing the nonconducted P wave is less than
two PP intervals
d. RR interval containing the nonconducted P wave equals two
PP intervals
2. Features Iavoring Mobitz I (Wenckebach) over Mobitz II
second-degree AV block in patients with 2:1 AV conduction
include:
a. Classic Mobitz I AV block is present on another part oI the
ECG
b. AV conduction improves with exercise
c. BiIascicular block
Answers: ECG 6
1. This 85-year-old Iemale presenting with an acute anteroseptal
myocardial inIarction has damaged her AV and His-Purkinje
conduction systems, resulting in right bundle branch block and
Mobitz II AV block. The diagnosis oI Mobitz Type II second-
degree AV block requires that the PR interval remains constant
in the conducted beats, that there are intermittently
nonconducted P waves without evidence oI premature atrial
complexes, and that the RR interval containing the
nonconducted P wave equals two PP intervals. II the RR interval
containing the nonconducted P wave is less than two PP
intervals, Mobitz Type I second-degree AV block is suggested
and evidence Ior PR interval prolongation should be assessed.
(Answer: c)
2. Patients with 2:1 AV block can have either a Mobitz Type I
(Wenckebach) or Mobitz Type II mechanism. Maneuvers that
increase heart rate and PR conduction (e.g., exercise, atropine)
will improve AV conduction and decrease heart block in patients
with Mobitz I block at the level oI the AV node. In contrast,
patients with Mobitz II and block in the His-Purkinje system
will oIten have worsening AV block as heart rate and PR
conduction improve. II classic Mobitz I AV block is seen on
another part oI the ECG, then the episode oI 2:1 AV block is
most likely based on a Mobitz I mechanism. The presence oI
bundle branch block or biIascicular block indicates disease in
the Purkinje system and suggests that 2:1 AV block is due to a
Mobitz II mechanism. (Answer: a, b)
56
- («:·/ k:.::« ( - - («:·/ k:.::« ( - - («:·/ k:.::« ( - - («:·/ k:.::« ( -
AV block, 2° - Mobitz Type ¡¡
· Regular sinus or atrial rhythm with intermittent
nonconducted waves (with/without) evidence
Ior atrial prematurity
· PR interval in the conducted beats is
(constant/variable)
· RR interval containing the nonconducted P wave is
(less than/equal to/greater than) two PP intervals
P, without
constant
equal to
8T and/or T wave abnormalities
suggesting myocardial ischemia
· Abnormally tall, symmetrical, (upright/inverted) T
waves
· Horizontal or ST segments with or without T
wave inversion
· Associated ECG Iindings:
QT interval is usually (normal/prolonged)
Reciprocal wave changes may be evident
Prominent U waves are oIten present and may
be upright or inverted (true/Ialse)
inverted
downsloping
prolonged
T
true
- («:·/ k:.::« ( - - («:·/ k:.::« ( - - («:·/ k:.::« ( - - («:·/ k:.::« ( -
Left ventricular hypertrophy
· &RUQHOO&ULWHULD(most accurate): R wave in aVL
¹ S wave in V
3
~ mm in males or ~ mm
in Iemales
· 2WKHUYROWDJHEDVHGFULWHULD
Precordial leads (one or more)
(1) R wave in V
5
or V
6
¹ S wave in V
1
~ mm iI age ~ 40 years
~ mm iI age 30-40 years
~ mm iI age 16-30 years
(2) Maximum R wave ¹ S wave in precordial
leads ~ mm
(3) R wave in V
5
~ mm
(4) R wave in V
6
~ mm
Limb leads (one or more)
(1) R wave in lead I ¹ S wave in lead II ~
mm
(2) R wave in lead I ~ mm
(3) S wave in aVR ~ mm
(4) R wave in aVL ~ mm
(5) R wave in aVF ~ mm
· 1RQYROWDJHUHODWHGFULWHULDIRU/9+
(LeIt/right) atrial abnormality
(LeIt/right) axis deviation
Onset oI intrinsicoid deIlection ~ seconds
Small or absent R waves in leads
Absent waves in leads I, V
5
, V
6
Abnormal waves in leads II, III, aVF
Prominent waves, especially in leads with
large R and T waves
R wave amplitude in V
6
(greater than/less than)
V
5
, provided there are dominant R waves in
these leads
28, 20
35
40
60
45
26
20
26
14
15
12
21
leIt
leIt
0.05
V
1
-V
3
Q
Q
U
greater than
—57—
K A L E M I A
N
P J E
R D R U
I I N V E R T E D
M G H Y
U O S
M Y X E D E M A
I
S I N O A T R I A L
ACRO88
1. Hyper¸¸¸¸¸isassociatedwithQT
shortening,asinewaveQRSpattern,
andsinoventricularconduction
3. WPWresultsinaPRinterval·0.12
secondsandaconstant¸¸¸¸¸interval
thatis0.26seconds
6. ReversaloIrightandleItarmleads
resultsinP-QRS-Tcomplexesthat
are¸¸¸¸¸inIandaVL
7. AssociatedIindingsincludelowQRS
voltage,sinusbradycardia,and
pericardialeIIusion
8. MobitzTypeI¸¸¸¸¸exitblock
demonstratesshorteningoIthePP
intervaluptoPPpause,aconstantPR
interval,andaPPpauselessthan
twicethenormalPPinterval
DOWN
2. SuggestedbySTelevation1mmpersisting4ormoreweeksaIteracuteMI
inleadswithabnormalQwaves
3. TypeoIatrialseptaldeIectassociatedwithleItaxisdeviation
4. ¸¸¸¸¸toxicitycancauseatrialIibrillationwitharegularventricularresponse
duetocompleteheartblockandjunctionaltachycardia
5. Associatedwithrightaxisdeviation,adominantRwaveinV
1
,secondaryST-T
changes,andrightatrialabnormality
—ECGCRO88WORDPUZZLE—
58
ECG 7. 51-year-old female with shortness of breath:
6
4
0
5
0
_
I
N
D
D
_
O
v
e
r
t
a
k
e
s
.
i
n
d
d



7
9
/
4
/
0
8



3
:
0
5
:
5
4

P
M
59
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—60—
ECG7wasobtainedIroma51-year-oldIemalewithshortnessoIbreath.TheECGshowsnormalsinusrhythmatarateoI89beats/minute,
right axis deviation (¹130o), and right bundle branch block. The very tall QRS complex in lead V
1
(R wave amplitude ÷ 29 mm)(arrow),
particularlyinassociationwithrightaxisdeviation,isconsistentwithrightventricularhypertrophy(RVH).LeItposteriorIascicularblock(LPFB)
shouldnotbecodedsinceitrequirestheabsenceoIothercausesoIrightaxisdeviation(e.g.,RVH).
Codes: 07 Sinusrhythm
37 Rightaxisdeviation(~¹100o
41 Rightventricularhypertrophy
43 RBBB,complete
67 STand/orTwaveabnormalitiessecondarytohypertrophy
61
Ouestions: ECG 7
1. Repolarization abnormalities associated with right ventricular
hypertrophy (RVH) are typically most prominent in leads:
a. V
4
-V
6
b. V
1
-V
3
c. I, aVL
d. aVR, aVL
2. Conditions that can mimic RVH on ECG include:
a. WolII-Parkinson-White pattern
b. Anterior myocardial inIarction
c. Posterior myocardial inIarction
d. Right bundle branch block (RBBB)
Answers: ECG 7
1. The "strain pattern" oI right ventricular hypertrophy maniIests
shallow T wave inversion with or without downslopping ST
segment depression in leads V
1
-V
3
. When RVH complicates
COPD, ST segment depression in the inIerior leads is sometimes
seen when RVH is caused by chronic lung disease (i.e.,
pulmonary hypertension). (Answer: b)
2. Many conditions are associated with a tall R wave in V
1
and
right axis deviation, and can thus mimic right ventricular
hypertrophy. These conditions include WolII-Parkinson-White
syndrome, posterior MI, and right bundle branch block. Anterior
MI results in absent or diminished anterior Iorces. (Answer: a,
c, d)
- («:·/ k:.::« I - - («:·/ k:.::« I - - («:·/ k:.::« I - - («:·/ k:.::« I -
Right ventricular hypertrophy
· Mean QRS axis degrees
· Dominant wave in V
1
:
R/S ratio in V
1
or V
3R
(·, ÷, ~) 1, orR/S ratio
in V
5
or V
6
( , ~) 1
R wave in V
1
mm
R wave in V
1
¹ S wave in V
5
or V
6
~
mm
rSR in V
1
with R ~ mm
· Secondary downsloping ST depression & T-wave
inversion in the (right/leIt) precordial leads
· (Right/leIt) atrial abnormality
100
R
~

7
10.5
10
right
right
RBBB, complete
· QRS duration seconds
· Secondary R wave (R) in lead is usually
(shorter/taller) than the initial R wave
· Onset oI intrinsicoid deIlection in leads V
1
and
V
2
~ seconds
· ST segment and T wave
in V
1,
V
2
· Wide slurred S wave in leads
· QRS axis is usually (normal/leItward/rightward)
· RBBB (does/does not) interIere with the ECG
diagnosis oI ventricular hypertrophy or Q wave
MI
0.12
V
1
taller
0.05
depression
inversion
I, V
5
, V
6
normal
does not
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 62 —
A.
B.
C.
D.
Answer: Tracings A, C and D all show atrial futter with typical futter waves. The imposter is tracing B, which shows supraventricu-
lar tachycardia, probably AV nodal reentry tachycardia. This is evident from the lack of P waves or any atrial activity.
63
Differential Diagnosis
PEAKED T WAVE8
(T wave amplitude ~ 6 mm in limb
leads or ~ 10 mm in precordial leads)
· Acute MI (hyperacute phase; transient)
· Normal variant (most common in the mid-precordial
leads)
· Hyperkalemia
· Intracranial bleeding
· LeIt ventricular hypertrophy
· LBBB
64
ECG 8. 72-year-old male with chest pain and
shortness of breath:
65
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary
embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—66—
ECG8wasobtainedIroma72-year-oldmalewithchestpainandshortnessoIbreath.TheECGshowsabnormalQwavesinII,III,andaVF
associatedwithSTelevationoIacuteinjury,consistentwithacuteinIeriormyocardialinIarction.Inthiscase,ischemicoItheAVnodehas
resultedinanAVWenckebachpattern;groupbeatingoccursina3:2or4:3patternwithprogressivePRprolongationpriortoaPwavethat
Iailstoconducttotheventricle(arrow).The6
th
QRScomplexandPwaveoccursimultaneously(asterisk).Thisimpliesthatthesinusnodehad
activatedtheatrium,butbeIoreitcouldconductthroughtheAVnodetheventriclewasactivatedbyajunctionalescapebeat.
Codes: 07 Sinusrhythm
21 AVjunctionalescapecomplexes
30 AVblock,2°-MobitztypeI(Wenckebach)
57 InIerior(agerecentoracute)
3:2 4:3
— 68 —
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 69 —
A.
B.
C.
D.
Answer: Tracings B, C and D represent ventricular tachycardia, with a rapid wide QRS complex rhythm. The imposter is tracing A,
which shows sinus rhythm with artifact resembling the wide QRS complexes of ventricular tachycardia. The several rapid upstroke
defections throughout the apparent 'wide complex rhythm¨ are sinus beats ÷ they resemble the preceding and subsequent narrow QRS
complexes of sinus rhythm and march out regularly across the entire tracing (with the use of calipers).
70
ECG 9. 69-year-old male with orthopnea and pedal
edema:
71
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
72
ECG 9 was obtained Irom a 69-year-old male with orthopnea and pedal edema. The ECG shows sinus rhythm with normally-conducted APCs
(arrows mark the premature P waves, which are superimposed on the preceding T waves). RBBB and leIt anterior Iascicular block are also
present. The T wave Iollowing the Iirst APC in the rhythm strip is slightly more peaked than the previous T waves, consistent with a post-
extrasystolic T wave abnormality.
Codes: 07 Sinus rhythm
13 Atrial premature complexes
43 RBBB, complete
45 LeIt anterior Iascicular block
73
Ouestions: ECG 9
1. The tall R wave in aVL is highly speciIic Ior LVH:
a. True
b. False
2. Findings in this tracing that can be attributed to leIt anterior
Iascicular block include:
a. rS in leads II, III and aVF
b. qR in leads I and aVL
c. Large S wave in leads V
4
- V
6
d. Poor R wave progression
3. The most common cause oI right bundle branch block plus leIt
anterior Iascicular block (biIascicular block) is:
a. Cardiomyopathy
b. Hypertensive heart disease
c. Coronary artery disease
d. Lenegre`s disease
4. The most common type oI myocardial inIarction to cause RBBB
plus LAFB is:
a. InIerior MI
b. Anterior MI
c. Lateral MI
d. Posterior MI
5. What is the incidence oI complete heart block when biIascicular
block occurs during myocardial inIarction:
a. · 5°
b. 5 - 10°
c. 10 - 20°
d. ~ 20°
6. Did the premature atrial contraction (4th beat in rhythm strip)
reset the sinus node:
a. Yes
b. No
Answers: ECG 9
1. An R wave in lead aVL ~ 12 mm is highly speciIic Ior
anatomical LVH. However, speciIicity is reduced when leIt
anterior Iascicular block (LAFB) is present, since LAFB by
itselI can produce tall R waves in aVL. (Answer: b)
2. ECG maniIestations oI leIt anterior Iascicular block include leIt
axis deviation, qR in leads I and aVL, and rS in leads II, III, and
aVF. Large S waves in V
4
- V
6
and poor R wave progression
may also be seen. (Answer: all)
3. Coronary artery disease is the most common cause oI
biIascicular block (RBBB plus LAFB), and is responsible Ior up
to 50° oI cases. Other causes include hypertensive heart
74
disease, calciIic aortic valve disease (with extension oI the
calciIication into the anterior interventricular septum),
cardiomyopathy, Lev`s disease, Lenegre`s disease, surgical
trauma, post-cardiac transplant, among others. Complete heart
block develops in 5-15° oI patients with chronic biIascicular
block and in 25-40° oI patients with acute biIascicular block
secondary to acute MI. (Answer: c)
4. Anterior wall myocardial inIarction Irom occlusion oI the
proximal leIt anterior descending coronary artery is the most
common cause oI acute biIascicular block (RBBB plus LAFB).
The right bundle branch and anterior division oI the leIt bundle
branch course together in the anterior portion oI the
interventricular septum, and receive their blood supply Irom
septal perIorators oI the LAD. (Answer: b)
5. Since progression to complete heart block develops in more than
20° oI patients who develop acute biIascicular block during MI,
temporary transvenous pacing should be considered. When
extensive anterior inIarction is evident, mortality remains high
despite the presence oI a pacemaker; death is oIten due to pump
Iailure rather than progression to complete heart block.
(Answer: d)
6. The PP interval remains constant and the sinus node is
undisturbed by the premature atrial contraction in this tracing.
(Answer: b)
- («:·/ k:.::« 7 - - («:·/ k:.::« 7 - - («:·/ k:.::« 7 - - («:·/ k:.::« 7 -
Atrial premature complexes, normally
conducted
· P wave is (normal/abnormal) in conIiguration
· QRS complex is (similar/diIIerent) in morphology
to the QRS complex present during sinus rhythm
· PR interval may be normal, increased, or decreased
(true/Ialse)
· The post-extrasystolic pause is usually
(compensatory/noncompensatory)
abnormal
similar
true
noncompensatory
RBBB, complete
· QRS duration ~ seconds
· Secondary R wave (R) in lead is usually
(shorter/taller) than the initial R wave
· Onset oI intrinsicoid deIlection in leads V
1
and V
2
~ seconds
· ST segment and T wave
in V
1,
V
2
· Wide slurred S wave in leads
· QRS axis is usually (normal/leItward/rightward)
· RBBB (does/does not) interIere with the ECG
diagnosis oI ventricular hypertrophy or Q wave MI
0.12
V
1
taller
0.05
depression
inversion
I, V
5
, V
6
normal
does not
Left anterior fascicular block
· axis deviation with a mean QRS axis between
and degrees
· (qR/rS) complex in leads I and aVL
· (qR/rS) complex in lead III
· Normal or slightly prolonged QRS duration
(true/Ialse)
· No other cause Ior leIt axis deviation should be
present (true/Ialse)
· Poor R wave progression is (common/uncommon)
leIt
-45, -90
qR
rS
true
true
common
—75—
—POPOU¡Z—
PatternRecognItIon:AVConductIonAbnormaIItIes
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. ReIlectsprolongedconductionIrom
thesinusnodetoatrialtissue
b. 1
N
AVblock
c. Canbeseeninnormalindividuals
d. 2
N
AVblock,TypeI
e. Groupedbeatingduetononconducted
Pwaves
I. BlockusuallyoccursatleveloIAV
node
g. MorecommonininIeriorMIthan
anteriorMI
h. 2
N
AVblock,TypeII
i. Blockmayimprovewithcarotidsinus
massageandworsenwithatropine
j. CanbeeitherMobitzTypeIorII
k. Atrialandventricularrhythmsare
independentoIeachother
l. 3
N
AVblock
m.Blockedatrialprematurecomplex
n. 2:1AVblock
Complete (3
°
) AV blockresultsinatrialimpulses
thatconsistentlyIailtoreachtheventricles.
Independentatrialandventricularrhythms(AV
dissociation)result,maniIestasvariablePR
intervalsandconstantPPandRRintervals(when
atrialrateexceedsventricularrate).Ventricular
rhythmismaintainedbyajunctionalor
idioventricularescaperhythmoraventricular
pacemaker.(Answer:k,l)
2:1 AV blockresultsinaregularsinusoratrial
rhythminwhicheveryotherPwaveis
nonconducted(i.e.,twoPwavesIoreachQRS
complex).AVblockcanbeMobitzTypeIor
TypeIIsecond-degreeAVblock,andmayrequire
anEPstudytodistinguishbetweenmechanisms.
(Answer:j,n)
Nonconducted atrial premature complex (APC)is
identiIiedbyaprematureectopicatrialbeat
(nonsinusPwave)notIollowedbyaQRS-T
complex.ThePwaveisoItenhiddeninthe
precedingTwave(arrow),resultinginanRR
pausethatissometimesmistakenIorasinus
pause.(Answer:c,I,m)
76
ECG 10. 80-year-old male with light-headedness:
77
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—78—
ECG10wasobtainedinan80-year-oldmalewithlight-headedness.TheECGshowsaninconsistentsinusbradycardiaatapproximately50
beats/minute. AIter the Iirst sinus beat, there is a sinus pause oI 1.9 seconds that is terminated by a ventricular paced beat. The ventricular
pacemakerispacingat60beats/minutebutisdisplayingabnormalsensingIunction:Oversensing(pacedbeatoccurslaterelativetotheintrinsic
pacemakerrate)ispresentaItertheIirstbeat(asterisk),andIailuretosenseisseenaItertheIourthbeat(pacedbeatoccursearlyrelativetothe
intrinsicpacemakerrate)(arrowhead).AnoldinIeriorwallmyocardialinIarction(abnormalQwavesinleadsIIIandaVF)ispresent,asare
repolarizationabnormalitiessuggestinganteriormyocardialischemia(arrow).ThisconstellationoIIindings—sinusbradycardiaandasinus
pauseinanelderlypatientwithahistoryoIpreviouspacemakerimplantation—suggestsadiagnosisoIsicksinussyndrome.
Codes: 09 Sinusbradycardia(·60)
11 Sinuspause
58 InIeriorQwaveMI(ageindeterminateorold)
64 STand/orTabnormalitiessuggestingmyocardialischemia
89 Sicksinussyndrome
94 PacemakermalIunction,notconstantlysensing(atriumorventricle)
79
Ouestions: ECG 10
1. Abnormal sensing Iunction oI a pacemaker can maniIest as all
oI the Iollowing except:
a. A pacing spike that is not Iollowing by an appropriate
depolarization
b. A pause resulting Irom oversensing oI artiIact
c. An early paced beat due to undersensing oI an intrinsic
depolarization
d. Failure oI a DDD pacemaker to trigger a ventricular
depolarization in response to an intrinsic depolarization that
Iailed to reach the ventricle due to AV block
2. ECG Ieatures consistent with the diagnosis oI sick sinus
syndrome include:
a. Sinus pause or arrest
b. Tachycardia alternating with bradycardia
c. SA exit block
d. Low voltage QRS complexes
e. Atrial Iibrillation with a slow ventricular response
I. LeIt atrial abnormality or enlargement
3. A recurring sinus pause that is a multiple oI the regular sinus PP
interval is consistent with:
a. Sinus arrhythmia
b. Blocked atrial premature contraction
c. Atrial parasystole
d. SA exit block
4. A sinus pause is deIined by a PP interval :
a. 1.5 seconds
b. 1.6 seconds
c. 1.4 seconds
d. 1.3 seconds
Answers: ECG 10
1. Abnormal pacemaker sensing can cause early paced beats or
inappropriately long pauses depending on the type oI sensing
malIunction. 2YHUVHQVLQJ results in inappropriate inhibition oI
the pacemaker, usually maniIesting as a pause. Oversensing may
occur in response to artiIact, large T waves, or myopotentials
Irom arm movements (more common with unipolar
pacemakers). 8QGHUVHQVLQJ occurs when the pacemaker ignores
or Iails to recognize (e.g., low-ampliIied VPC) intrinsic
depolarizations, and thus, paces prematurely. In the triggered
mode, abnormal sensing maniIests as Iailure oI the pacemaker
to be triggered by an appropriate intrinsic depolarization (e.g.,
Iailure to pace the ventricle in response to a nonconducted
intrinsic P wave). (Answer: a)
2. Sick sinus syndrome (SSS) is due to sinus node dysIunction, and
usually maniIests as marked sinus bradycardia with or without
episodes oI sinus arrest, sinus pauses, or SA exit block. SSS is
also commonly reIerred to as the 'tachy-brady¨ syndrome, due
to the Irequent occurrence oI supraventricular tachycardia
alternating with bradycardia. Patients with tachy-brady
syndrome may have severe sinus bradycardia or long sinus
pauses (i.e., prolonged sinus node recovery time) Iollowing an
episode oI atrial tachyarrhythmia (i.e., SVT, atrial Iibrillation).
Atrial Iibrillation with a slow ventricular response is another
80
clue to the presence oI underlying sinus node dysIunction.
(Answers: a, b, c, e)
3. Second-degree sinoatrial (SA) exit block occurs when sinus
impulses intermittently Iail to capture the atria, resulting in the
intermittent absence oI a P wave. In type II block, the PP
interval is constant and is Iollowed by a pause that is a multiple
oI the normal PP interval. SA exit block is usually a
maniIestation oI sick sinus syndrome but can also be due to
other Iactors such as use oI digitalis or antiarrhythmic drugs.
Other causes oI SA exit block include hyperkalemia, myocardial
inIarction, and vagal stimulation. (Answer: d)
4. Sinus pause or arrest is deIined as a PP interval ≥ 1.6 seconds.
The sinus pause should not be a multiple oI the basic PP
interval, in which case, SA exit block is suggested. It is also
important to distinguish a sinus pause Irom a nonconducted
atrial premature complex, in which case the P wave is typically
buried in the repolarization phase oI the preceding beat, usually
causing a discernable deIormity in the ST-segment or T wave oI
the last complex beIore sinus pause. Sinus pause or arrest is due
to transient Iailure oI impulse Iormation oI the SA node. In
contrast, SA exit block results in sinus impulse Iormation, but
conduction to the atrium is either delayed (1° SA exit block) or
intermittently Iails to capture the atrium (2° SA exit block). 3°
SA exit block occurs when there is complete Iailure oI sinoatrial
conduction to capture the atrium and cannot be distinguished
Irom complete sinus arrest on the surIace ECG. (Answer: b)
- («:·/ k:.::« 10 - - («:·/ k:.::« 10 - - («:·/ k:.::« 10 - - («:·/ k:.::« 10 -
8inus pause or arrest
· PP interval ~ seconds
· Resumption oI sinus rhythm at a PP interval that
(is/is not) a multiple oI the basic sinus PP interval
· II sinus rhythm resumes at a multiple oI the basic
PP, consider
1.6-2.0
is not
sinoatrial exit block
8ick sinus syndrome
· Marked sinus
· arrest or exit block
· Bradycardia alternating with
· Atrial Iibrillation with ventricular response
preceded or Iollowed by sinus bradycardia, sinus
arrest, or sinoatrial exit block
· Prolonged sinus node time aIter atrial
premature complex or atrial tachyarrhythmias
· AV junctional rhythm
· Additional conduction system disease is oIten
present, including AV block, IVCD, and/or
bundle branch block (true/Ialse)
bradycardia
Sinus, sinoatrial
tachycardia
slow
recovery
escape
true
Pacemaker malfunction, not constantly
sensing {atrium or ventricle}
· Pacemakers in the inhibited mode: Pacemaker
Iails to be by an appropriate intrinsic
depolarization
· Pacemakers in the triggered mode: Pacemaker
Iails to be by an appropriate intrinsic
depolarization
· Premature depolarizations may not be sensed iI
they Iall within the programmed period oI
the pacemaker, RU have insuIIicient at the
sensing electrode site
inhibited
triggered
reIractory
amplitude
—81—
—POPOU¡Z—
PatternRecognItIon:Pacemakers
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. Atrialpacing
b. AIteranintervaloItimewithno
sensedatrialactivity,anatrial
pacedbeatoccurs
c. AIteranintervaloItimewithno
sensedatrialactivity,a
ventricularpacedbeatoccurs
d. Ventriculardemandpacing
e. Asynchronousventricularpacing
I. InterIereswiththeECGdiagnosis
oIacuteMIandventricular
hypertrophy
g. DDDpacing
Inatrial pacing,eachpacemakerstimulusisIollowedbyan
atrialdepolarization.AIteranintervaloItime(A-Ainterval)
withnosensedatrialactivity,anatrialpacedbeatisdelivered
andanewcyclebegins.InresponsetoanativePwave,atrial
pacingisinhibitedandthepacemakertimingclockisreset.
(Answer:a,b)
Inventricular demand pacing,eachpacemakerstimulusis
IollowedbyaQRScomplexoIdiIIerentmorphologythanthe
intrinsicQRS.AIteranintervaloItime(V-Vinterval)with
nosensedventricularactivity,aventricularpacedbeatis
deliveredandanewcyclebegins.Inresponsetoanative
QRS,ventricularpacingisinhibitedandthepacemaker
timingclockisreset.Aventriculardemand(VVI)
pacemakersensesandpacesonlyintheventricle,andis
oblivioustonativeatrialactivity.(Answer:d,I)
Indual chamber (DDD) pacing,iItherateoItheintrinsic
rhythmisslowerthantheprogrammedlowerratelimit,atrial
(A)andventricular(V)pacedbeatswilloccur(separatedby
deIinedA-VandV-Aintervals).Followingventricular-
sensedactivity(eitherQRSorV-pacedbeats),thetiming
clockisreset:IIintrinsicatrialactivity(P)issensedpriorto
theendoItheV-Ainterval,atrialoutputoIthepacemaker
willbeinhibited;iInointrinsicatrialactivity(P)issensedby
theendoItheV-Ainterval,anatrialpacedbeatwilloccur.
ThepacemakertimingclockisalsoresetIollowingatrial-
sensedactivity(eitherintrinsicP-waveorA-pacedbeats):II
intrinsicventricularactivity(QRS)issensedpriortotheend
oItheA-Vinterval,ventricularoutputoIthepacemakerwill
beinhibited;iInointrinsicventricularactivity(QRS)is
sensedbytheendoItheA-Vinterval,aventricularpaced
beatwilloccur.(Answer:a,b,I,g)
82
ECG 11. 73-year-old male with new onset
neurological deficit:
83
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
84
ECG 11 was obtained in a 73-year-old male with an acute neurological deIicit. The ECG shows sinus rhythm, low voltage in the limb leads
(but not the precordial leads, so 'low voltage¨ should not be coded), deep anterolateral T wave inversions (arrows), and a prolonged QT interval.
Given the clinical presentation, the deeply inverted T waves and prolonged QT interval are likely due to the acute central nervous system event.
However, since myocardial ischemia/inIarction occurs in 15-20° oI patients with stroke and since the anterior T wave changes are worrisome
Ior ischemia, item 64 should also be coded.
Codes: 07 Sinus rhythm
64 ST and/or T wave abnormalities suggesting myocardial ischemia
68 Prolonged QT interval
86 Central nervous system disorder
85
Ouestions: ECG 11
1. ECG Iindings in acute central nervous system (CNS) disorders
such as cerebral or subarachnoid hemorrhage include:
a. Large upright T waves in precordial leads
b. Increased QRS voltage
c. Deeply inverted T waves in precordial leads
d. Prolonged QT interval
e. Prominent U waves in precordial leads
2. ECG changes associated with acute CNS events can mimic:
a. Acute myocardial inIarction
b. LeIt ventricular hypertrophy
c. Right ventricular hypertrophy
d. Pericarditis
e. Antiarrhythmic drug eIIects
Answers: ECG 11
1. Classic ECG changes oI acute central nervous system disorders
such as cerebral hemorrhage and subarachnoid hemorrhage
usually occur in the precordial leads, and include large upright
or deeply inverted T waves, prolonged QT interval, and
prominent U waves. Other changes may include T wave
notching, loss oI T wave amplitude, diIIuse ST segment
elevation, and abnormal Q waves. Abnormalities oI cardiac
rhythm include atrial Iibrillation, ventricular tachycardia, sinus
bradycardia, and sinus tachycardia. Increased QRS voltage is
not a Ieature oI acute CNS disorders. (Answer: All except b)
2. ECG changes associated with acute CNS events can mimic acute
myocardial inIarction (abnormal Q waves, large upright T
waves, ST elevation), myocardial ischemia (deep T wave
inversion), acute pericarditis (diIIuse ST elevation), and
antiarrhythmic drug eIIects (prolonged QT interval, prominent
U waves). Increased QRS amplitude mimicking ventricular
hypertrophy does not occur. (Answer: a, d, e)
86
- («:·/ k:.::« 11 - - («:·/ k:.::« 11 - - («:·/ k:.::« 11 - - («:·/ k:.::« 11 -
Prolonged OT interval
· Corrected QT interval (QTc) ~ seconds,
where QTc ÷ QT interval divided by the square
root oI the preceding interval
· QT interval varies (directly/inversely) with heart
rate
· The normal QT interval should be (less than/greater
0.44
RR
inversely
less than
Central nervous system disorder
· 'Classic changes¨ usually occur in the
(limb/precordial) leads
Large upright or deeply inverted waves
Prolonged interval (oIten marked)
Prominent waves
· Other changes:
ST segment changes:
& DiIIuse ST elevation mimicking acute
& Focal ST elevation mimicking
& ST depression may also occur (true/Ialse)
Abnormal waves mimicking MI
Almost any rhythm abnormality including sinus
tachycardia or bradycardia, junctional rhythm,
VPCs, ventricular tachycardia, etc. (true/Ialse)
precordial
T
QT
U
pericarditis
acute injury
true
Q
true
rate is between 65-90.
than) 50° oI the RR interval when the ventricular
87
Differential Diagnosis
GROUP BEAT¡NG
· Mobitz Type I second-degree AV block
· Blocked APCs
· Type II second-degree AV block
· Concealed His-bundle depolarizations
88
ECG 12. 81-year-old female with palpitations:
89
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary
embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—90—
ECG12wasobtainedIroman81-year-oldIemalewithpalpitations.TheECGshowsparoxysmalsupraventriculartachycardia(PSVT).The
PSVTmechanismisconsistentwithtypicalreentrywithintheAVnode(i.e.,antegradeconductiondowntheslowpathwayandretrograde
conductionuptheIastpathway).TheleadV
1
rhythmstripinitiallyrecordsSVTwithanR’attheendoIeachQRScomplex(arrow).AIterthe
9
th
QRScomplex(asterisk),therhythmconvertstosinus;attheconversionpoint,theR’isnolongerpresent.TheR’representsretrograde
conductionthroughtheAVnodeovertheIastpathwaywithactivationoItheatriumoccurringatthetailendoItheQRScomplex.ThisIinding
stronglysuggeststhatthetachycardiamechanismistypicalreentrywithintheAVnode(i.e.,AVnodereentranttachycardia,AVNRT).
Codes: 07 Sinusrhythm
17 Supraventriculartachycardia,paroxysmal
91
Ouestions: ECG 12
1. Which oI the Iollowing statements about atrioventricular nodal
reentrant tachycardia (AVNRT) are true:
a. The majority oI cases oI paroxysmal supraventricular
tachycardia (PSVT) are due to reentry within the
atrioventricular node
b. The most common mechanism oI AVNRT involves
antegrade conduction (Irom atrium to ventricle) over the
Iast AV nodal pathway and retrograde conduction over the
slow AV nodal pathway (typical P wave inverted in II, III,
aVF, and may appear as R` in V
1
)
c. In the present ECG, an accessory pathway is present
connecting the atrium and ventricle in the region oI the AV
node
Answers: ECG 12
1. The most common mechanism oI PSVT is reentry within the
atrioventricular node. This is termed typical AV node reentry
tachycardia and utilizes the slow AV nodal pathway Ior
conduction Irom the atrium to the ventricle and the Iast AV
nodal pathway Ior conduction Irom the ventricle back to the
atrium (see Table). This gives rise to a short RP tachycardia
(RP interval · 50° RR interval), in which the retrograde P
wave is either buried in the QRS complex or seen at the tail end
oI the QRS complex, especially in V
1
, where it appears as an R`
complex. In contrast, the atypical Iorm oI AV node reentry
tachycardia conducts in the reverse direction conduction
Irom the atrium to the ventricle occurs over the Iast AV nodal
pathway, giving rise to a short PR interval, and conduction Irom
the ventricle to the atrium occurs over the slow AV nodal
pathway, giving rise to a long RP interval. The slow and Iast
AV nodal pathways are components oI the AV node and are not
a separate accessory pathway as in WPW. (Answer: a)
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Typical
AVNRT (70°
oI SVT`s)
Slow pathway Fast pathway Short RP
tachycardia (RP
interval · 50° oI
RR interval)
Atypical
AVNRT (2-5°
oI SVT`s)
Fast pathway Slow pathway Long RP
tachycardia (RP
interval ~ 50° oI
RR interval)
- («:·/ k:.::« 1z- - («:·/ k:.::« 1z- - («:·/ k:.::« 1z- - («:·/ k:.::« 1z-
8upraventricular tachycardia,
paroxysmal
· (Regular/irregular) rhythm
· Rate ~ per minute
· P waves (easily/not easily) identiIied
· QRS complex is usually (narrow/wide)
· II rate is 150 per minute, consider
Regular
100
not easily
narrow
atrial Ilutter
with 2:1 block
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 92 —
A.
B.
C.
D.
Answer: Tracings A, B, and C demonstrate atrial fbrillation manifest as irregularly irregular rhythms; fbrillatory waves of varying
amplitude, duration and morphology; and absent of discrete P waves. Tracing D shows multifocal atrial tachycardia and is the im-
poster. MAT manifests as an atrial rate > 100 bpm, 3 or more different P wave morphologies (each originating from a separate atrial
focus), and varying PP and PR intervals. Multifocal atrial tachycardia, like atrial fbrillation is characterized by an irregular rhythm.
However, while defnite atrial depolarizations and P waves are noted in tracing D, they are absent the tracings A, B, and C. MAT may
also be confused with sinus tachycardia with multifocal APCs.
93
Don't Forgetl
· Atrial Ilutter waves can deIorm QRS complexes, ST
segments, and T waves to mimic intraventricular
conduction delay or myocardial ischemia
· Think digoxin toxicity when regularization oI the QRS
is present during atrial Iibrillation this is usually due
to complete heart block with junctional tachycardia
· Think WolII-Parkinson-White syndrome in patients
with atrial Iibrillation when the ventricular rate exceeds
200 per minute and the QRS is wide (~ 0.12 seconds)
· Look Ior retrograde P waves aIter ventricular premature
complexes and other junctional, ventricular, or low
ectopic atrial rhythms
· In junctional premature complexes, the P wave may
precede the QRS by 0.11 seconds (retrograde atrial
activation), be buried in the QRS (and not visualized),
or Iollow the QRS complex
· Although multiIorm VPCs are usually multiIocal in
origin (i.e., originate Irom more than one ventricular
Iocus), a single ventricular Iocus can produce VPCs oI
varying morphology
94
ECG 13. 46-year-old female with chest pain:
95
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
96
ECG 13 was obtained in a 46-year-old Iemale with chest pain. The ECG shows sinus tachycardia, diIIuse ST segment elevation (arrows), mild
PR segment depression (relative to the TP segment) (arrowheads), and PR segment elevation in lead aVR. These Iindings are consistent with
acute pericarditis. The diIIuse nature oI the ST segment elevation in the absence oI Q waves, the upwardly concave conIiguration oI the ST
segments, and the PR depression suggest pericarditis rather than acute myocardial ischemia. Subtle electrical alternans is noted in lead V
4
(asterisk), which is likely due to pericardial eIIusion.
Codes: 10 Sinus tachycardia (~ 100)
38 Electrical alternans
83 Pericardial eIIusion
84 Acute pericarditis
*
97
Ouestions: ECG 13
1. The present ECG is consistent with the diagnosis oI early
repolarization:
a. True
b. False
2. Which oI the Iollowing statements about pericarditis are true:
a. Electrical alternans is a common and speciIic Iinding in
pericarditis complicated by pericardial eIIusion
b. PR segment depression occurs in all leads
c. P wave amplitude usually decreases
Answers: ECG 13
1. The diIIuse ST segment elevation in this tracing is consistent
with early repolarization. (PR segment depression can
sometimes be seen on normal ECGs and does not exclude this
diagnosis). However, in a patient with pleuritic chest pain, acute
pericarditis is the most likely diagnosis. (Answer: a)
2. The typical evolutionary pattern oI ST and T wave changes
associated with pericarditis include: (1) diIIuse ST elevation
(except Ior ST depression in aVR); (2) return oI the ST segment
to baseline with decreasing T wave amplitude; (3) T wave
inversion; and (4) return oI the ECG to normal. However,
pericarditis may be Iocal (e.g., post-pericardiotomy) rather than
diIIuse, resulting in regional rather than diIIuse ST elevation.
Also, classic ST and T wave changes are more likely to occur in
purulent compared to idiopathic, rheumatic, or malignant
pericarditis. Pericarditis does not typically aIIect P wave
amplitude or contour, although P wave alternans may occur iI
pericardial eIIusion is present. While PR depression is common
and oIten diIIuse, it is typically elevated in lead aVR. Electrical
alternans is present in a minority oI patients with pericardial
eIIusion, and can be seen in several other conditions (e.g., severe
LV Iailure, deep respirations, coronary artery disease). (Answer:
none)
98
- («:·/ k:.::« 1; - - («:·/ k:.::« 1; - - («:·/ k:.::« 1; - - («:·/ k:.::« 1; -
8T and/or T wave changes suggesting
acute pericarditis
· Classic evolutionary pattern consists oI stages
Stage 1: Upwardly concave ST segment
in almost all leads
Stage 2: ST junction (J point) returns to
baseline and T wave amplitude begins
to (increase/decrease)
Stage 3: T waves (invert/remain upright)
Stage 4: ECG (does/does not) return to normal
· Other clues to acute pericarditis:
Sinus
PR early (PR elevation in aVR)
(High/low) voltage QRS
Electrical alternans iI pericardial is present
4
elevation
decrease
invert
does
tachycardia
depression
low
eIIusion
Pericardial effusion
· (High/low) voltage QRS
· Electrical , especially iI complicated by
cardiac
· Other Ieatures oI acute may also be present
Low
alternans
tamponade
pericarditis
99
Don't Forgetl
Age oI myocardial inIarction can be approximated Irom
the ECG pattern:
· Acute MI: Abnormal Q waves, ST elevation
(associated ST depression is sometimes
present in noninIarct leads)
· Recent MI: Abnormal Q waves, isoelectric ST
segments, ischemic (usually inverted) T
waves
· Old MI: Abnormal Q waves, isoelectric ST
segments, nonspeciIic or normal T waves
MI may be present without Q waves in:
· Anterior MI: May only see low anterior R wave Iorces
with decreasing R wave progression in leads V
2
-V
5
· Posterior MI: Dominant R wave with ST depression in
leads V
1
-V
3
RVH, WPW, and RBBB interIere with the ECG diagnosis
oI posterior MI
100
ECG 14. 79-year-old male with ºa racing heart°:
aVR V1 V4 I
VI
II
V5
aVL V2 V5 II
aVF V3 V6 III
101
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—102—
ECG14wasobtainedIroma79-year-oldmalewhilebeingevaluatedIorcomplaintsoI“aracingheart.”TheECGshowsaregular,rapid
rhythmat133beats/minuteandleItanteriorIascicularblock(LAFB)(QRSaxis–56o).ThesawtoothpatternoIthebaseline,mostobviousin
leadsII(asterisk),IIIandaVF,isdiagnosticoIatrialIlutter(atrialrate÷266beats/minute)with2:1AVblock,resultinginaventricularrateoI
133beats/minute.TheRwaveinaVLmeasures14mm(arrow).Underusualcircumstances,anRwavemeasuring12mmisaspeciIicIinding
IorleItventricularhypertrophy(LVH).However,LVHshouldnotbediagnosedsolelyonthebasisoIaVLvoltageinthepresenceoILAFB,
whichcanartiIactuallyincreasethesizeoItheRwaveinaVL.TheqRcomplexinleadsIandaVL,therScomplexinleadIII,andpoorRwave
progressionintheprecordialleadsarealsoconsistentwithLAFB.
Codes: 18 AtrialIlutter
32 AVblock2:1
45 LeItanteriorIascicularblock
aVR V1 V4 I
VI
II
V5
aVL V2 V5 II
aVF V3 V6 III
103
Ouestions: ECG 14
1. By deIinition, leIt anterior Iascicular block is associated with a
mean QRS axis oI:
a. 90° to ¹ 90°
b. 30° to 60°
c. 45° to 90°
d 45° to 100°
2. By deIinition, leIt posterior Iascicular block is associated with
a mean QRS duration oI:
a. ¹100° to ¹180°
b. ¹90° to ¹180°
c. ¹80° to ¹180°
d. ¹90° to ¹270°
3. Which oI the Iollowing Iindings on ECG precludes the diagnosis
oI leIt posterior Iascicular block:
a. LVH
b. RVH
c. Lateral MI
d. InIerior MI
Answers: ECG 14
1. LeIt anterior Iascicular block results in a mean QRS axis
between 45° and 90°. LAFB can increase the size oI the R
wave in leads I and/or aVL, predisposing to a Ialse-positive
diagnosis oI LVH. LAFB also Irequently results in poor R wave
progression across precordial leads, sometimes Ialsely
suggesting a diagnosis oI old anterior inIarction. LAFB is a
diagnosis oI exclusion and should not be coded iI another cause
Ior leIt axis deviation is present (e.g., LVH, inIerior MI, chronic
lung disease, LBBB, ostium primum ASD, severe
hyperkalemia). LAFB is generally associated with organic heart
disease or congenital heart disease and is seen only rarely in
normal hearts. (Answer: c)
2. LeIt posterior Iascicular block (LPFB) results in a mean QRS
axis oI ¹ 100° to ¹ 180°. The QRS duration is generally normal
or only slightly prolonged (0.08-0.10 seconds). LPFB is much
less prevalent than LBBB, RBBB, or LAFB. Coronary artery
disease is most common cause oI LPFB, and LPFB is rarely seen
in normal hearts. (Answer: a)
3. LPFB is a diagnosis oI exclusion and should not be coded iI
another cause Ior right axis deviation is present, including RVH,
a vertical heart, emphysema, pulmonary embolism, lateral MI,
dextrocardia, limb lead reversal, or WolII-Parkinson-White.
(Answer: b, c)
104
- («:·/ k:.::« 1; - - («:·/ k:.::« 1; - - («:·/ k:.::« 1; - - («:·/ k:.::« 1; -
Atrial flutter
· Rapid (regular/irregular) atrial undulations ('F¨
waves) at a rate oI per minute
· Flutter rate may (increase/decrease) in the
presence oI Types IA, IC or III antiarrhythmic
drugs
· Flutter waves in leads II, III, AVF are typically
(inverted/upright) (with/without) an isoelectric
baseline
· Flutter waves in lead V
1
are typically small
(positive/negative) deIlections (with/without) a
distinct isoelectric baseline
· QRS complex may be normal or aberrant
(true/Ialse)
· AV conduction ratio, i.e., ratio oI Ilutter waves to
QRS complexes, is usually (Iixed/variable)
Conduction ratios oI 1:1 and 3:1 are
(common/uncommon)
In untreated patients, AV block
suggests the coexistence oI AV conduction
disease
regular
240-340
decrease
inverted,without
positive, with
true
Iixed
uncommon
4:1
AV block, 2:1
· Regular sinus or rhythm
· 2 waves Ior every QRS complex
· Can be Mobitz type I or type II 2° AV block
(true/Ialse)
ectopic atrial
P
true
· Progressive prolongation oI the interval and
shortening oI the interval until a P wave is
blocked
· RR interval containing the nonconducted P wave
is (less than/equal to/greater than) the sum oI two
PP intervals
· Results in beating due to the presence oI
nonconducted P waves
PR
RR
less than
group
- («:·/ k:.::« 1; - - («:·/ k:.::« 1; - - («:·/ k:.::« 1; - - («:·/ k:.::« 1; -
Left anterior fascicular block
· axis deviation with a mean QRS axis
between and degrees
· (qR/rS) complex in leads I and aVL
· (qR/rS) complex in lead III
· Normal or slightly prolonged QRS duration
(true/Ialse)
· No other cause Ior leIt axis deviation should be
present (true/Ialse)
· Poor R wave progression is
(common/uncommon)
leIt
-45, -90
qR
rS
true
true
common
—105—
—POPOU¡Z—
RhythmRecognItIon:HR<100;ReguIarRRIntervaI
Instructions:DeterminethecardiacrhythmIoreachoItheIollowingECGs.
ECG Diagnosis
Answer:Sinusbradycardia.Description:Regularsinusrhythm(normalP
waveaxisandmorphology)atarate·60perminute.Causesincludehigh
vagaltone,myocardialinIarction(usuallyinIerior),drugs(beta-blockers,
digitalis,amiodarone,verapamil,others),hypothyroidism,hypothermia,
obstructivejaundice,hyperkalemia,increasedintracranialpressure,andsick
sinussyndrome.Note:IItheatrialrateis·40perminute,consider2:1
sinoatrialexitblock.
Answer:Sinuspause/arrestwithjunctionalescapecomplexes.Description:
PPinterval(pause)~1.6-2.0seconds,duetotransientIailureoIimpulse
Iormationatthesinoatrialnode.CausesincludesinusnodedysIunction,
organicheartdisease,drugs,hyperkalemia,vagalstimulation,andMI.
CannotbediIIerentiatedIromcompleteIailureoIsinoatrialconduction(3°
sinoatrialexitblock)onsurIaceECG.
Answer:Ectopicatrialrhythm.Description:Ectopic(nonsinus)Pwaveata
rate·100perminute.Pwavescanbeupright(whentheectopicatrialIocus
originatesnearthesinusnode)orinverted(whentheectopicIocusoriginates
intheloweratrium).PRintervalcanbeprolonged,normalorshort,
dependingontheproximityoItheectopicatrialimpulsetotheAVnodeand
whetherdelayispresentintheAVconductionsystem.QRSandQTinterval
canbenormalorprolonged.Note:InvertedPwavesinII,III,andaVF
suggesteitheralowatrialrhythmoranAVjunctionalrhythmwithretrograde
atrialactivation.Todistinguishbetweenthesemechanisms,measurethePR
interval:PRinterval~0.11secondssuggestsalowatrialrhythm;PRinterval
0.11secondssuggestsanAVjunctionalrhythm.
106
ECG 15. 66-year-old female with chest pain:
107
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
108
ECG 15 was obtained in a 66-year-old Iemale with chest pain. The ECG shows sinus rhythm, Iirst-degree AV block, and leIt posterior
Iascicular block. The most striking Ieatures on this tracing include marked peaking oI the T waves (arrows) and a myocardial injury pattern in
leads V
1
-V
3
and aVL (asterisks). Since a pathological Q wave is present in lead aVL only, acute myocardial inIarction should not be coded.
This woman was shown to have an occluded leIt anterior descending (LAD) coronary artery and a potassium level oI 8.0 mg/dL.
Codes: 07 Sinus rhythm
29 AV block, 1°
46 LeIt posterior Iascicular block
49 NonspeciIic intraventricular conduction disturbance
65 ST and/or T wave abnormalities suggesting myocardial injury
66 ST and/or T wave abnormalities suggesting electrolyte disturbances
74 Hyperkalemia
*
*
*
*
109
Ouestions: ECG 15
1. Peaked T waves can occur with:
a. Intracranial bleeding
b. Acute myocardial inIarction
c. LeIt ventricular hypertrophy (LVH)
d. Normal variant early repolarization abnormality
e. Hyperkalemia
I. LeIt bundle branch block (LBBB)
2. Hyperkalemia can cause all oI the Iollowing ECG changes
except:
a. QRS widening
b. PR prolongation
c. Prominent U waves
d. LeIt anterior Iascicular block
Answers: ECG 15
1. Peaked T waves can be seen in hyperkalemia, acute myocardial
inIarction, intracranial bleeding, and normal variant early
repolarization abnormality. Other causes oI peaked T waves
include marked LVH (usually in right precordial leads) and
LBBB. (Answer: all)
2. Hyperkalemia can cause PR prolongation, QRS widening,
peaked T waves, and leIt anterior Iascicular block.
Hypokalemia, not hyperkalemia, is associated with prominent U
waves. (Answer: c)
- («:·/ k:.::« 1, - - («:·/ k:.::« 1, - - («:·/ k:.::« 1, - - («:·/ k:.::« 1, -
Peaked T waves
· T wave ~ mm in the limb leads or ~
mm in the precordial leads
6, 10
Hyperkalemia
· K
+
¬ 5.5 - ô.5 mEq/L
Tall, peaked, narrow based waves
QT interval (shortening/lengthening)
(Reversible/irreversible) leIt anterior or
posterior Iascicular block
· K
+
¬ ô.5 - 7.5 mEq/L
degree AV block
Flattening and widening oI the wave
ST segment (depression/elevation)
widening
· K
+
> 7.5 mEq/L
Disappearance oI waves
LBBB, RBBB, or markedly widened and diIIuse
intraventricular conduction delay resembling a
wave pattern
Arrhythmias and conduction disturbances
including VT, VF, idioventricular rhythm,
asystole (true/Ialse)
T
shortening
Reversible
First
P
depression
QRS
P
sine
true
110
- POP OU¡Z -
Make The DIagnosIs
,QVWUXFWLRQV Determine the clinical disorder that best corresponds to the
ECG Ieatures listed below (see items 70-89 on answer sheet Ior options).
(&*)HDWXUHV 'LDJQRVLV
· QT interval shortening
· May see PR prolongation
· No eIIect on P, QRS, and T wave
Hypercalcemia
· Earliest and most common Iinding is prolonged QT
interval Irom ST segment lengthening
· Occasional Ilattening, peaking, or inversion oI T waves
Hypocalcemia
· Tall, peaked, narrow based T waves
· QT interval shortening
· Reversible leIt anterior or posterior Iascicular block
· QRS widening
· Disappearance oI P waves
Hyperkalemia
· Prominent U waves
· ST segment depression
· Flattened T waves
· Prolonged QT interval
· Arrhythmias and conduction disturbances, including
paroxysmal atrial tachycardia with block, Iirst-degree AV
block, Type I second-degree AV block, AV dissociation,
VPCs, ventricular tachycardia, and ventricular Iibrillation
Hypokalemia
· Typical RSR or rSR complex in lead V
1
with a QRS
duration · 0.11 seconds
· Incomplete RBBB
· Right axis deviation + right ventricular hypertrophy
· Right atrial abnormality in 30°
· First-degree AV block in · 20°
Atrial septal
deIect,
secundum
111
Don't Forgetl
· In RBBB, mean QRS axis is determined by the initial
unblocked 0.06-0.08 seconds oI QRS, and should be
normal unless leIt anterior or leIt posterior Iascicular
block is present
· RBBB does not interIere with the ECG diagnosis oI
ventricular hypertrophy or Q-wave MI
· LAFB may result in a Ialse-positive diagnosis oI LVH
based on voltage criteria using leads I or aVL
· LeIt anterior Iascicular block can mask the presence oI
inIerior wall MI
· LeIt posterior Iascicular block can mask the presence
oI lateral wall MI
· LBBB interIeres with QRS axis and the ECG
diagnoses oI ventricular hypertrophy and acute MI
· Intermittent LBBB is more commonly seen at high
rates (tachycardia-dependent), but may be
bradycardia-dependent as well
· In up to 30° oI cases, P-pulmonale can maniIest as
leIt atrial enlargement on ECG. Suspect this
possibility when leIt atrial abnormality is present in
lead V
1
112
ECG 16. 86-year-old male with palpitations and
shortness of breath:
113
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
114
ECG 16 was obtained Irom an 86-year-old male with palpitations and shortness oI breath. The ECG shows multiIocal atrial tachycardia and
nonspeciIic ST and/or T wave changes. Several diIIerent P wave morphologies are evident in the lead II rhythm strip (arrows).
Codes: 16 Atrial tachycardia, multiIocal
63 NonspeciIic ST and/or T wave abnormalities
115
Ouestions: ECG 16
1. ECG Ieatures oI multiIocal atrial tachycardia include:
a. Variable PR and RR intervals
b. Absence oI one dominant atrial pacemaker
c. Atrial rate ~ 100 per minute
d. P waves oI at least three morphologies
e. Isoelectric baseline between P waves
2. Irregularly irregular rhythms include:
a. Sinus tachycardia with Irequent atrial premature complexes
b. MultiIocal atrial tachycardia
c. Ventricular trigeminy
d. Atrial Iibrillation
e. Atrial Ilutter with 4:1 AV conduction
Answers: ECG 16
1. MultiIocal atrial tachycardia (MAT) is an irregular rhythm with
an atrial rate ~ 100 per minute and at least 3 diIIerent P wave
morphologies (each originating Irom a separate atrial Iocus).
The absence oI one dominant atrial pacemaker distinguishes
MAT Irom sinus tachycardia with Irequent multiIocal atrial
premature complexes, and the presence oI an isoelectric baseline
between P waves distinguishes MAT Irom coarse atrial
Iibrillation. Rhythm irregularity results in variable PR and RP
intervals. MAT does not eIIect or require AV conduction and
can persist during AV block. (Answer: all)
2. Irregularly irregular rhythms include atrial Iibrillation,
multiIocal atrial tachycardia, and sinus tachycardia with Irequent
APCs. Ventricular trigeminy (two normal QRS complexes
Iollowed by a ventricular premature complex in a repeating
pattern) results in a regularly irregular rhythm. Atrial Ilutter
with 4:1 AV conduction presents as a regular rhythm. (Answer:
a, b, d)
116
- («:·/ k:.::« 1( - - («:·/ k:.::« 1( - - («:·/ k:.::« 1( - - («:·/ k:.::« 1( -
Atrial tachycardia, multifocal
· Atrial rate ~ per minute
· P waves with ~ morphologies
· PR, RR and RP intervals (are constant/vary)
· May be conIused with sinus tachycardia with
multiIocal APCs, or atrial Iibrillation/Ilutter with a
rapid ventricular response, but:
Unlike sinus tachycardia with multiIocal APCs,
multiIocal atrial tachycardia (does/does not)
maniIest a dominant P wave morphology
Unlike atrial Iibrillation/Ilutter, multiIocal atrial
tachycardia has a distinct baseline
· P waves may be blocked or conducted with a
narrow or aberrant QRS complex (true/Ialse)
100
3
vary
does not
isoelectric
true
Nonspecific 8T and/or T wave
abnormalities
· Slight segment depression or elevation
· Slightly inverted or Ilat wave
ST
T
117
Differential Diagnosis
NON8PEC¡F¡C 8T AND/OR T WAVE ABNORMAL¡T¡E8
Slight (· 1mm) ST depression or elevation
and/or Ilat or slightly inverted T waves
· Organic heart disease
· Drugs (e.g., quinidine)
· Electrolyte disorders (e.g., hypokalemia)
· Hyperventilation
· Hypothyroidism
· Stress
· Pancreatitis
· Pericarditis
· CNS disorders
· LVH
· RVH
· Bundle branch block
· Healthy adults (normal variant)
118
ECG 17. 64-year-old female with recurrent syncope:
119
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
120
ECG 17 was obtained in a 64-year-old Iemale with recurrent syncope. The ECG shows sinus arrest (asterisk) with junctional escape complexes
(arrows). Near the end oI the tracing is a normally conducted junctional premature beat (arrowhead), which is Iollowed immediately by output
Irom an AV sequential pacemaker (double asterisk). The pacemaker Iails to sense the premature beat, and Iails to Iire during sinus arrest. Failure
oI the pacemaker to capture the ventricle the Iirst time it Iires occurs because the myocardium has not yet repolarized; item 93, 'pacemaker
malIunction, not constantly capturing,¨ should not be coded. The sinus arrest is suggestive oI sick sinus syndrome.
Codes: 11 Sinus pause or arrest
20 AV junctional premature complexes
21 AV junctional escape complexes
89 Sick sinus syndrome
92 Dual-chamber pacemaker (DDD)
94 Pacemaker malIunction, not constantly sensing (atrium or ventricle)
* *
**
121
Ouestions: ECG 17
1. Abnormal sensing by a ventricular pacemaker is diagnosed
when:
a. A pacemaker stimulus does not result in appropriate capture
b. The ventricular pacemaker Iails to be inhibited by a QRS
complex Ialling in an appropriate range
c. A ventricular premature complex Ialls within the
programmed reIractory period oI the pacemaker
d. A pacemaker stimulus occurs within the QRS complex
Answers: ECG 17
1. Pacemaker sensing malIunction can involve the atrium and/or
ventricle. For a pacemaker in the 'inhibited¨ mode (e.g., VVI),
Iailure to sense maniIests as Iailure oI the pacemaker to be
inhibited by an appropriate intrinsic depolarization, such as a
native QRS. For a pacemaker in the 'triggered¨ mode (e.g.,
DDD), Iailure to sense maniIests as Iailure oI the pacemaker to
trigger appropriately Iollowing a native event, such as a P wave.
Pacemaker spikes Ialling within the QRS complex generally do
not represent sensing malIunction. Failure to sense results in
asynchronous Iiring oI the pacemaker, resulting in a paced
rhythm that competes with the intrinsic rhythm. Causes oI
Iailure to sense include low amplitude signals (especially VPCs),
inappropriate programming oI the sensitivity, and all causes oI
Iailure to capture. Failure to sense can oIten be corrected by
reprogramming the sensitivity oI the pacemaker. (Answer: b)
- («:·/ k:.::« 1I - - («:·/ k:.::« 1I - - («:·/ k:.::« 1I - - («:·/ k:.::« 1I -
8inus pause or arrest
· PP interval ~ seconds
· Resumption oI sinus rhythm at a PP interval that
(is/is not) a multiple oI the basic sinus PP interval
· II sinus rhythm resumes at a multiple oI the basic
PP, consider
1.6-2.0
is not
sinoatrial exit
block
AV sequential pacing
· Atrial Iollowed by pacing ventricular
Pacemaker malfunction, not constantly
sensing {atrium or ventricle}
· Pacemakers in the inhibited mode: Pacemaker Iails
to be by an appropriate intrinsic
depolarization
· Pacemakers in the triggered mode: Pacemaker Iails
to be by an appropriate intrinsic
depolarization
· Premature depolarizations may not be sensed iI
they Iall within the programmed period oI the
pacemaker, RU have insuIIicient at the sensing
electrode site
inhibited
triggered
reIractory
amplitude
— 122 —
CommonDilemmas
inECG¡nterpretation
Problem
Adominantjunctionalorventricularrhythmispresent.Is
itnecessarytocodetheunderlyingatrialrhythmiIoneis
present?
Recommendation
Yes.IIanatrialrhythmispresentinadditiontoa
dominantjunctionalorventricularrhythm,theatrial
rhythm(andAVblock,iIpresent)shouldalsobecoded
(e.g.,ventriculartachycardiaandsinusrhythmwiththird-
degreeAVblock).
123
- POP OU¡Z -
Make The DIagnosIs
,QVWUXFWLRQV Determine the clinical disorder that best corresponds to each group oI ECG
Ieatures listed below (see items 70-89 oI answer sheet Ior options)
(&*)HDWXUHV 'LDJQRVLV
· Right atrial abnormality is common
· Majority have abnormal QRS complexes:
Large amplitude QRS
Large abnormal Q waves (can give pseudoinIarct pattern in
inIerior, lateral, and anterior precordial leads)
Tall R wave with inverted T wave in V
1
simulating RVH
NonspeciIic ST and/or T wave abnormalities common
LeIt axis deviation in 20°
Hypertrophic
cardiomyopathy
· Low voltage QRS
· Electrical alternans and other Ieatures oI acute pericarditis may be
present
Pericardial eIIusion
· Sinus tachycardia and Iindings consistent with right ventricular
pressure overload:
Right atrial abnormality
Inverted T waves in leads V
1
-V
3
Right axis deviation
S
1
Q
3
or S
1
Q
3
T
3
pattern
PseudoinIarct pattern in the inIerior leads
Incomplete or complete RBBB
Supraventricular tachyarrhythmias are common
· ECG abnormalities are oIten transient
Acute cor pulmonale,
incl. pulmonary
embolus
124
ECG 18. 59-year-old male with shortness of breath:
125
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—126—
ECG18wasobtainedIroma59-year-oldmalewithshortnessoIbreath.TheECGshowssinusrhythmatarateoI66beats/minute.Anumber
oIspikesappearthroughoutthetracing,raisingthepossibilityoIpacemakermalIunctionwithIailuretosenseandcapture.However,thereis
noconsistentpatterntothespikes,andthemultiplespikesthatoccuraIterthe5thQRScomplex(arrows)arenotconsistentwithanystandard
pacemaker/ICDpattern.Inaddition,therearecoarse,almostIibrillatory-likeoscillationsinleadsV
1
-V
3
(asterisks),correspondingtoanatrial
rateinexcessoI800beats/minute,muchtooIastIoratrialIibrillationorIlutter.Themultiplespikesandcoarse,irregularoscillationsrepresent
baselineartiIact(thepatientdidnothaveapacemakeroranyotherimplanteddevice).OtherECGabnormalitiesincludeSTandTwavechanges
inleadsV
4
-V
5
concerningIormyocardialischemiaandalongQTinterval.
Codes: 04 ArtiIact
07 Sinusrhythm
64 STand/orTwaveabnormalitiessuggestingmyocardialischemia
68 ProlongedQTinterval
127
Ouestions: ECG 18
1. Baseline artiIact should be suspected when:
a. There is a regular rhythm in which some leads suggest a
very rapid variant oI atrial Iibrillation other leads clearly
show sinus rhythm
b. There are pacemaker-like spikes with behavior that is not
consistent with normal (or even abnormal) pacemaker
Iunction
c. There are runs oI wide-complex tachycardia superimposed
on a background oI narrow complex beats that appear to
regularly march through the tracing (Irom beIore, until aIter the
wide complex beats)
2. ECG baseline artiIact can mimic:
a. Premature ventricular complexes
b. Ventricular tachycardia
c. Ventricular Iibrillation
d. Atrial Ilutter
e. Atrial Iibrillation
Answers: ECG 18
1. Each situation described above represents an example in which
baseline artiIact can resemble abnormal heart rhythms. (Answer:
all)
2. Baseline artiIact can mimic any oI the arrhythmias above.
Causes oI baseline artiIact include AC electrical interIerence (60
cycles per second), tremor (Parkinson`s or physiologic), rapid
arm motion, skeletal muscle Iasciculations (e.g., shivering),
electrocautery, and IV inIusion pump. (Answer: all)
- («:·/ k:.::« 12 - - («:·/ k:.::« 12 - - («:·/ k:.::« 12 - - («:·/ k:.::« 12 -
8T and/or T wave abnormalities
suggesting myocardial ischemia
· Abnormally tall, symmetrical, (upright/inverted) T
waves
· Horizontal or ST segments with or without T
wave inversion
· Associated ECG Iindings:
QT interval is usually (normal/prolonged)
Reciprocal wave changes may be evident
Prominent U waves are oIten present and may
be upright or inverted (true/Ialse)
inverted
downsloping
prolonged
T
true
Prolonged OT interval
· Corrected QT interval (QTc) seconds,
where QTc ÷ QT interval divided by the square
root oI the preceding interval
· QT interval varies (directly/inversely) with heart rate
· The normal QT interval should be (less
than/greater than) 50° oI the RR interval when
0.42-0.46
RR
inversely
less than
the ventricular rate is between 65-90.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 128 —
A.
B.
C.
D.
Answer: Tracings A, B, and D show multifocal atrial tachycardia manifest as a narrow complex tachycardia preceded by P waves ex-
hibiting 3 or more different morphologies. Tracing C shows atrial fbrillation with a rapid ventricular response and is the imposter.
129
- POP OU¡Z -
)LQG7KH0LVWDNH
,QVWUXFWLRQV IdentiIy the incorrect ECG Ieature(s) Ior each oI the ECG
diagnoses listed below.
(&*)HDWXUHV 0LVWDNH
Wolff-Parkinson-White pattern
· Non-sinus P wave
· PR interval · 0.12 seconds
· Initial slurring oI QRS ( delta wave) resulting in QRS
duration ~ 0.10 seconds
· Secondary ST-T wave changes
· PJ interval (beginning oI P wave to end oI QRS) varies
Sinus P wave is
present, and PJ
interval is constant
(not variable)
2
o
AV block, Mobitz Type ¡ {Wenkebach}
· Progressive prolongation oI the PR and RR intervals
until a P wave is blocked
· RR interval containing the nonconducted P wave is less
than the sum oI two PP intervals
· Results in group beating due to the presence oI
nonconducted P waves
Progressive
shortening (not
prolongation) oI the
RR interval occurs
until a P wave is
blocked
2
o
AV block, Mobitz Type ¡¡
· Regular sinus or atrial rhythm with intermittent
nonconducted P waves without evidence Ior atrial
prematurity
· PR interval in the conducted beats is constant
· RR interval containing the nonconducted P wave is less
than or equal to the sum oI two PP intervals
RR interval
containing
nonconducted P
wave is equal to
(not ) two PP
intervals
130
ECG 19. 24-year-old asymptomatic female {rhythm
strip}:
V1
V5
II
—131—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutivecomplexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIic intraventricular conduction disturbance
G 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. Pacemaker malIunction, not constantly capturing
(atriumorventricle)
G 94. Pacemaker malIunction, not constantly sensing
(atriumorventricle)
132
ECG 19 is a rhythm strip obtained Irom an asymptomatic 24-year-old Iemale. The ECG shows atrial and ventricular rhythms that are
independent oI each other (the sinus rate is 99 beats/minute and the ventricular rate is 60 beats/minute). The narrow QRS complexes at a rate
oI 60 beats/minute suggest a junctional escape rhythm in the setting oI complete heart block. LeIt atrial enlargement (large inverted P wave in
V
1
) is also present. Because this tracing is a rhythm strip only, a Iull analysis Ior QRS axis, presence oI MI, etc., is not possible. This woman
was diagnosed with congenital complete heart block. In contrast to complete heart block Irom ischemia or cardiomyopathy, which typically
occurs within the His-Purinje system and results in a wide QRS complex (ventricular escape) rhythm, congenital complete heart block usually
occurs at the level oI the AV node and results in a narrow QRS complex (junctional escape) rhythm.
Codes: 06 LeIt atrial abnormality/enlargement
07 Sinus rhythm
21 Junctional escape complexes
33 AV block, 3o
V1
V5
II
133
Ouestions: ECG 19
1. Which statement best describes the PP and RR intervals in
complete heart block:
a. Constant PP and RR intervals
b. Variable PP and RR intervals
c. Constant PP and variable RR intervals
d. Variable PP and constant RR intervals
2. The typical heart rate oI a ventricular escape rhythm is
beats/minute:
a. 10-20
b. 20-30
c. 30-40
d. 40-50
3. In an AV junctional escape rhythm, which oI the Iollowing
statements about the P wave are true:
a. P wave can be buried in the QRS
b. P wave can precede the QRS
c. P wave can Iollow the QRS
Answers: ECG 19
1. Although the P waves and QRS complexes are independent oI
each other in complete heart block, PP and RR intervals are
Iairly constant (and the atrial rate is usually Iaster than the
ventricular rate). The heart rate in complete heart block is
usually maintained by either a junctional escape rhythm (narrow
QRS complex), as in the current ECG, or a ventricular escape
rhythm (wide QRS complex). (Answer: a)
2. The rate oI a ventricular escape rhythm is typically 30-40
beats/minute, but can vary Irom 20-50 beats/minute. The QRS
duration is prolonged (~ 0.12 sec), and QRS morphology is
similar to that oI ventricular premature contractions. (Answer:
c)
3. The P wave in the junctional escape rhythm tends to be in close
proximity to the QRS complex, and may precede it (PR · 0.11
seconds), be buried in it, or Iollow it. Junctional rhythms usually
display a narrow QRS morphology, similar to a sinus or
supraventricular impulse. Junctional escape rhythms can occur
in the presence oI P waves (high-degree AV block) or in the
absence oI P waves (sinus arrest). The typical rate oI a
junctional rhythm is 40-60 beats/minute. (Answer: all)
134
- («:·/ k:.::« 17 - - («:·/ k:.::« 17 - - («:·/ k:.::« 17 - - («:·/ k:.::« 17 -
AV ]unctional escape complexes
· QRS complex occurs as a phenomenon in
response to decreased sinus impulse Iormation or
conduction, or high-degree AV block
· Rate is typically per minute
· Atrial mechanism may be sinus rhythm,
paroxysmal atrial tachycardia, atrial Ilutter, or
atrial Iibrillation (true/Ialse)
· QRS morphology is (similar to/diIIerent Irom)
the sinus or supraventricular impulse
secondary
40-60
true
similar to
AV block, 3
o
· Atrial and ventricular rhythms are oI each
other
· Atrial rate is (Iaster/slower) than the ventricular
rate
independent
Iaster
135
1 2 3
4 5
6 7
8 9
10
11
12
ACRO88
1. 'Group beating¨ can result Irom this
type oI AV block
5. A type oI AV sequential pacemaker
6. The type oI complex that occurs when
an impulse activates a chamber,
returns to the site oI origin, and
reactivates the same chamber again
10. Associated with Iusion beats and
VPCs with nonIixed coupling
11. The type oI complex that occurs when
an atrial impulse stimulates the
ventricle during VT
12. MultiIocal atrial tachycardia is
associated with varying PR, RP and
¸¸¸¸¸ intervals
W E N C K E B A C H
P A S
W L L D D D
C V
E C H O
P M B T
E I E A
P A R A S Y S T O L E
K I L
E C A P T U R E
D Y R R
DOWN
1. Associated with atrial Iibrillation or Ilutter with a QRS that varies in width
(generally wide) and a ventricular response rate ~ 200 per minute
2. Hypo¸¸¸¸¸ results in a prolonged QT interval due to ST segment prolongation
3. Associated with an RSR` complex in V
1
, leIt or right axis deviation, and a
murmur
4. R wave in aVL ~ 12 mm
7. Can cause leIt axis deviation and low voltage
8. ¸¸¸¸¸ T waves can be caused by hyperkalemia, acute MI, intracranial bleeding
9. In the setting oI a wide QRS tachycardia, the presence oI an R` wave in V
1
that
is ¸¸¸¸¸ than the R wave is suggestive oI SVT with aberrancy
- ECG CRO88WORD PUZZLE -
136
ECG 20. 62-year-old male with history of treated
atrial fibrillation and recent weakness:
137
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—138—
ECG20wasobtainedIroma62-year-oldmalewithahistoryoItreatedatrialIibrillationandrecentweakness.Therhythmisjunctionalwith
occasionalventricularprematurecomplexes(inabigeminalpatternataIixedcouplinginterval)(arrows)andsinuspauses.Thereisalsomarked
prolongationoItheQTinterval(QTcinterval÷660msec).SmallqwavesarepresentintheinIeriorleadsbutdonotmeetcriteriaIormyocardial
inIarction.Giventhepatient’shistoryoItreatedatrialIibrillation(heiscurrentlyonsotalol),theECGisconsistentwithantiarrhythmicdrug
toxicity.
Codes: 11 Sinuspauseorarrest
22 AVjunctionalrhythm/tachycardia
23 Ventricularprematurecomplexes
64 STand/orTwaveabnormalitiessuggestingmyocardialischemia
68 ProlongedQTinterval
73 Antiarrhythmicdrugtoxicity
139
Ouestions: ECG 20
1. Conditions associated with a prolonged QT interval include:
a. Hyperkalemia
b. Hypercalcemia
c. Beta blockers
d. Myocarditis
e. Febrile illness
2. Which oI the Iollowing statements about the QT interval is true:
a. Prolongs as heart rate slows
b. Shortens as heart rate slows
c. Shorter when asleep than awake
d. Shortens in the beat Iollowing a premature ventricular
complex
Answers: ECG 20
1. The QT interval represents the time Ior ventricular
depolarization and repolarization to occur. Causes oI a
prolonged QT interval include low serum magnesium or calcium
levels, myocarditis, mitral valve prolapse, hypothyroidism, and
hypothermia. Shortening oI the QT interval occurs with beta
blockers, digitalis, hyperkalemia, hypercalcemia,
hyperthyroidism, and hypothermia. (Answer: d)
2. The QT interval varies inversely with heart rate, and lengthens
during sleep and in the beat Iollowing a ventricular premature
complex. (Answer: a)
- («:·/ k:.::« z0 - - («:·/ k:.::« z0 - - («:·/ k:.::« z0 - - («:·/ k:.::« z0 -
AV ]unctional rhythm
· Rate per minute
· QRS complex may be narrow or aberrant
(true/Ialse)
· Inverted P waves in leads and upright P
waves in leads are common
· RR interval oI escape rhythm is usually
(constant/variable)
60
true
II, III, aVF
I, aVL
constant
Prolonged OT interval
· Corrected QT interval (QTc) seconds,
where QTc ÷ QT interval divided by the square
root oI the preceding interval
· QT interval varies (directly/inversely) with heart
rate
· The normal QT interval should be (less
than/greater than) 50° oI the RR interval
0.42-0.46
RR
inversely
less than
Antiarrhythmic drug toxicity
· Widening oI the complex and interval
· Various degrees oI block
QRS, QT
AV
—140—
DifferentialDiagnosis
“P8EUDO¡NFARCT8”
(ECGpatterncanmimicQ-wavemyocardialinIarction)
• WolII-Parkinson-Whitepattern
• Hypertrophiccardiomyopathy
• LeItventricularhypertrophy
• Rightventricularhypertrophy
• LeItanteriorIascicularblock
• Chroniclungdisease
• Amyloidheart(orotherinIiltrative
diseases)
• Cardiomyopathy
• ChestdeIormity(e.g.,pectusexcavatum)
• Pulmonaryembolism
• Myocarditis
• Myocardialtumors
• Hyperkalemia
• Leadreversal
• Correctedtransposition
• Dextrocardia
• LeItbundlebranchblock
• Pancreatitis
• Musculardystrophy
• Mitralvalveprolapse
• Myocardialcontusion
• LeIt/rightatrialenlargement:Prominent
atrialrepolarizationwave(Ta)candepress
thePRsegmenttomimicaQwave
• Pneumothorax
—141—
—POPOU¡Z—
PatternRecognItIon:DrugEIIectsandRhythmDIsturbances
Instructions:ChoosealldrugscommonlyassociatedwitheachoItheIollowingrhythmabnormalities.
ECG Choose All That Apply Answer
a. Amiodarone
b. Atropine
c. Aminophylline
d. Digitalis
e. Atorvastatin
I. Ramipril
g. Nitroglycerin
h. Metoprolol
i. Verapamil
Sinus bradycardiaresultsinaregularsinus(uprightPwavesin
leadII)rhythmatarate·60perminute.Commoncauses
includebeta-blockers,amiodarone,verapamil,diltiazem,
digitalis,TypeIantiarrhythmics,clonidine,alpha-methyldopa,
reserpine,guanethidine,cimetidine,andlithium.Low-dose
atropinemayalsocauseaparadoxicalslowingoIheartrate.
(Answer:a,b|lowdose|,d,h,i)
Paroxysmal atrial tachycardia (PAT) with block resultsin
nonsinusPwavesataregularatrialrate(usually150-240per
minute),isoelectricintervalsbetweenPwaves,andsome
nonconductedPwavesdueto2°AVblock.Digoxintoxicityis
responsibleIor75°oIcasesandorganicheartdiseaseIor25°
oIcases.AtropinemayworsenTypeII2°AVblock,butrarely
causesthisarrhythmia.Note:2:1AVblockinthisECGmaybe
eitherMobitzTypeIorTypeII.(Answer:d)
Multifocal atrial tachycardia(MAT)resultsinanirregular
atrialrate~100perminutewithatleastthreediIIerentPwave
morphologies(originatingIromseparateatrialIoci)andvarying
PPandPRintervals.MATisusuallyassociatedwithsome
IormoIlungdisease(COPD,corpulmonade,hypoxia),andcan
beprecipitatedbyaminophylline.(Answer:c)
142
ECG 21. 73-year-old male with chest pain:
143
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULARRHYTHM8 RHYTHM8 RHYTHM8 RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
144
ECG 21 was obtained Irom a 73-year-old-male with chest pain. The ECG shows an atrial paced rhythm at a rate oI 83 beats/minute (arrows
mark atrial pacing spikes; arrowhead marks small atrial depolarization Iollowing pacer spike). About 0.21 seconds aIter each atrial pacemaker
spike is a native QRS complex with RBBB morphology. LeIt anterior Iascicular block is present (QRS axis ÷ - 50°), and is responsible Ior the
small R waves in leads II, III and aVF. The ST segment elevation and upright T waves in leads V
1
-V
4
are consistent with acute myocardial
injury.
Codes: 43 RBBB, complete
45 LeIt anterior Iascicular block
65 ST and/or T wave abnormalities suggesting myocardial injury
90 Atrial or coronary sinus pacing
145
Ouestions: ECG 21
1. The presence oI atrial pacemaker spikes on a 12-lead ECG
without ventricular pacemaker activity rules out dual chamber
(DDD) pacing:
a. True
b. False
2. The most common cause oI ST segment elevation on the resting
ECG is:
a. LeIt ventricular hypertrophy
b. Ventricular aneurysm
c. Pericarditis
d. Normal variant early repolarization
e. Acute myocardial inIarction
3. ST segment elevation up to mm in leads V
2
-V
4
can be
considered part oI the normal variant early repolarization
pattern:
a. 1 mm
b. 2 mm
c. 3 mm
d. 4 mm
4. What ratio oI ST elevation to T wave amplitude in lead V
6
is
most helpIul in distinguishing pericarditis Irom normal variant
early repolarization:
a. 15°
b. 25°
c. 50°
d. 75°
Answers: ECG 21
1. In a person with a dual chamber (DDD) pacemaker, atrial
pacemaker activity depends on native heart rate, and occurs
whenever the native (intrinsic) heart rate Ialls below the
programmed lower rate oI the pacemaker. Ventricular
pacemaker activity, on the other hand, depends on native AV
conduction: II native AV conduction exceeds the programmed
AV delay, atrial pacing spikes are Iollowed by ventricular
pacemaker activity. II native AV conduction is shorter than the
programmed AV delay, ventricular pacemaker output is
inhibited, resulting in atrial spikes Iollowed by native QRS
complexes. For examination purposes, atrial spikes without
ventricular pacemaker activity should be coded Ior atrial
pacing, not dual chamber pacing. (Answer: b).
2. Normal variant early repolarization maniIests as concave
upward ST segment elevation leading into a symmetrical,
upright T wave, which may be relatively large in amplitude.
146
Some degree oI early repolarization ST elevation is present in
most oI young, healthy individuals. (Answer: d)
3. Concave upward ST segment elevation up to 1 mm in the limb
leads and 3 mm in the mid-precordial leads (V
2
-V
4
) can be seen
in normal individuals. However, since ST elevation may be
caused by myocardial injury or inIarction, acute pericarditis, or
ventricular aneurysm, it is important to consider the clinical
context and associated ECG Iindings (e.g., abnormal Q waves,
reciprocal ST segment depression) beIore interpreting ST
elevation as 'normal.¨ (Answer: c)
4. Both acute pericarditis and early repolarization maniIest diIIuse,
concave upward ST segment elevation. The ratio oI ST
elevation to T wave amplitude in lead V
6
helps distinguish
between these conditions: ST elevation is usually ~25° oI T
wave amplitude in pericarditis, and ·25° oI T wave amplitude
in early repolarization. (Answer: b)
- («:·/ k:.::« z1 - - («:·/ k:.::« z1 - - («:·/ k:.::« z1 - - («:·/ k:.::« z1 -
RBBB, complete
· QRS duration ~ seconds
· Secondary R wave (R) in lead is usually
(shorter/taller) than the initial R wave
· Onset oI intrinsicoid deIlection in leads V
1
and V
2
~ seconds
· ST segment and T wave
in V
1,
V
2
· Wide slurred S wave in leads
· QRS axis is usually
(normal/leItward/rightward)
· RBBB (does/does not) interIere with the ECG
diagnosis oI ventricular hypertrophy or Q
wave MI
0.12
V
1
taller
0.05
depression
inversion
I, V
5
, V
6
normal
does not
Left anterior fascicular block
· axis deviation with a mean QRS axis
between and degrees
· (qR/rS) complex in leads I and aVL
· (qR/rS) complex in lead III
· Normal or slightly prolonged QRS duration
(true/Ialse)
· No other cause Ior leIt axis deviation should
be present (true/Ialse)
· Poor R wave progression is
(common/uncommon)
leIt
45, 90
qR
rS
true
true
common
147
Don't Forgetl
· Classic evolutionary ECG pattern oI acute pericarditis
consists oI 4 stages (but is not always present):
Stage 1: Upwardly concave ST segment elevation in
almost all leads except aVR; no reciprocal
ST depression in other leads except aVR
Stage 2: ST junction (J point) returns to baseline and
T wave amplitude begins to decrease
Stage 3: T waves invert
Stage 4: ECG returns to normal
· Digitalis toxicity can cause almost any type oI cardiac
dysrhythmia or conduction disturbance except bundle
branch block.
· ECG Iindings in CNS disease can mimic those oI:
Acute MI
Acute pericarditis
Drug eIIect or toxicity
148
ECG 22. 80-year-old female with chronic renal failure:
149
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
150
ECG 22 was obtained in 80-year-old Iemale with chronic renal Iailure. The ECG shows sinus rhythm with Iirst-degree AV block, nonspeciIic
ST-T wave abnormalities, and QT interval prolongation (corrected QT interval measures 0.50 seconds). The long QT interval is primarily due
to prolongation oI the ST segment (rather than the T wave), which is characteristic oI hypocalcemia. This patient was shown to have a serum
calcium level oI 6.8 mg/dL.
Codes: 07 Sinus rhythm
29 AV block, 1°
63 NonspeciIic ST and/or T wave abnormalities
68 Prolonged QT interval
77 Hypocalcemia
151
Ouestions: ECG 22
1. Electrolyte abnormalities associated with a prolonged QT
interval include:
a. Hypocalcemia
b. Hyperkalemia
c. Hypokalemia
d. Hypercalcemia
e. Hypomagnesemia
I. Hypermagnesemia
2. ECG abnormalities associated with hypocalcemia include all oI
the Iollowing except:
a. QT prolongation due to ST segment prolongation
b. Normal T wave duration
c. Flattened, peaked, or inverted T waves
d. Notching oI the terminal QRS (Osborne wave)
Answers: ECG 22
1. When it comes to electrolyte disorders associated with a
prolonged QT interval, think 'hypo¨: hypokalemia,
hypocalcemia, hypomagnesemia. (Answer: a, c, e)

2. Hypocalcemia prolongs the QT interval in a very characteristic
way by prolonging the ST segment, but not the T wave. The
T wave can be mildly Ilattened, peaked, or inverted, but has a
normal duration. Abnormal notching oI the terminal QRS
complex (Osborne wave) occurs in hypothermia, not
hypocalcemia. (Answer: d)
- («:·/ k:.::« zz - - («:·/ k:.::« zz - - («:·/ k:.::« zz - - («:·/ k:.::« zz -
Prolonged OT interval
· Corrected QT interval (QTc) ~ seconds,
where QTc ÷ QT interval divided by the square
root oI the preceding interval
· QT interval varies (directly/inversely) with heart
rate
· The normal QT interval should be (less
than/greater than) 50° oI the RR interval
0.44
RR
inversely
less than
Hypocalcemia
· Earliest and most common Iinding is prolonged
interval
· Occasional Ilattening, peaking, or inversion oI
waves
QT
T
152
ECG 23. 76-year-old asymptomatic female:
153
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
154
ECG 23 was obtained in a 76-year-old asymptomatic Iemale. During the Iirst halI oI the ECG, sinus rhythm with Iirst-degree AV block and
a nonspeciIic intraventricular conduction disturbance (QRS in sinus rhythm ÷ 0.11 seconds) are present. This is overridden by an accelerated
idioventricular rhythm (arrows), resulting in isorhythmic AV dissociation and Iusion complexes (QRS with asterisk is intermediate in
morphology between the QRS complexes labeled 1 and 2).
Codes: 07 Sinus rhythm
26 Accelerated idioventricular rhythm
29 AV block, 1°
35 AV dissociation
49 NonspeciIic intraventricular conduction disturbance
*
② ①
155
Ouestions: ECG 23
1. AV dissociation is characterized by an atrial rate that is
usually¸¸¸ the ventricular rate:
a. Faster than
b. Slower than
c. Equal to
2. By deIinition, the rate oI an accelerated idioventricular rhythm
is:
a. · 30 bpm
b. 60-110 bpm
c. 40-60 bpm
d. 30-50 bpm
Answers: ECG 23
1. AV dissociation occurs when the atrial and ventricular activities
are independent oI each other, and the atrial rate is slower than
the ventricular rate. This generally occurs in the setting oI
extreme sinus bradycardia or normal sinus rhythm with a Iaster
(escape or accelerated) junctional or idioventricular rhythm.
(Answer: b)
2. Accelerated idioventricular rhythm is a regular rhythm with
wide QRS complexes occurring at a rate oI 60-110 BPM. AV
dissociation, capture complexes, and Iusion beats are common
during AIVR because oI the competition between normal sinus
and ectopic ventricular rhythms. AIVR does not have the same
adverse impact on prognosis that ventricular tachycardia does.
(Answer: b)
- («:·/ k:.::« z; - - («:·/ k:.::« z; - - («:·/ k:.::« z; - - («:·/ k:.::« z; -
Accelerated idioventricular rhythm
· Highly irregular ventricular rhythm (true/Ialse)
· Ventricular rate oI per minute
· QRS morphology is similar to
· Ventricular complexes, beats, and
AV are common
Ialse
60-110
VPCs
capture, Iusion
dissociation
AV dissociation
· Atrial and ventricular rhythms are oI each
other
· Ventricular rate is (·/~) than the atrial rate
independent
~
156
- POP OU¡Z -
Rhythm RecognItIon: HR > 100; Narrow QRS; ReguIar RR IntervaI
,QVWUXFWLRQV Determine the cardiac rhythm Ior each oI the Iollowing ECGs.
(&* 'LDJQRVLV
Answer: AV node reentrant tachycardia (AVNRT). Description: Narrow complex
SVT usually at a rate oI 150-250 per minute. There is typically a P wave buried in or
immediately Iollowing the QRS with a short RP interval (· 0.09 seconds), and an rSr`
complex in lead V
1
that is not present during sinus rhythm. Reentry within the AV
node occurs as a consequence oI antegrade conduction down the slow () AV nodal
pathway and retrograde conduction up the Iast () AV nodal pathway. AVNRT is
oIten initiated by an APC, and Irequently slows or abruptly terminates in response to
carotid sinus massage. AVNRT accounts Ior 60-70° oI SVTs.
Answer: Sinus tachycardia. Description: Regular sinus rhythm at a rate ~ 100 per
minute. Causes include physiologic response to stress, anemia, Iever, drugs (e.g.,
caIIeine, ephedrine, alcohol, nicotine), thyrotoxicosis, myocardial ischemia/inIarction,
heart Iailure, myocarditis, hypoxemia, pulmonary embolism, pheochromocytoma, and
AV Iistula. Cannot be distinguished Irom sinus node reentrant tachycardia (which has
sudden onset and termination) based on surIace ECG alone.
Answer: Atrial Ilutter. Description: Rapid, regular atrial undulations (Ilutter or 'F¨
waves) usually at a rate oI 240-340 per minute. Flutter waves are typically inverted in
leads II, III and aVF, and maniIest small positive upright deIlections in V
1
; 'atypical
Ilutter¨ can show upright F waves in the inIerior leads. QRS complexes may be
narrow or wide (iI underlying aberrancy or bundle branch block). AV conduction ratio
(ratio oI Ilutter waves to QRS complexes) is usually a Iixed, even number (e.g., 2:1,
4:1), but variable conduction sometimes occurs (e.g., 2:1 and 4:1 in the same tracing).
Atrial Ilutter with 1:1 AV conduction oIten conducts aberrantly and may be conIused
with VT. In untreated patients, block ~ 4:1 suggest coexistent AV conduction disease.
Flutter waves sometime deIorm the QRS, ST, T waves to mimic intraventricular
conduction delay or myocardial ischemia/injury.
157
- POP OU¡Z -
DIIIerentIaI DIagnosIs: P-wave
,QVWUXFWLRQV Match the P wave characteristic with all ECG diagnoses that apply.
3:DYH&KDUDFWHULVWLF &KRRVH$OO7KDW$SSO\ $QVZHU
1. Inverted P-QRS-T in lead I; normal
precordial R wave progression
a. Ectopic atrial rhythm
b. Ventricular rhythm with retrograde
atrial activation
c. Dextrocardia
d. Reversal oI right and leIt arm
leads
e. Right atrial abnormality
I. LeIt atrial abnormality
g. Atrial Ilutter
h. Physiologic tremor
i. MultiIocal atrial tachycardia
j. Sinoventricular conduction 2° to
hyperkalemia
k. Junctional escape rhythm
1. Reversal oI right and leIt arm leads. Other Iindings include
transposition oI leads II and III, and leads aVR and aVL. (Answer: d)
2. Inverted P-QRS-T in lead I; reverse
precordial R wave progression
2. Dextrocardia. Normal precordial R wave progression suggests limb
lead reversal. (Answer: c)
3. Tall peaked P wave in lead II 3. Right atrial abnormality. (Answer: e)
4. BiIid P wave in lead II with peak-to-
peak interval ~ 0.03 seconds
4. LeIt atrial abnormality. BiIid P wave in lead II with peak-to-peak
interval · 0.03 seconds is a normal variant. (Answer: I)
5. Sawtooth regular P waves at a rate oI
300 per minute
5. Atrial Ilutter. Physiologic tremor occurs at a rate oI 5-7 cycles/sec (~
500 per minute). Parkinson`s tremor occurs at a rate oI 4-6 cycles/sec
(~ 300 per minute). IV inIusion pump changes can also mimic P
waves. (Answer: g)
6. Multiple P wave morphologies 6. Multiple P wave morphologies can be seen in multiIocal atrial
tachycardia or sinus/atrial rhythm with multiple APCs.
(Answer: i)
7. Tall upright P wave in V
1
7. Right atrial abnormality. (Answer: e)
8. Deeply inverted P wave in V
1
only 8. LeIt atrial abnormality. (Answer: I)
9. P waves present but hidden 9. Causes include ectopic atrial rhythm or APCs (P wave hidden in
preceding T wave), junctional rhythm or SVT (P wave buried in
QRS), or supraventricular rhythm with marked Iirst-degree AV block
(P wave hidden in preceding T wave). (Answer: a, k)
10. P waves absent 10. Causes include marked sinoatrial exit block, sinus arrest with
junctional or ventricular rhythm (escape or accelerated), or
sinoventricular conduction 2° to hyperkalemia. Atrial Ilutter presents
with 'F¨ waves, not P waves. (Answer: g, j)
158
ECG 24. 72-year-old asymptomatic male with
previous myocardial infarction:
159
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
160
ECG 24 was obtained in a 72-year-old asymptomatic male with a history oI myocardial inIarction. The ECG shows sinus bradycardia at 54
beats/minute. The abnormal Q waves in leads II, III, and aVF (arrows) and prominent R waves in leads V
1
and V
2
(arrowheads) are consistent
with prior inIeroposterior myocardial inIarction. NonspeciIic ST and T wave changes are present in the inIerior leads.
Codes: 09 Sinus bradycardia (· 60)
58 InIerior Q wave MI (age indeterminate or old)
60 Posterior MI (age indeterminate or old)
63 NonspeciIic ST and/or T wave abnormalities
161
Ouestions: ECG 24
1. Conditions that interIere with the diagnosis oI posterior
myocardial inIarction on ECG include:
a. InIerior MI
b. Right ventricular hypertrophy
c. WolII-Parkinson-White syndrome
d. Right bundle branch block
2. The ECG equivalent oI a pathological Q wave in posterior
myocardial inIarction is:
a. Deep S wave in V
1
-V
2
b. ST depression in V
1
-V
2
c. Tall R wave in V
1
-V
2
Answers: ECG 24
1. Posterior myocardial inIarction is diagnosed on ECG in part by
the presence oI R wave amplitude exceeding S wave amplitude
in leads V
1
and V
2
. This diagnosis is diIIicult to make in the
setting oI RVH, WPW, and RBBB, since these conditions also
maniIest a dominant R wave in the right precordial leads.
Posterior MI typically occurs in the setting oI inIerior MI, and
is oIten accompanied by pathological Q waves in leads II, III,
and aVF. (Answer: b, c, d)
2. The posterior wall oI the leIt ventricular diIIers Irom the
anterior, inIerior, and lateral walls by not having ECG leads
directly overlying it. Instead oI Q waves and ST elevation, acute
posterior MI presents with mirror-image changes in the anterior
precordial leads (V
1
-V
2
), including dominant R waves (the
mirror-image oI abnormal Q waves) and horizontal ST segment
depression (the mirror-image oI ST elevation). This can be
appreciated by turning the ECG over and looking at leads V
1
-V
2
Irom behind, which will demonstrate the classic appearance oI
Q waves and ST elevation. (Answer: c)
- («:·/ k:.::« z; - - («:·/ k:.::« z; - - («:·/ k:.::« z; - - («:·/ k:.::« z; -
¡nferior M¡, age indeterminate or
probably old
· Abnormal Q waves (with/without) ST elevation in
at least two oI leads
without
II, III, aVF
Posterior M¡, age indeterminate or
probably old
· Initial R wave ~ seconds in leads

and

with:
R wave amplitude (greater than/less than) S
wave amplitude
0.04, V
1
- V
2
greater than
162
ECG 25. 68-year-old male with palpitations:
163
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—164—
ECG25wasobtainedina68-year-oldmalewithpalpitations.TheECGshowssinustachycardiaatarateoI125beats/minute,withatallP
wave(~2.5mm)inleadIIconsistentwithrightatrialenlargement.AIterthe18
th
QRScomplexthereisaPwavethatIailstoconducttothe
ventricle(arrow).BycomparingthePRintervalbeIore(b)andaIter(a)thenonconductedPwave,itisevidentthatPRprolongationhasoccurred
prior to the nonconducted P wave Iollowed by shortening oI the PR interval. This is consistent with second-degree AV block, Mobitz I
(Wenckebach)withanextremelylongWenckebachcycle.WiththeresumptionoIconductionIollowingthenonconductedPwave,thePR
intervalisprolonged,consistentwithIirst-degreeAVblock.
Codes: 05 Rightatrialabnormality/enlargement
10 Sinustachycardia(~100)
29 AVblock,1o
30 AVblock,2°-MobitztypeI(Wenckebach)
b a
165
Ouestions: ECG 25
1. In Mobitz Type I second-degree AV block, classic Wenkebach
periodically is always evident on ECG:
a. True
b. False
2. In Mobitz Type I second-degree AV block with inIrequent
pauses, the PR interval oI the beats immediately preceding the
blocked P wave may not demonstrate progressive prolongation:
a. True
b. False
Answers: ECG 25
1. In Mobitz Type I second-degree AV block, classical
Wenckebach periodicity progressive prolongation oI the PR
interval and progressive shortening oI the RR interval until a P
wave is blocked may not always be evident, especially when
sinus arrhythmia is present or an abrupt change in autonomic
tone occurs. (Answer: b)
2. In Mobitz Type I second-degree AV block with high conduction
ratios (i.e., inIrequent pauses), the PR interval oI the beats
immediately preceding the blocked P wave may be equal to
each other, suggesting Type II block. In these situations, it is
best to compare the PR intervals immediately beIore and aIter
the blocked P wave: diIIerences in the PR intervals suggest
Type I block, whereas a constant PR interval suggests Type II
block. (Answer: a)
- («:·/ k:.::« z, - - («:·/ k:.::« z, - - («:·/ k:.::« z, - - («:·/ k:.::« z, -
AV block, 1°
· PR interval seconds 0.20
AV block, 2° - Mobitz Type ¡
{Wenckebach}
· Progressive prolongation oI the interval and
shortening oI the interval until a P wave is
blocked
· RR interval containing the nonconducted P wave
is (less than/equal to/greater than) the sum oI two
PP intervals
· Results in beating due to the presence oI
nonconducted P waves
PR
RR
less than
group
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 166 —
A.
B.
C.
D.
Answer: Tracings B, C, and D show sinus rhythm with blocked APCs. In these tracings, the premature (and blocked) P waves are
superimposed on the T waves, giving the impression of a sinus pause. Tracing A shows 2° AV block, Mobitz type 1 (Wenckebach), and
is the imposter. In this tracing, there is gradual prolongation of the PR interval leading up to the blocked P wave. The easiest way to
confrm the presence of Wenckebach block is to confrm the presence of a longer PR interval in the beat immediately before the non-
conducted P wave and a shorter PR interval in the beat immediately after the nonconducted P wave.
167
- POP OU¡Z -
DIIIerentIaI DIagnosIs: U-wave
,QVWUXFWLRQV Determine whether the diagnoses below are associated with prominent upright U waves, inverted
U waves, or both.
'LDJQRVLV $QVZHU
Hypokalemia Prominent upright U waves. ST depression and Ilattened T waves are
common.
Bradycardia Prominent upright U waves.
Hypothermia Prominent upright U waves. Osborne (J) waves and prolongation oI PR, QRS,
and QT are common.
LeIt ventricular hypertrophy (LVH) Prominent upright or inverted U waves.
Coronary artery disease Prominent upright or inverted U waves.
Digoxin Prominent upright U waves. Sagging ST depression with upward concavity
and T wave changes (Ilat, inverted, or biphasic) are common. QT shortening
and PR prolongation may occur.
Antiarrhythmic drugs Prominent upright U waves (one oI earliest Iindings). Prolonged QT interval
and nonspeciIic ST and T wave changes are common.
168
ECG 26. 24-year-old male with palpitations and near
syncope:
169
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary
embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
170
ECG 26 was obtained in an 24-year-old male with palpitations and near syncope. The ECG is consistent with atrial Iibrillation with an
irregularly-irregular ventricular response and a ventricular rate varying between 150 and 300 beats/minute. The QRS complex is wide with a
variable degree oI intraventricular conduction delay that does not Iit the typical right bundle branch block or leIt bundle branch block pattern.
The variation in the QRS duration coupled with a wide complex tachycardia are consistent with WPW pattern (ventricular pre-excitation). The
accessory pathway is connecting the leIt atrium and leIt ventricle (indicated by the positive QRS complex in lead V
1
) and is located in the
posterior portion oI the leIt atrium (indicated by the negative QRS complexes in leads II, III, and aVF). The combination oI an irregularly-
irregular rhythm with a rapid, wide QRS complex should always bring to mind atrial Iibrillation with WPW syndrome and rapid conduction
over the accessory AV pathway.
Codes: 19 Atrial Iibrillation
34 WolII-Parkinson-White pattern
—171—
Ouestions:ECG26
1. ThelocationoItheaccessorypathwayinapatientwithWPW
andpositivedeltawaves/QRSpolarityinleadsV
1
andaVFis:
a. LeItlateral c. Rightposterior
b. LeItposterior d. Rightlateral
Answers:ECG26
1. Several algorithms have been published to predict accessory
pathway location by assessing the initial polarity oI the delta
wave and the QRS complex using the 12-lead ECG. Each
algorithm has inaccuracies in individuals demonstrating less
thanmaximalpreexcitationoItheQRScomplex.TheIollowing
tablelistsasimplealgorithmthatallowsidentiIicationoIthe
generalaccessorypathwaylocationinpatientswithWPW.The
IirststepIorlocalizingthepathwayistoidentiIythepolarity
(positive, negative, or isoelectric) oI the delta wave and the
mainportionoItheQRScomplexinECGleadsaVL,aVF,and
V
1
.Thetablebelowisthenusedtodeterminetheapproximate
locationoItheaccessorypathway(Answer:a)
Table. Delta Wave/QRS Polarity and Relationship to
Location of the Accessory Pathway
V
1
aVF aVL
LeItlateral
LeItposterior/septal
Rightposterior/septal
Rightlateral/anterior
¹
¹


¹


¹

¹
¹
¹
—(«:·/k:.::«z(— —(«:·/k:.::«z(— —(«:·/k:.::«z(— —(«:·/k:.::«z(—
Atrialfibrillation
• wavesareabsent
• Atrialactivityistotallyandrepresentedby
Iibrillatory(I)wavesoIvaryingamplitudes,
durationandmorphology
• Atrialactivityisbestseenintheand
leads
• Ventricularrhythmis(regularly/irregularly)
irregular
• toxicitymayresultinregularizationoIthe
RRintervalduetocompleteheartblockwith
junctionaltachycardia
• Ventricularrateisusuallyperminuteinthe
absenceoIdrugs
ThinkiItheventricularrateis~200per
minuteandtheQRSis~0.12seconds
P
irregular
right
precordial,
inIerior
irregularly
Digitalis
100-180
WolII-Parkinson-
White
Wolff-Parkinson-Whitepattern
• (Sinus/nonsinus)Pwave
• PRinterval·seconds
• InitialslurringoIQRS(wave)resultingin
QRSduration~seconds
• SecondaryST-Twavechangesoccur(true/Ialse)
• PJinterval,i.e.,beginningoIPwavetoendoI
QRS,(isconstant/varies)
sinus
0.12
delta
0.10
true
isconstant
172
- POP OU¡Z -
0DNH7KH'LDJQRVLV
,QVWUXFWLRQV Determine the clinical disorder that best corresponds to the ECG
Ieatures listed below (see items 70-89 on score sheet Ior options).
(&*)HDWXUHV 'LDJQRVLV
· Sinus bradycardia
· PR, QRS, and QT prolonged)
· Osborne ('J¨) wave: late upright terminal deIlection oI QRS
complex
· Atrial Iibrillation in 50-60°
Hypothermia
· 'Classic changes¨ usually occur in the precordial leads
Large upright or deeply inverted T waves
Prolonged QT interval (oIten marked)
Prominent U waves
· Other changes:
ST segment changes:
· Can mimic acute pericarditis or acute myocardia
injury
· ST depression may also occur
Abnormal Q waves mimicking MI
Almost any rhythm abnormality including sinus
tachycardia or bradycardia, junctional rhythm, VPCs,
ventricular tachycardia, etc.
CNS disorder
· Low QRS voltage in all leads
· Sinus bradycardia
· T wave Ilattened or inverted
· PR interval may be prolonged
· Frequently associated with pericardial eIIusion
· Electrical alternans may occur
Myxedema
—173—
Don’tForgetl
• WhenaVPCoriginatesonthesamesideasabundlebranch
block,theresultingIusioncomplexcanbenarrow
• ThinkoIparasystolewhenyouseeventricularcomplexeswith
nonIixedcouplingandIusionbeats
• LookIorventricularcapturecomplexesandIusionbeatsas
markersIorVTinthesettingoIawideQRStachycardia
• ClassicalWenckebachperiodicitymaynotalwaysbeevident,
especiallywhensinusarrhythmiaispresentoranabruptchange
inautonomictoneoccurs
• 2:1AVblockcanbeMobitzTypeIorTypeII
• InWPW,thePJinterval(beginningoIPwavetoendoIQRS
complex)isconstantand0.26seconds
• ThinkoIWPWwhenatrialIibrillationorIlutterisassociated
withaQRSthatvariesinwidth(generallywide)andhasarate
~200perminute
174
ECG 27. 39-year-old male with acute shortness of
breath:
175
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—176—
ECG27wasobtainedina39-year-oldmalewithacuteshortnessoIbreath.TheECGshowssinustachycardiaat127beats/minutewithright
axisdeviation(QRSaxis÷104o)andaprominentSwaveinleadIandQwaveinleadIII(theclassicS
1
Q
3
pattern)(arrows).TheseIindings
suggest the diagnosis oI pulmonary embolism. Further clues include the presence oI incomplete RBBB (asterisk) and ischemic looking
repolarizationabnormalitiesinV
I
-V
3
.
Codes: 10 Sinustachycardia
37 Rightaxisdeviation
44 RBBB,incomplete
63 NonspeciIicSTand/orTwaveabnormalities
82 Acutecorpulmonale,includingpulmonaryembolism
177
Ouestions: ECG 27
1. Pulmonary embolism can mimic acute myocardial inIarction
based on clinical presentation and ECG appearance:
a. True
b. False
2. The most common ECG Iinding in acute pulmonary embolism
is:
a. Sinus tachycardia
b. RBBB
c. Inverted T waves in lead V
1
to V
4
d. S
1
Q
3

Answers: ECG 27
1. The clinical presentation and ECG Iindings oI acute pulmonary
embolism (PE) can be conIused with acute inIerior or anterior
myocardial inIarction (MI). T wave inversions and Q waves are
oIten seen inIeriorly in the setting oI PE, although a Q wave in
lead II is uncommon in PE and suggests MI. T wave inversions
in leads V
1
-V
4
is a sign oI right ventricular strain and can
sometimes be associated with ST elevation in leads V
1
and V
2
(as noted in the current case). Symptoms such as dyspnea, chest
discomIort, tachycardia, and syncope can be seen in both PE and
acute MI. Clinically, it is important to remember that both
conditions may exist simultaneously; pulmonary embolism can
complicate acute MI and vice versa. (Answer: a)
2. Sinus tachycardia is a very common Iinding in the setting oI
signiIicant pulmonary embolism. Other classic ECG Iindings Ior
pulmonary embolism RBBB, S
1
Q
3
, inverted T waves in the
precordial leads, right axis deviation are seen less Irequently
than sinus tachycardia. ECG abnormalities are oIten transient in
PE, although sinus tachycardia usually persists. Evidence Ior
acute right ventricular strain and clockwise rotation oI the heart
may be absent despite persistent embolus. Most ECG Iindings
oI pulmonary embolism are secondary to acute right ventricular
strain. (Answer: a)
- («:·/ k:.::« zI - - («:·/ k:.::« zI - - («:·/ k:.::« zI - - («:·/ k:.::« zI -
Acute cor pulmonale, including
pulmonary embolism
·
1

3
or
1

3

3
occurs in up to 30° oI
cases and last 1-2 weeks
· (Right/leIt) bundle branch block, either incomplete
or complete, may be seen in up to 25° oI cases
and usually lasts less than 1 week
· (Inverted/peaked) T waves secondary to right
ventricular strain may be seen in the (right/leIt)
precordial leads and can last Ior months
· Other ECG Iindings include (right/leIt) axis
deviation, nonspeciIic ST and T wave changes, and
P pulmonale
· Arrhythmias and conduction disturbances include
tachycardia (most common arrhythmia),
atrial Iibrillation, atrial Ilutter, atrial tachycardia,
and (Iirst/second) degree AV block
· The clinical presentation and ECG oI acute
pulmonary embolism may sometimes be conIused
with acute (inIerior/anterior) MI; however, a Q
wave in lead II is (uncommon/common) in
pulmonary embolism and suggests MI
· ECG abnormalities are oIten (transient/permanent)
· A normal ECG may be recorded despite
persistence oI the embolus (true/Ialse)
S
1
Q
3
or S
1
Q
3
T
3
right
inverted
right
right
sinus
Iirst
inIerior
uncommon
transient
true
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 178 —
A.
B.
C.
D.
Answer: Tracings A, C and D all show sinus tachycardia. Tracing C is a more subtle example of sinus tachycardia with the sinus P
waves superimposed on the end of the preceding T waves. Tracing B represents supraventricular tachycardia with no evident P waves
and is the imposter.
179
- POP OU¡Z -
To Treat or Not to Treat, That Is the QuestIon
,QVWUXFWLRQV Select the best Iorm oI treatment Ior each oI the Iollowing ECGs.
(&* &KRRVH6LQJOH%HVW$QVZHU $QVZHU
a. No treatment
b. Digoxin
c. Digoxin antibody
d. Adenosine
e. Cardioversion/deIibrillation
I. Stop aminophylline
g. Pericardiocentesis
h. Glucose ¹ insulin
Early deIibrillation is the major determinant oI survival in cardiac
arrest due to YHQWULFXODUILEULOODWLRQ. Resuscitation rates approach
100° iI promptly managed in the Iirst minute. When CPR and
deIibrillation are delayed Ior as little as 4-5 minutes, successIul
resuscitation occurs in only 25-35°. (Answer: e)
Palpitations and dyspnea Ior 6 hours
$WULDOILEULOODWLRQ results in absent P waves, totally irregular atrial
activity (causing random oscillation oI the baseline), and an
irregularly irregular ventricular rhythm. Treatment consists oI
anticoagulation, rate control (digoxin, beta-blocker, or calcium
antagonist) Iollowed by chemical or electrical cardioversion,
depending on the duration oI atrial Iibrillation and the severity oI
symptoms. This patient is best treated with electrical
cardioversion since the rate is already under control. (Answer: e)
Patients with SK\VLRORJLFWUHPRU can maniIest P wave-like artiIact
at a rate oI 7-9 cycles per second (~500 per minute), as in this
ECG. Parkinson`s tremor results in baseline artiIact at a rate oI 4-
6 cycles per second (~300 per minute), which can be mistaken Ior
atrial Ilutter. (The baseline undulations in this tracing are too Iast
Ior atrial Ilutter, which occurs at rates oI 240-340 per minute.)
Other causes oI P wave artiIact include alternating current (AC)
electrical interIerence, skeletal muscle Iasciculations (shivering),
and IV inIusion pump. (Answer: a)
180
ECG 28. 76-year-old female with chest pain and
syncope:
181
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
182
ECG 28 was obtained in a 76-year-old Iemale with chest pain and syncope. The ECG shows normal sinus rhythm with ventricular premature
complexes (arrowhead). The second VPC (arrow) is a Iusion complex, which is intermediate in morphology between a regular sinus beat and
a VPC. Also present are RBBB and acute anteroseptal myocardial inIarction, with Q waves and ST segment elevation most notable in leads V
1
-
V
3
(asterisks). ST-T changes suggesting myocardial injury should also be coded.
Codes: 07 Sinus rhythm
23 Ventricular premature complexes
43 RBBB, complete
53 Anterior or anteroseptal Q wave MI (age recent or acute)
65 ST and/or T wave abnormalities suggesting myocardial injury
*
*
*
183
Ouestions: ECG 28
1. The presence oI right bundle branch block (RBBB) invalidates
the usual criteria Ior diagnosing acute anteroseptal myocardial
inIarction:
a. True
b. False
Answers: ECG 28
1. Patients with right bundle branch block without underlying
structural heart disease have essentially the same prognosis as
the general population. Among patients with coronary artery
disease, RBBB is associated with a 2-Iold increase in mortality
compared to patients without bundle branch block. RBBB does
not interIere with identiIication oI abnormal Q waves or ST
segment elevation oI acute myocardial inIarction, since the
initial 0.08 seconds oI the QRS complex is Iormed by
conduction down the leIt bundle. (Answer: b)
- («:·/ k:.::« z2 - - («:·/ k:.::« z2 - - («:·/ k:.::« z2 - - («:·/ k:.::« z2 -
Ventricular premature complexes
· A wide, notched or slurred complex that is
premature relative to the normal RR interval andis
not preceded by a wave
· QRS duration is almost always ~ seconds
· Initial direction oI the QRS is oIten (similar
to/diIIerent Irom) the QRS during sinus rhythm
· Secondary ST & T wave changes in the
(same/opposite) direction as the major deIlection oI
the QRS (i.e., ST depression & T wave inversion in
leads with a dominant wave; ST elevation
and upright T wave in leads with a dominant
wave or complex)
· Coupling interval is constant or varies by ·
seconds
· Morphology oI VPCs in any given lead is (the
same/diIIerent)
· Retrograde capture oI atria may occur (true/Ialse)
· A Iull pause (PP interval containing the VPC
is twice the normal PP interval) is usually evident
QRS
P
0.12
diIIerent Irom
opposite
R
S
QS
0.08
the same
true
compensatory
Anterior or anteroseptal M¡ {age recent
or acute}
· Abnormal Q or QS deIlection and ST elevation in
leads (and sometimes V
4
)
· The presence oI a Q wave in lead
distinguishes anteroseptal Irom anterior inIarction
V
1
-V
3

V
1
184
- («:·/ k:.::« z2 (·-«i'J¹ - - («:·/ k:.::« z2 (·-«i'J¹ - - («:·/ k:.::« z2 (·-«i'J¹ - - («:·/ k:.::« z2 (·-«i'J¹ -
8T and/or T wave changes suggesting
myocardial in]ury
· Acute ST segment (elevation/depression) with
upward (convexity/concavity) in the leads
representing the area oI inIarction
· T waves invert (beIore/aIter) ST segments return to
baseline
· Associated ST (elevation/depression) in the
noninIarct leads is common
· Acute wall injury oIten has horizontal or
downsloping ST segment depression with upright T
waves in V
1
-V
3
, with or without a prominent R
wave in these same leads
elevation
convexity
beIore
depression
posterior
185
- POP OU¡Z -
Make The DIagnosIs
,QVWUXFWLRQV Determine the clinical disorder that best corresponds to
the ECG Ieatures listed below (see answer sheet Ior options).
(&*)HDWXUHV $QVZHU
· Abnormal Q waves and ST elevation in leads I and
aVL
Lateral MI, acute
or recent
· Abnormal Q waves and ST elevation in at least two
oI leads II, III, and aVF
· Associated ST depression usually evident in leads I,
aVL, V
1
-V
3
InIerior MI,
probably acute or
recent
· Abnormal Q waves (duration ~ 0.03 seconds) and
ST segment elevation in leads V
4
-V
6

Anterolateral MI,
acute or recent
· Abnormal Q or QS deIlection with ST elevation in
V
1
-V
4

Anteroseptal or
anterior MI, acute
or recent
· Initial R wave ~ 0.04 seconds in leads V
1
and V
2
with R wave amplitude ~ S wave amplitude, and ST
segment depression with upright T waves
· Usually seen in the setting oI acute inIerior MI
Posterior MI,
probably acute or
recent
· ST segment elevation ~ 1 mm persisting 4 or more
weeks aIter acute MI in leads with abnormal Q
waves
Probable
ventricular
aneurysm
186
ECG 29. 56-year-old female with breast cancer,
shortness of breath, and weakness:
187
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
188
ECG 29 was obtained in a 56-year-old Iemale with breast cancer, shortness oI breath, and weakness. The ECG shows atrial Ilutter with 2:1
AV block (2 Ilutter waves Ior every QRS complex). The Ilutter waves are inverted in lead II and upright in lead V
1
, as is typically the case.
Low voltage QRS is present, and there is subtle evidence Ior electrical alternans, which is most noticeable in the rhythm strip (asterisk). These
Iindings are consistent with pericardial eIIusion (which is probably malignant in this case). Q waves in leads V
1
-V
4
(arrows) suggest old
anteroseptal/anterior myocardial inIarction. Although Q waves are present in V
4
-V
5
, anterolateral MI should not be coded since abnormal Q
waves are absent in V
6
.
Codes: 18 Atrial Ilutter
32 AV block, 2:1
38 Electrical alternans
39 Low voltage
54 Anterior or anteroseptal Q wave MI (age indeterminate or old)
83 Pericardial eIIusion
*
189
Ouestions: ECG 29
1. The diagnosis oI low voltage requires a QRS amplitude less than
¸¸¸ mm in all limb leads and less than ¸¸¸ mm in all precordial
leads:
a. 7, 10
b. 5, 15
c. 5, 10
d. 10, 5
2. Atrial Ilutter with 2:1 block usually results in a ventricular rate
oI approximately ¸¸¸ beats per minute:
a. 100
b. 150
c. 300
d. 180
3. ECG Iindings characteristic oI pericardial eIIusion include:
a. ST elevation
b. Low voltage QRS complexes
c. PR depression
d. Electrical alternans
Answers: ECG 29
1. For board scoring purposes, a diagnosis oI 'low voltage¨
requires the presence oI low voltage in all limb and precordial
leads. Low voltage in the limb leads requires a total QRS
amplitude (maximal deIlection oI R ¹ S wave ) · 5 mm; low
voltage in the precordial leads requires a total QRS amplitude ·
10 mm. Clinical conditions associated with low voltage QRS
complexes include pleural or pericardial eIIusion, restrictive or
inIiltrative cardiomyopathies, diIIuse myocardial disease with
multiple prior inIarctions, obesity, and emphysema (chronic lung
disease). (Answer: c)
2. In typical atrial Ilutter, Ilutter (or 'F¨ waves) occur at a rate oI
300 per minute. ThereIore, atrial Ilutter with 2:1 block usually
results in a ventricular rate oI 150 per minute. Flutter waves are
sometimes diIIicult to recognize, and are usually best seen in the
inIerior leads (II, III, and aVF) and in lead V
1
. The ventricular
rhythm may be regular or irregular depending on whether AV
nodal conduction is constant or variable. (Answer: b)
3. Low voltage QRS complexes and electrical alternans are
consistent with (but neither sensitive nor speciIic Ior) the
diagnosis oI pericardial eIIusion. ECG Iindings oI acute
pericarditis (PR depression, ST segment elevation) may or may
not be present. (Answer: b, d)
190
- («:·/ k:.::« z7 - - («:·/ k:.::« z7 - - («:·/ k:.::« z7 - - («:·/ k:.::« z7 -
Atrial flutter
· Rapid (regular/irregular) atrial undulations ('F¨
waves) at a rate oI per minute
· Flutter rate may (increase/decrease) in the presence
oI Types IA, IC or III antiarrhythmic drugs
· Flutter waves in leads II, III, AVF are typically
(inverted/upright) (with/without) an isoelectric
baseline
· Flutter waves in lead V
1
are typically small
(positive/negative) deIlections (with/without) a
distinct isoelectric baseline
· QRS complex may be normal or aberrant
(true/Ialse)
· AV conduction ratio (ratio oI Ilutter waves to QRS
complexes) is usually (Iixed/variable)
Conduction ratios oI 1:1 and 3:1 are
(common/uncommon)
In untreated patients, AV block ~ suggests
the coexistence oI AV conduction disease
regular
240-340
decrease
inverted,
without
positive, with
true
Iixed
uncommon
4:1
Pericardial effusion
· (High/low) voltage QRS
· Electrical , especially iI complicated by
cardiac
· Other Ieatures oI acute may also be present
Low
alternans
tamponade
pericarditis
191
Differential Diagnosis
¡NTRAVENTR¡CULAR CONDUCT¡ON D¡8TURBANCE
(QRS duration ~ 0.11 seconds in duration but QRS
morphology does not meet criteria Ior LBBB or RBBB, RU
abnormal notching oI the QRS complex is present without
prolongation)
· Antiarrhythmic drug toxicity (especially Type IA and IC
agents)
· Hyperkalemia
· LVH
· WolII-Parkinson-White
· Hypothermia
· Severe metabolic disturbances
192
ECG 30. 71-year-old male with palpitations:
193
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
194
ECG 30 was obtained in a 71-year-old male with palpitations. The ECG shows a regular narrow complex tachycardia at 153 beats/minute with
ST depression in V
3
-V
6
suggesting subendocardial ischemia (arrows). Retrograde P waves are most noticeable in lead II, immediately Iollowing
the QRS complex (arrowhead; also see Iull-size ECG on previous page). This tracing is most appropriately coded as supraventricular
tachycardia. Electrical alternans is commonly seen in SVT and is present in this tracing (asterisk). Also noted is a prolonged QT interval. At
electrophysiologic study, this patient was shown to have AV nodal re-entrant tachycardia.
Codes: 17 Supraventricular tachycardia, paroxysmal
38 Electrical alternans
64 ST and/or T wave abnormalities suggesting myocardial ischemia
68 Prolonged QT interval
*
195
Ouestions: ECG 30
1. Retrograde P waves are usually upright in leads II, III, and aVF:
a. True
b. False
2. ECG Ieatures consistent with a supraventricular origin rather
than a ventricular origin Ior a tachycardia include:
a. Capture or Iusion beats
b. Narrow QRS width
c. LeIt axis deviation
d. AV dissociation
Answers: ECG 30
1. Retrograde atrial activation results in inverted P waves in leads
II, III, and aVF. The retrograde atrial waveIront moves in a
superior direction away Irom the AV node and inIerior leads,
resulting in inverted P waves in these leads. Retrograde P waves
typically occur with junctional beats and AV nodal re-entrant
tachycardia, and sometimes with ventricular tachycardia or
VPCs (iI retrograde AV nodal conduction is present). (Answer:
b)
2. The diIIerentiation oI a supraventricular Irom a ventricular
rhythm is an important and Irequent clinical dilemma.
A supraventricular origin is Iavored iI:
& The QRS is narrow
& QRS morphology is similar to that noted during a sinus
rhythm or during an aberrantly conducted atrial premature
complex
& The tachyarrhythmia is initiated by an atrial premature
complex
A ventricular origin is Iavored iI:
& The QRS is wide (~0.14 seconds in duration)
& AV dissociation, capture beats, Iusion beats are present
& The QRS axis is leItward or northwest
& Ventricular concordance is present
& The dysrhythmia is initiated by a VPC
(Answer: b)
- («:·/ k:.::« ;0 - - («:·/ k:.::« ;0 - - («:·/ k:.::« ;0 - - («:·/ k:.::« ;0 -
8upraventricular tachycardia
· (Regular/irregular) rhythm
· Rate ~ per minute
· P waves (always/sometimes) identiIied
· QRS complex is usually (narrow/wide)
· II rate is 150 per minute, consider
Regular
100
sometimes
narrow
atrial Ilutter with 2:1 block
Electrical alternans
· Alteration in the and/or oI
the P, QRS and/or T waves
amplitude, direction
196
ECG 31. 78-year-old female with dizziness:
197
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
198
ECG 31 was obtained in a 78-year-old Iemale complaining oI dizziness. The ECG shows proIound sinus bradycardia at 40 BPM (arrows mark
sinus P waves) competing with a junctional rhythm (arrowheads mark junctional QRS complexes) and resulting in AV dissociation. Also present
are sinus arrhythmia, RBBB with secondary ST-T changes, and leIt anterior Iascicular block (leIt axis deviation does not require coding). The
IiIth complex on the tracing shows a normally conducted P wave resulting in a ventricular capture complex (which is premature compared to
the junctional complexes). These Iindings are consistent with sick sinus syndrome.
Codes: 08 Sinus arrhythmia
09 Sinus bradycardia (· 60)
22 AV junctional rhythm/tachycardia
35 AV dissociation
43 RBBB, complete
45 LeIt anterior Iascicular block
89 Sick sinus syndrome
199
Ouestions: ECG 31
1. LeIt anterior Iascicular block requires an axis leItward oI:
a. 30
b. 45
c. 0
d. 90
2. Which oI the Iollowing statements about junctional escape
rhythms are true:
a. AV dissociation is common
b. Retrograde atrial activation is always evident
c. The usual heart rate is 60-80 BPM
d. The P wave may proceed the QRS
3. Incomplete RBBB and complete RBBB requires a QRS duration
oI ¸¸¸¸ and ¸¸¸¸ seconds, respectively:
a. 0.9-0.12; ~ 0.12
b. 0.9-0.11; ~ 0.11
c. 0.9 to · 0.12; ~ 0.12
d. 0.11; 0.14
Answers: ECG 31
1. LeIt anterior Iascicular block (LAFB) requires a QRS axis
between - 45 and -90, and is typically associated with a normal
to slightly prolonged QRS duration (0.08-0.10 seconds). Since
LAFB is a diagnosis oI exclusion, be sure to exclude other
causes oI leIt axis deviation (e.g., LVH, inIerior inIarction,
LBBB, emphysema) beIore coding LAFB. (Answer: b)
2. The usual heart rate noted with a junctional escape rhythm is
between 40-60 BPM. Junctional rhythms are oIten associated
with isorhythmic AV dissociation (P waves and QRS complexes
appear to bear a close relationship to each other but actually
represent independent atrial and ventricular activation) or
retrograde atrial activation (inverted P waves in leads II, III, and
aVF). The P wave inscribed by a junctional pacemaker may
proceed (by · 0.11), be superimposed upon, or Iollow the QRS
complex. (Answer: a, d)
3. Complete RBBB requires a QRS duration oI ~ 0.12 seconds
(whereas incomplete RBBB requires a QRS duration between
0.09 and · 0.12 seconds). Lead V
1
is usually the most helpIul
lead Ior diagnosing RBBB, and typically displays an rSr' pattern.
RBBB is not usually associated with extensive and diIIuse ST-T
wave (repolarization) abnormalities, although T wave inversions
are oIten present in leads V
1
- V
3
. (Answer: c)
200
- («:·/ k:.::« ;1 - - («:·/ k:.::« ;1 - - («:·/ k:.::« ;1 - - («:·/ k:.::« ;1 -
AV dissociation
· Atrial and ventricular rhythms are oI each other
· Ventricular rate is (·/~) than the atrial rate
independent
~
RBBB, complete
· QRS duration ~ seconds
· Secondary R wave (R) in lead is usually
(shorter/taller) than the initial R wave
· Onset oI intrinsicoid deIlection in leads V
1
and V
2

~ seconds
· ST segment and T wave
in V
1,
V
2
· Wide slurred S wave in leads
· QRS axis is usually (normal/leItward/rightward)
· RBBB (does/does not) interIere with the ECG
diagnosis oI ventricular hypertrophy or Q wave MI
0.12
V
1
taller
0.05
depression
inversion
I, aVL, V
5
, V
6
normal
does not
Left anterior fascicular block
· axis deviation with a mean QRS axis between
and degrees
· (qR/rS) complex in leads I and aVL
· (qR/rS) complex in lead III
· Normal or slightly prolonged QRS duration
(true/Ialse)
· No other cause Ior leIt axis deviation should be
present (true/Ialse)
· Poor R wave progression is (common/uncommon)
leIt
45, 90
qR
rS
true
true
common
201
- POP OU¡Z - - POP OU¡Z - - POP OU¡Z - - POP OU¡Z -
2:1 AV BIock: MobItz Type I or II
,QVWUXFWLRQV Decide iI the ECG Ieatures listed below Iavor Mobitz
Type I (Wenkebach) or Mobitz Type II second-degree AV block
(&*)HDWXUHV 0RELW]7\SH,RU,,
AV block improves in response to
maneuvers that reduce heart rate and
AV conduction (e.g., carotid sinus
massage)
Type II
AV block improves in response to
maneuvers that increase heart rate and
AV conduction (e.g., atropine,
exercise)
Type I
2:1 block develops during anterior MI Type II
Type I on another part oI ECG Type I
Wide QRS complex Type II
History oI syncope Type II
202
ECG 32. 97-year-old female with confusion and
weakness:
203
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
204
ECG 32 was obtained Irom a 97-year-old Iemale who presents with conIusion and weakness. The ECG shows sinus bradycardia with complete
heart block and a junctional escape rhythm at 35 BPM (arrows mark P waves; arrowheads mark junctional escape complexes). The junctional
escape complexes show evidence Ior LVH (R wave in I ~ 14 mm; R wave in aVL ~ 12 mm; R wave in aVL ¹ S wave in III ~ 20 mm), with
associated ST-T changes, nonspeciIic IVCD, and leIt axis deviation. The sinus bradycardia, complete heart block, and junctional escape are
all consistent with the diagnosis oI sick sinus syndrome.
Codes: 09 Sinus bradycardia (· 60)
21 AV junctional escape complexes
33 AV block, 3
o
36 LeIt axis deviation (~ -30
o
)
40 LeIt ventricular hypertrophy
57 ST and/or T wave abnormalities secondary to hypertrophy
89 Sick sinus syndrome
205
Ouestions: ECG 32
1. The distorted T wave best seen in the Iirst beat in leads II, III,
and aVF is due to:
a. Repolarization abnormality
b. ArtiIact
c. Superimposed P wave
2. Is ventriculophasic sinus arrhythmia present in this ECG?
a. Yes
b. No
3. Can the diagnosis oI leIt anterior Iascicular block be made with
certainty on this tracing?
a. Yes
b. No
4. Voltage criteria Ior LVH in the present ECG include:
a. R wave in lead I
b. R wave in lead aVL ¹ S wave in lead III
c. R wave in lead V
1
¹ S wave in lead V
6
d. R wave in lead aVL
e. S wave in lead aVR
5. Complete AV block can be diagnosed when the ventricular rate
is Iaster than the atrial rate:
a. True
b. False
6. Causes oI complete heart block include:
a. Hyperkalemia
b. Hypokalemia
c. Endocarditis
d. Acute MI
e. Digitalis toxicity
I. Lyme disease
7. In patients with complete congenital heart block, the site oI
block is typically the:
a. AV node
b. Bundle oI His
c. His-Purinkje system
206
Answers: ECG 32
1. Complete heart block occurs when atrial impulses consistently
Iail to reach the ventricles (i.e., atria and ventricles beat
independently oI each other). On ECG, the PP and RR intervals
are constant, but the PR interval varies (since the P wave bares
no constant relationship to the QRS complex). The P wave may
precede, be buried within (and not visualized), or Iollow the
QRS to deIorm the ST segment or T wave, as seen in several
beats in the present tracing. The presence oI biIid T waves in
the Iirst but not the second beats in leads II and III speaks
against repolarization abnormality, which, iI present in one beat,
should be present in all beats in that lead. ArtiIact may deIorm
the T wave, but this diagnosis is unlikely since the positive
deIlection appears in the early portion oI the T wave and
nowhere else on the ECG. (Answer: c)
2. Ventriculophasic sinus arrhythmia occurs in approximately 30°
oI cases oI complete heart block, and is diagnosed when the PP
interval containing a QRS complex is shorter than the PP
interval not containing a QRS complex. In the present tracing,
the PP intervals are regular, so ventriculophasic sinus arrhythmia
is not present. (Answer: b)
3. LeIt anterior Iascicular block (LAFB) is a diagnosis oI
exclusion, and can only be made with certainty when other
conditions causing leIt axis deviation are absent, such as leIt
ventricular hypertrophy (which is present on this tracing),
inIerior myocardial inIarction, or chronic lung disease.
(Answer: b)
4. Voltage criteria satisIied in this tracing include an R wave in
lead I ~ 14 mm, and an R wave in lead aVL ~ 12 mm. (Answer:
a, d)
5. The diagnosis oI complete heart block requires that atrial and
ventricular activity are independent oI each other, and that the
atrial rate is Iaster than the ventricular rate. When the
ventricular rate exceeds the atrial rate, $9 GLVVRFLDWLRQ (as
opposed to AV block) is said to be present; the ventricles may
be reIractory to incoming atrial impulses even though AV
conduction is intact. (Answer: b)
6. Complete heart block may occur in advanced hyperkalemia,
although death usually occurs Irom the development oI
ventricular tachyarrhythmias. In endocarditis, inIlammation and
edema oI the septum and peri-AV nodal tissues may cause
conduction Iailure and complete heart block; PR prolongation
usually precedes this event. Five to IiIteen percent oI acute
myocardial inIarctions are complicated by complete heart block.
In inIerior MI, complete heart block is usually preceded by Iirst-
degree AV block or Type I second-degree AV block, typically
occurs at the level oI the AV node, is oIten transient (· 1 week),
and is usually associated with a stable junctional escape rhythm
(narrow QRS at a rate ~ 40 BPM). In anterior MI, complete
heart block occurs as a result oI extensive damage to the leIt
ventricle, and is typically preceded by Type II second-degree
AV block or biIascicular block; mortality rates up to 70° may
occur, and is usually due to pump Iailure rather than heart block
per se. Digitalis toxicity is one oI the most common causes oI
reversible complete AV block, and is usually associated with a
junctional escape rhythm (narrow QRS) that is oIten accelerated.
Lyme disease is caused by a tick-borne spirochete (Borrelia
burgdorIeri) and can also cause complete heart block. This
disorder begins with a characteristic skin rash (erythema
207
chronicum migrans), and may be Iollowed in subsequent weeks
to months by joint, cardiac and neurological involvement.
Cardiac involvement includes AV block, which can be partial or
complete, usually occurs at the level oI the AV node, and is
sometimes accompanied by syncope. Other causes oI complete
heart block include inIiltrative diseases oI the myocardium
(amyloid, sarcoid), myocardial contusion, acute rheumatic Iever,
aortic valve disease, and degenerative diseases oI the conduction
system (Lev`s/Lenegre`s disease). (Answer: a, c, d, e, I)
7. Complete congenital heart block usually occurs at the level oI
the AV node and is typically associated with a stable junctional
escape rhythm. Very young patients oIten have escape rates ~
55 BPM and usually do not require permanent pacing until age
25-30. (Answer: a)
- («:·/ k:.::« ;z - - («:·/ k:.::« ;z - - («:·/ k:.::« ;z - - («:·/ k:.::« ;z -
AV ]unctional escape complexes
· QRS complex occurs as a phenomenon in
response to decreased sinus impulse Iormation or
conduction, or high-degree AV block
· Rate is typically per minute
· Atrial mechanism may be sinus rhythm,
paroxysmal atrial tachycardia, atrial Ilutter, or atrial
Iibrillation (true/Ialse)
· QRS morphology is (similar to/diIIerent Irom) the
sinus or supraventricular impulse
secondary
40-60
true
similar to
AV block, 3
o
· Atrial and ventricular rhythms are oI each
other
· Atrial rate is (Iaster/slower) than the ventricular
rate
independent
Iaster
8ick sinus syndrome
· Marked sinus
· arrest or exit block
· Bradycardia alternating with
· Atrial Iibrillation with ventricular response
preceded or Iollowed by sinus bradycardia, sinus
arrest, or sinoatrial exit block
· Prolonged sinus node time aIter atrial
premature complex or atrial tachyarrhythmias
· AV junctional rhythm
· Additional conduction system disease is oIten
present, including AV block, IVCD, and/or bundle
branch block (true/Ialse)
bradycardia
Sinus, sinoatrial
tachycardia
slow
recovery
escape
true
208
—POPOU¡Z—
PatternRecognItIon:ST&TChangesInPatIentsWITHOUTChestPaIn
Instructions:MatchtheIollowingECGswithalldiagnoses/descriptionsthatapply.
ECG Choose All That Apply Answer
a. Earlyrepolarization
b. Normalvariant
c. Myocardialischemia
d. Canbetreatedwiththrombolytic
therapy
e. Myocardialinjury
I. TotalocclusionoIrightcoronary
artery
g. Pericarditis
h. AssociatedwithPRsegment
depression
i. CNSdisorder
j. Pseudo-STdepression
k. SubtotalocclusionoIleIt
circumIlexcoronaryartery
l. Repolarizationabnormality2
o
to
hypertrophy
ClassicchangesoIcerebral or subarachnoid hemorrhage
usuallyoccurintheprecordialleads,withlargeuprightor
deeplyinvertedTwaves,prolongedQTinterval(oIten
marked),andprominentUwaves.STsegmentchanges
sometimesoccur,includingdiIIuseSTelevation(mimicking
acutepericarditis),IocalSTelevation(mimickingacute
myocardialinjury),orSTdepression/abnormalQwaves
(mimickingischemia,MI).Almostanyrhythmabnormality
canbeseen,includingsinustachycardiaorbradycardia,
junctionalrhythm,VPCs,orVT.(Answer:i)
Normal variant early repolarizationresultsinelevatedtake-
oIIoItheSTsegmentatthejunctionbetweentheQRSand
STsegment(Jjunction),concaveupwardSTelevation
endingwithasymmetricaluprightTwave(oItenoIlarge
amplitude),anddistinctnotchingorslurringonthe
downstrokeoItheRwave.Earlyrepolarizationmost
commonlyinvolvesV
2
-V
5
(sometimesII,III,aVF),andis
notassociatedwithreciprocalSTsegmentdepression.Note:
SomedegreeoISTelevationispresentinthemajorityoI
younghealthyindividuals,especiallyintheprecordialleads.
(Answer:a,b)
Left ventricular hypertrophy (LVH)resultsintallRwavesin
theleItprecordial/limbleads,andSTandTwavechanges
oppositeindirectiontothemajorQRSdeIlection:ST
depressioninI,aVL,III,aVF,V
4
-V
6
,andSTelevation
(·0.5-3mm)inV
1
-V
3
.InvertedTwavesinI,aVL,V
4
-V
6
andprominentuprightorinvertedUwavesmayalsobe
seen.LVHrepolarizationabnormalitiesareoItenmistaken
Iormyocardialischemia(lateralwall)ormyocardial
inIarction(anteriororinIerior).Note:QRSvoltage~12
mminaVLinthisECGmeetscriteriaIorLVH.(Answer:l)
209
- POP OU¡Z -
0DNH7KH'LDJQRVLV
,QVWUXFWLRQV Determine the clinical disorder that best corresponds to each group oI
ECG Ieatures listed below (see score sheet Ior options)
(&*)HDWXUHV $QVZHU
· Amplitude oI the entire QRS complex (R¹S) · 10 mm in all
precordial leads and · 5 mm in all limb leads
Low voltage
· Alternation in the amplitude and/or direction oI the P, QRS
and/or T waves
Electrical alternans
· Mean QRS axis ~ 100
o
· Dominant R wave V
1
· Secondary downsloping ST depression & T wave inversion
in the right precordial leads
· Right atrial abnormality
Right ventricular
hypertrophy
· QRS duration ~ 0.12 seconds
· Onset oI intrinsicoid deIlection in leads I, V
5
, V
6
~ 0.05 seconds
· Broad monophasic R waves in leads I, V
5
, V
6
, which are usually
notched or slurred
· Secondary ST & T wave changes opposite in direction to the major
QRS deIlection
· rS or QS complex in the right precordial leads
LBBB, complete
· Upright P wave ~ 2.5 mm in leads II, III and aVF RU ~ 1.5 mm in
leads V
1
or V
2
· P wave axis ~ 70 degrees
Right atrial
abnormality
· Notched P wave with a duration ~ 0.12 seconds in leads II, III or
aVF, RU
· Terminal negative portion oI the P wave in lead V
1
~ 1 mm deep
and ~ 0.04 seconds in duration
LeIt atrial abnormality
210
ECG 33. 48-year-old female with recent throat
tightness and diaphoresis:
211
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
212
ECG 33 was obtained in a 48-year-old Iemale with recent throat tightness and diaphoresis. The ECG shows sinus rhythm with Iirst-degree
AV block, RBBB (widened rSR` complex in V
1
- V
2
, and wide S waves in I, V
5
, V
6
), and striking T wave inversion and QT prolongation
throughout most oI the tracing (most prominent in the lateral precordial leads; asterisks). The deep T wave inversions in V
4
-V
6
, especially in
a patient with chest pain, suggest myocardial ischemia or even a recent non-Q-wave myocardial inIarction (note: secondary T waves oI RBBB
should be upright in these leads). Myocardial inIarction should not be coded since abnormal Q waves are not present.
Codes: 07 Sinus rhythm
29 AV block, 1°
43 RBBB, complete
64 ST and/or T wave abnormalities suggesting myocardial ischemia
68 Prolonged QT interval
*
*
*
213
Ouestions: ECG 33
1. Deep T wave inversion in the precordial leads may be seen in:
a. Non-Q-wave anterior MI
b. Normal variant
c. Hypertrophic cardiomyopathy
d. Subarachnoid bleeding
2. QT prolongation can be seen in:
a. CNS injury
b. Hypercalcemia
c. Quinidine eIIect
d. Myocardial ischemia or injury
Answers: ECG 33
1. Deep T wave inversion in the precordial leads can be seen with
non-Q-wave anterior MI, hypertrophic cardiomyopathy
(especially the apical variant), subarachnoid hemorrhage, and
Iollowing ventricular pacing. In contrast, normal variant T wave
inversion is shallow, not deep, and is not associated with QT
prolongation. (Answer: a, c, d)
2. QT prolongation can be seen with CNS injury (e.g.,
subarachnoid bleed), hypothermia, quinidine and other
antiarrhythmic drugs, and myocardial ischemia or injury.
Among electrolyte disturbances, hypocalcemia and hypokalemia
result in QT prolongation; hypercalcemia and hyperkalemia
result in QT shortening. (Answer: a, c, d)
- («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; -
8T and/or T wave abnormalities
suggesting myocardial ischemia
· Abnormally tall, symmetrical, (upright/inverted) T
waves
· Horizontal or ST segments with or without T
wave inversion
· Associated ECG Iindings:
QT interval is usually (normal/prolonged)
Reciprocal wave changes may be evident
Prominent U waves are oIten present and may
be upright or inverted (true/Ialse)
inverted
downsloping
prolonged
T
true
Prolonged OT interval
· Corrected QT interval (QTc) seconds,
where QTc ÷ QT interval divided by the square
root oI the preceding interval
· QT interval varies (directly/inversely) with heart
rate
· The normal QT interval should be (less
than/greater than) 50° oI the RR interval
0.42-0.46
RR
inversely
less than
214
- POP OU¡Z -
Pattern RecognItIon: ST & T Changes In PatIents WITH Chest PaIn
,QVWUXFWLRQV Match the Iollowing ECGs with all descriptions that apply.
(&* &KRRVH$OO7KDW$SSO\ $QVZHU
36 y.o. Iemale with sharp chest pain relieved by
sitting Iorward; similar ST changes in other leads
a. Early repolarization
b. Normal variant
c. Myocardial ischemia
d. Can be treated with thrombolytic
therapy
e. Myocardial injury
I. Total occlusion oI right coronary
artery
g. Pericarditis
h. Associated with PR segment
depression
i. CNS disorder
j. Pseudo-ST depression
k. Subtotal occlusion oI leIt circumIlex
coronary artery
l. Repolarization abnormality 2° to
hypertrophy
$FXWHSHULFDUGLWLV results in upwardly concave ST segment
elevation in almost all leads (except aVR) without
reciprocal ST depression (except aVR). T wave inversion
oIten occurs aIter ST segments return to baseline (in
contrast to acute MI). Other Iindings may include sinus
tachycardia, PR depression (early), or low voltage QRS and
electrical alternans iI pericardial eIIusion is present. Note:
Focal pericarditis (e.g., post-pericardiotomy) results in
regional (not diIIuse) ST elevation. (Answer: g , h)
72 y.o. Iemale with GI bleed and chest pain
0\RFDUGLDOLVFKHPLD results in horizontal or downsloping
ST segments + T wave inversion. T wave changes can be
biphasic, symmetrical and deeply inverted, or upright and
peaked (hyperacute), and may occur without signiIicant ST
segment depression. Prominent U waves (upright or
inverted) and prolonged QT interval are sometimes seen.
(Answer: c, k)
65 y.o. male with 2 hrs oI substernal chest pressure
0\RFDUGLDOLQMXU\ results in acute ST segment elevation
with upward convexity in leads over the area oI injury. ST
& T wave changes evolve, and T waves invert beIore ST
segments return to baseline. Reciprocal ST depression in
noninIarct leads is common (unlike pericarditis).
Hyperacute (upright and peaked) T waves are sometimes
evident prior to ST segment elevation. Acute posterior
wall injury results in ST segment GHSUHVVLRQ with upright T
waves in V
1
-V
3
+ prominent R waves. (Answer: d, e, I)
215
- POP OU¡Z -
DIIIerentIaI DIagnosIs: ST Segment
,QVWUXFWLRQV Determine whether each diagnosis below is associated with: (a) ST elevation; (b) ST depression; or (c) both.
'LDJQRVLV $QVZHU
Hyperkalemia ST depression. Tall, peaked T waves and QRS widening are common. (Answer: b)
Hypokalemia ST depression. Flattened T waves and prominent U waves are common. (Answer: b)
Myocardial injury ST elevation (convex upward) in area oI injury; ST depression in reciprocal leads. Q waves absent. (Answer: c)
Myocardial ischemia ST depression (horizontal or downsloping). T waves usually inverted; Q waves absent. Prinzmetal`s (variant)
angina presents with ST elevation. (Answer: c)
Myocardial inIarction ST elevation (with reciprocal ST depression) or primary ST depression (non-ST-elevation MI or posterior MI). In
the days-to-weeks post-MI, ST elevation without reciprocal ST depression can be seen in pericarditis or
ventricular aneurysm. (Answer: c)
Digoxin Sagging ST segment depression with upward concavity. T waves may be Ilattened, inverted or biphasic. QT
shortening and PR prolongation may also occur. (Answer: b)
Early repolarization ST elevation (concave upward) ending with a symmetrical (oIten tall) upright T wave, most oIten in V
2
-V
6
. No
reciprocal ST depression. Distinct notching/slurring on downstroke oI R wave. (Answer: a)
Intracranial hemorrhage Can present with diIIuse ST elevation (mimicking pericarditis), Iocal ST elevation (mimicking acute myocardial
injury), or ST depression. Large upright or deeply inverted T waves, prolonged QT interval, and prominent U
waves are common, especially in the precordial leads. (Answer: c)
Ventricular aneurysm ST elevation 1 mm persisting Iour or more weeks aIter acute MI in leads with abnormal Q waves. (Answer: a)
LeIt ventricular hypertrophy (LVH) ST and T wave displacement opposite to major QRS deIlection: ST depression (upwardly concave) and T wave
inversion when the QRS is mainly positive (leads I, V
5
, V
6
); subtle (· 1 mm) ST elevation and upright T waves
when the QRS is mainly negative (leads V
1
, V
2
). (Answer: c)
LeIt bundle branch block (LBBB) Secondary ST and T wave changes opposite in direction to major QRS deIlection: ST depression and T wave
inversion in leads I, V
5
, V
6
; ST elevation and upright T waves in leads V
1
, V
2
. (Answer: c)
216
ECG 34. 37-year-old male with palpitations:
217
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
218
ECG 34 was obtained Irom a 37-year-old male with palpitations. The ECG shows sinus rhythm at a rate oI 94 beats/minute with occasional
nonconducted P waves (arrows) resulting in grouped beating (asterisk). There is gradual prolongation oI the PR interval leading up to the
dropped beat, consistent with Mobitz type I - second-degree AV block. The conduction ratio is 4:3 (4 P waves Ior every 3 QRS complexes). Also
noted are leIt atrial enlargement, RBBB with secondary repolarization changes (T wave inversions in leads V
1
-V
3
), leIt anterior Iascicular block (QRS
axis ÷ 50°), and a prolonged QT interval (QTc ÷ 0.48 seconds).
Codes: 06 LeIt atrial abnormality/enlargement
07 Sinus rhythm
30 AV block, 2°- Mobitz type I (Wenckebach)
43 RBBB, complete
45 LeIt anterior Iascicular block
68 Prolonged QT interval
* * *
219
Ouestions: ECG 34
1. The diagnosis oI leIt anterior Iascicular block (LAFB) requires:
a. QRS axis between -30° and -90°
b. QRS axis between -45° and -90°
c. QRS prolongation 0.11 seconds
d. No other Iactor responsible Ior leIt axis deviation
2. LeIt anterior Iascicular block (LAFB) can result in a Ialse
positive diagnosis oI:
a. InIerior myocardial inIarction
b. Anterior myocardial inIarction
c. LeIt ventricular hypertrophy
d. Right ventricular hypertrophy
3. BiIascicular block (RBBB ¹ LAFB) with Mobitz Type I second-
degree AV block is a strong indication Ior a permanent
pacemaker in an asymptomatic patient:
a. True
b. False
Answer: ECG 34
1. LAFB results in a mean QRS axis between -45° and -90°, and
requires that no other cause oI leIt axis deviation is present (e.g.,
LVH, inIerior MI, leIt bundle branch block). QRS prolongation
0.11 seconds is not a diagnostic Ieature oI LAFB, although the
QRS is oIten slightly prolonged (0.08-0.10 seconds). (Answer:
b, d)
2. In addition to leIt axis deviation, LAFB can produce diminished
(sometimes absent) R waves in leads III and aVF, low anterior
Iorces, and a tall R wave in lead aVL, which may be mistaken
Ior inIerior MI, anterior MI, and LVH, respectively. (Answer:
a, b, c).
3. BiIascicular block with Mobitz I second-degree AV block is not
a strong indication Ior a pacemaker in an asymptomatic person.
In the setting oI symptomatic bradycardia, a pacemaker would
be an acceptable option. (Answer: b)
220
- («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; -
AV block, 2° - Mobitz Type ¡
{Wenckebach}
· Progressive prolongation oI the interval and
shortening oI the interval until a P wave is
blocked
· RR interval containing the nonconducted P wave is
(less than/equal to/greater than) the sum oI two PP
intervals
· Results in beating due to the presence oI
nonconducted P waves
PR
RR
less than
group
RBBB, complete
· QRS duration seconds
· Secondary R wave (R) in lead is usually
(shorter/taller) than the initial R wave
· Onset oI intrinsicoid deIlection in leads V
1
and V
2
~ seconds
· ST segment and T wave
in V
1,
V
2
· Wide slurred S wave in leads
· QRS axis is usually (normal/leItward/rightward)
· RBBB (does/does not) interIere with the ECG
diagnosis oI ventricular hypertrophy or Q wave MI
0.12
V
1
taller
0.05
depression
inversion
I, V
5
, V
6
normal
does not
Left anterior fascicular block
· axis deviation with a mean QRS axis between
and degrees
· (qR/rS) complex in leads I and aVL
· (qR/rS) complex in lead III
· Normal or slightly prolonged QRS duration
(true/Ialse)
· No other cause Ior leIt axis deviation should be
present (true/Ialse)
· Poor R wave progression is (common/uncommon)
leIt
-45, -90
qR
rS
true
true
common
221
- POP OU¡Z -
)LQG7KH0LVWDNH
,QVWUXFWLRQV IdentiIy the incorrect ECG Ieature(s) Ior each ECG diagnosis listed below.
(&*'LDJQRVLVDQG)HDWXUHV 0LVWDNH
Left anterior fascicular block
· LeIt axis deviation (-45 to -90 degrees)
· qR complex in lead I, aVL, and III
· Normal or slightly prolonged QRS duration
· No other cause Ior leIt axis deviation present
There is an rS complex (not a qR
complex) in lead III
Left posterior fascicular block
· Right axis deviation (¹100 to ¹180 degrees)
· S wave in lead I and Q wave in lead III
· Normal or slightly prolonged QRS duration
· Other cause Ior right axis deviation may be present
LPFB should not be diagnosed
when another cause Ior right axis
deviation exists
RBBB, complete
· QRS duration 0.12 seconds
· Secondary R wave (R) in lead V
1
is usually shorter than the initial
R wave
· Onset oI intrinsicoid deIlection in V
1
and V
2
~ 0.05 sec
· ST segment depression and T wave inversion in V
1,
V
2
· Wide slurred S wave in leads I, V
5
, V
6
· QRS axis is usually rightward
R` is usually taller (not shorter) than
the initial R wave in V
1
, and QRS
axis is usually normal (not
rightward)
LBBB, complete
· QRS duration 0.12 seconds
· Onset oI intrinsicoid deIlection in I, V
5
, V
6
~ 0.05 sec
· Broad monophasic R waves in leads I, V
5
, V
6
, which are usually
notched or slurred
· Secondary ST & T wave changes in same direction as the major
QRS deIlection
· rS or QS complex in the right precordial leads
Secondary ST & T wave changes
are in opposite (not the same)
direction to the major QRS
deIlection
222
ECG 35. 24-year-old female with post-partum
cardiomyopathy and palpitations:
223
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
224
ECG 35 was obtained in a 24-year-old Iemale with post-partum cardiomyopathy under evaluation Ior palpitations. The ECG shows an
underlying sinus rhythm at 90 beats/minute (arrows mark the P waves) and a wide complex tachycardia at 178 beats/minute consistent with
ventricular tachycardia (VT) with AV dissociation. Ventricular tachycardia morphology shows a LBBB pattern with right axis deviation,
localizing the site oI origin oI the VT to the right ventricular outIlow tract. (Note: Right-sided VT results in a LBBB SDWWHUQ, not a true LBBB).
Codes: 25 Ventricular tachycardia ( 3 consecutive complexes)
35 AV dissociation
37 Right axis deviation (~ ¹100°)
225
Ouestions: ECG 35
1. In the setting oI a wide QRS tachycardia, ECG Iindings that
Iavor the diagnosis oI ventricular tachycardia over SVT with
aberrancy include:
a. R` is taller than the R wave when an RSR` complex is
present in V
1
b. Capture beats
c. QRS duration · 0.16 seconds iI LBBB morphology is
present (assuming the QRS is narrow during sinus rhythm)
d. Some positive and some negative QRS deIlections in the
precordial leads
e. AV dissociation
2. Ventricular tachycardia always maniIests a QRS duration 0.12
seconds
a. True
b. False
Answers: ECG 35
1. In the setting oI wide QRS tachycardia, the diagnosis oI
ventricular tachycardia is Iavored over SVT with aberrancy
when: QRS morphology is similar to VPCs seen in an earlier
tracing; when the tachycardia is initiated by VPCs; AV
dissociation, capture beats, and/or Iusion beats are present; QRS
duration exceeds 0.14 seconds iI RBBB morphology is present
(or 0.16 seconds iI LBBB morphology is present); QRS
deIlections in the precordial leads are concordant (all positive or
all negative); or the R wave is taller than the R` wave in lead V
1
.
(Answer: b, e)
2. Although rare, iI the ventricular Iocus is high in the septum (i.e.,
immediately below the bundle oI His), ventricular tachycardia
can present with a relatively narrow QRS complex. (Answer: b)
- («:·/ k:.::« ;, - - («:·/ k:.::« ;, - - («:·/ k:.::« ;, - - («:·/ k:.::« ;, -
Ventricular tachycardia
· Rapid succession oI three or more premature
ventricular beats at a rate ~ per minute
· RR intervals are usually regular but may be
irregular (true/Ialse)
· (Abrupt/gradual) onset and termination are evident
· AV is common
· Look Ior ventricular complexes and
beats as markers Ior VT
100
true
Abrupt
dissociation
capture, Iusion
AV dissociation
· Atrial and ventricular rhythms are oI each
other
· Ventricular rate is (·/) than the atrial rate
independent

226
- POP OU¡Z -
Rhythm RecognItIon: WIde QRS TachycardIa
,QVWUXFWLRQV Determine the cardiac rhythm Ior each oI the Iollowing ECGs.
(&* 'LDJQRVLV
Answer: Ventricular tachycardia. Description: Regular (sometimes irregular)
ventricular rhythm with 3 consecutive beats at a rate ~ 100 per minute. Onset and
termination are usually abrupt. AV dissociation is common, and retrograde atrial
activation and ventricular capture complexes sometimes occur. Seen in organic
heart disease, hypokalemia, hyperkalemia, hypoxia, acidosis, drug toxicity, mitral
valve prolapse, and occasionally in normals.
Answer: Atrial Iibrillation with WolII-Parkinson-White (WPW) syndrome.
Description: Irregular supraventricular rhythm with absent P waves, irregularly
irregular RR intervals oIten at a rate ~ 200 per minute (can be · 200), and QRS
complexes that vary in width (but are generally wide). Classic Iibrillatory ('I¨)
waves may be seen at slower rates (but may not be evident at Iaster rates, as in this
ECG). The 12-lead ECG during sinus rhythm shows a short PR interval with initial
slurring oI the QRS (delta wave). The delta wave is due to pre-excitation oI the
ventricles Irom conduction across the bundle oI Kent, an accessory AV pathway
which bypasses the AV node (and AV nodal conduction delay). Variance in QRS
width is due to diIIerent degress oI Iusion between electrical waveIronts conducted
down the accessory pathway and AV node.
Answer: Sinus tachycardia with bundle branch block. Description: Sinus
tachycardia may present as a wide QRS tachycardia in the setting underlying bundle
branch block (as in this ECG) or Iunctional (rate-related) aberrancy. Although P
waves are sometimes seen with ventricular tachycardia, they are either due to
retrograde atrial activation (inverted in leads II, III) or are supraventricular in origin
(sinus or atrial) and maniIest AV dissociation (varying PR intervals). Fusion
complexes and ventricular capture complexes are consistent with ventricular
tachycardia, not sinus tachycardia with bundle branch block.
227
- POP OU¡Z -
97RU1RW977KDWLVWKH4XHVWLRQ
,QVWUXFWLRQV In the setting oI a wide QRS tachycardia, decide
whether the ECG Iindings below Iavor ventricular tachycardia or
SVT with aberrancy
(&*)HDWXUH
97RU697ZLWK
$EHUUDQF\
QRS morphology similar to VPCs VT
Tachycardia initiated by APCs SVT
AV dissociation absent SVT
Capture beats present VT
Fusion beats absent SVT
QRS duration during tachycardia ~ 0.14
seconds iI RBBB morphology or ~ 0.16
seconds iI LBBB morphology (assuming
QRS is narrow during sinus rhythm)
VT
QRS deIlection in precordial leads are all
positive or negative (concordance)
VT
RSR` in V
1
: R wave shorter than R` SVT
228
ECG 36. 48-year-old man with aortic stenosis:
229
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
230
ECG 36 was obtained in a 48-year-old male with aortic stenosis. The ECG shows a sinus rhythm with a single ventricular premature complex.
LVH is apparent with an R wave in aVL ¹ S wave in V
3
~ 28 mm (Cornell criteria). Repolarization abnormalities (downsloping ST depression
and asymmetrical T wave inversion) secondary to LVH are present (arrows) as well as prominent U waves (arrowhead), a common Iinding in
LVH.
Codes: 07 Sinus rhythm
23 Ventricular premature complexes
40 LeIt ventricular hypertrophy
67 ST and/or T wave abnormalities secondary to hypertrophy
69 Prominent U waves
231
Ouestions: ECG 36
1. Findings in this ECG that can be attributed to LVH include:
a. LeIt atrial abnormality
b. Prominent U wave
c. ST segment depression and T wave inversion
d. Intraventricular conduction delay
e. Poor R wave progression
I. Absent Q wave in V
5
g. ST elevation in V
3
2. The diIIerential diagnosis Ior prominent U waves includes:
a. Hypokalemia
b. Hyperkalemia
c. Digitalis
d. Quinidine
e. Amiodarone
I. Central nervous system disorders
g. LVH
3. Anatomical LVH is more likely to be present when
repolarization (ST and T wave) changes accompany voltage
criteria:
a. True
b. False
4. Which oI the Iollowing ECG criteria is most speciIic (i.e.,
Iewest Ialse-positives) Ior the diagnosis oI LVH:
a. R in V
5
or V
6
¹ S in V
1
~ 35 mm
b. R in aVL ~ 12 mm
c. Any R ¹ S in the precordial leads ~ 45 mm
d. R in aVL ¹ S in V
3
~ 28 mm (20 mm in Iemales)
5. Which oI the Iollowing ECG criteria is the most sensitive (i.e.,
Iewest Ialse-negatives) Ior the diagnosis oI LVH:
a. R in V
5
or V
6
¹ S in V
1
~ 35 mm
b. R in aVL ~ 12 mm
c. Any R ¹ S in the precordial leads ~ 45 mm
d. LeIt axis deviation ~ 30
o
e. R in aVL ¹ S in V
3
~ 28 mm (~ 20 mm in Iemales)
6. Factors/conditions reducing the sensitivity Ior the diagnosis oI
LVH by voltage criteria include:
a. Obesity
b. Thin body habitus
c. Severe COPD
d. Pericardial or pleural eIIusion
e. Coronary artery disease
I. Pneumothorax
g. Sarcoidosis or amyloidosis oI the heart
h. Severe right ventricular hypertrophy
i. LeIt bundle branch block
j. LeIt anterior Iascicular block
232
Answers: ECG 36
1. The ECG diagnosis oI leIt ventricular hypertrophy (LVH) is
based primarily on the presence oI large amplitude QRS
complexes generated Irom the hypertrophic leIt ventricle. LVH
also Irequently results in non-voltage based changes, some oI
which are evident in this ECG tracing. Left atrial abnormality,
while not a direct maniIestation oI LVH, increases the
probability that LVH is present, and is given 3 points in the
point score system Ior LVH by Romhilt and Estes (Table 1). A
prominent U wave is oIten seen in the right precordial leads (V
2
,
V
3
) but is neither sensitive nor speciIic Ior the diagnosis oI
LVH. S1 and 1 wave changes are very common in advanced
stages oI LVH; when present, the ECG speciIicity Ior the
diagnosis oI anatomical LVH is increased: In the leIt precordial
leads (V
4
- V
6
), these changes typically consist oI downsloping
ST segment depression with a slight upward concavity, and
asymmetrical T wave inversion, with more gentle sloping oI the
descending limb compared to the ascending limb. In the right
precordial leads (V
1
- V
3
), reciprocal ST segment elevation and
tall T waves are oIten seen, which, in conjunction with poor R
wave progression (or even Q waves or QS complexes) may
mimic anteroseptal or anterior MI. In the limb leads, ST and T
wave changes appear in a direction opposite Irom the main QRS
Iorces (i.e., in leads with largely positive QRS complexes, ST
depression and T wave inversion are present; in leads with
largely negative QRS complexes, ST elevation and tall T waves
are present). Other changes in this ECG consistent with LVH
include delayed onset of intrinsicoid deflection (onset oI QRS
to peak R wave 0.05 seconds; due to a delay in intraventricular
conduction), and inferior Q waves, the mechanism oI which is
unknown. Findings not present in this tracing but oIten evident
in LVH include notching of the QRS complex and left axis
deviation. (Answer: all)
2. Mild hyperkalemia (5.5 - 6.5 mEq/L) can result in T waves that
are tall, peaked, and symmetrical, and shortening oI the QT
interval. Moderate hyperkalemia (6.5 - 8.0 mEq/L) can result in
a decrease in P wave and R wave amplitudes, lengthening oI the
PR interval and QRS duration, and depression or elevation oI the
ST segment; ventricular premature complexes may also be seen.
In severe hyperkalemia, the P wave may be undetectable and the
QRS complex markedly widened, giving the appearance oI a
sine wave. Rhythms may include sinoventricular rhythm (no P
waves apparent), idioventricular rhythm, accelerated
idioventricular rhythm, ventricular tachycardia, ventricular
Iibrillation, and asystole. U waves, however, are not typically
seen. (Answer: all except b)
3. The sensitivity and speciIicity Ior the ECG diagnosis oI
anatomical LVH depend on the ECG criteria. Although ST and
T wave changes 'typical¨ Ior LVH may be caused by other
conditions (e.g., myocardial ischemia), their presence increases
the speciIicity Ior the diagnosis oI LVH by voltage criteria.
(Answer: a)
4. An R wave in aVL 12 mm in the absence oI leIt anterior
Iascicular block is highly speciIic Ior the diagnosis oI LVH.
However, only 11° oI individuals with LVH. meet this criteria
(i.e., poor sensitivity). &$9($7 Since the presence oI leIt
anterior Iascicular block results in large leItward Iorces (R
waves) in leads I and aVL, voltage criteria using these leads
(i.e., R wave in aVL ~ 12 mm; R wave in lead I ¹ S wave in lead
III ~ 28 mm; R wave in aVL ¹ S wave in V
3
~ 28 mm |Cornell
233
criteria|) will overestimate the diagnosis oI LVH. (Answer: b)
5. Sensitivity Ior identiIication oI LVH is highest (35-50°) Ior the
Cornell criteria (R wave in aVL ¹ S wave in V
3
~ 28 mm in
males or ~ 20 mm in Iemales) and lower (10-30°) Ior other
criteria. All standard voltage criteria Ior LVH are limited by low
sensitivity. (Answer: e)
6. The amplitude oI the QRS as recorded by the surIace
electrocardiogram (and the sensitivity Ior the diagnosis oI LVH
by voltage criteria) is oIten decreased by conditions that increase
the amount oI body tissue (obesity), air (COPD, pneumothorax),
Iluid (pericardial or plural eIIusion), or Iibrous tissue (coronary
artery disease, sarcoid or amyloid oI the heart) between the
myocardium and ECG electrodes. Severe RVH can also
underestimate the ECG diagnosis oI LVH by cancelling
prominent QRS Iorces Irom the thickened LV. LeIt bundle
branch block may also reduce QRS amplitude as well. In
contrast, thin body habitus and the presence oI leIt anterior
Iascicular block may increase QRS amplitude in the absence oI
LVH, thus decreasing the speciIicity oI the voltage criteria.
(Answer: all except b and j)
- («:·/ k:.::« ;( - - («:·/ k:.::« ;( - - («:·/ k:.::« ;( - - («:·/ k:.::« ;( -
LVH by both voltage and 8T-T segment
abnormalities
· Voltage criteria Ior LVH and one or more ST-T
abnormalities:
ST segment and T wave deviation in
(same/opposite) direction to the major deIlection
oI QRS
ST segment (elevation/depression) in leads I,
aVL, III, aVF, and/or V
4
-V
6
Subtle (· 1-2 mm) ST (elevation/depression) in
leads V
1
-V
3
Inverted waves in leads I, aVL, V
4
-V
6
(Absent/prominent) U waves
opposite
depression
elevation
T
prominent
234
ECG 37. 53-year-old asymptomatic male:
I
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
II
III
II
VI
235
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
236
ECG 37 was obtained in an asymptomatic 53-year-old male. The ECG shows an irregular, undulating baseline at approximately at 8 cycles
per second (cps). Upon close inspection oI the precordial leads, sinus P waves are present (arrows), and the PR interval is 220 msec, consistent
with Iirst-degree AV block. The heart rate is 54 beats/minute, with sinus arrhythmia causing lengthening oI the RR interval between the 6
th
and
7
th
beats (asterisk). LeIt axis deviation and a nonspeciIic intraventricular conduction disturbance (QRS duration ÷ 120 msec) are also present.
LeIt anterior Iascicular block should not be coded as the cause oI leIt axis deviation in this tracing since, by deIinition, the QRS duration in LAFB
is 80-100 msec. The undulating baseline in the current tracing has a cycle length oI 7-9 cps, characteristic oI a physiologic tremor.
Codes: 04 ArtiIact
08 Sinus arrhythmia
09 Sinus bradycardia (· 60)
29 AV block 1o
36 LeIt axis deviation (~ 30o
49 NonspeciIic intraventricular conduction disturbance
I
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
II
III
II
VI
—237—
Ouestions:ECG37
1. Match the Iollowing QRS durations with the associated
conductiondisturbance:
a. 0.08-0.10seconds 1. IncompleteLBBB
b. ≥0.12seconds 2. CompleteLBBB
c. 0.11seconds 3. LeItanteriorIascicularblock
d. 0.09-0.12seconds 4. NonspeciIicintraventricular
conductiondeIect
2. Insinusarrhythmia,thePwavemorphologyandaxisareusually
normal:
a. True
b. False
Answers:ECG37
1. (Answer:a-3,b-2,c-4,d-1)
2. Insinusarrhythmia,phasicchangesinthePPintervaloccurin
response to respirations; the cycle is usually gradual but can
sometimeschangeabruptly.BydeIinition,thelongest/shortest
PP intervals vary by more than 160 msec or 10° oI the PP
interval.ThePwavemorphologyandaxisareusuallynormalin
sinus arrhythmia, although leIt/right atrial enlargement can
coexistwithsinusarrhythmia.(Answer:a)
—(«:·/k:.::«;I— —(«:·/k:.::«;I— —(«:·/k:.::«;I— —(«:·/k:.::«;I—
Artifact
Commonlyduetotremor
• Parkinsonstremorsimulatesatrialwitharate
oIpersecond
• Physiologictremorrateispersecond
• Tremorismostprominentin(limb/precordial)
leads
Ilutter
4-6
7-9
limb
8inusarrhythmia
• (Sinus/nonsinus)Pwave
• LongestandshortestPPintervalsvaryby~
secondsor10°
• SinusarrhythmiadiIIersIrom“ventriculophasic”
sinusarrhythmia,thelatteroIwhichoccursinthe
settingoI
Sinus
0.16
heartblock
Leftaxisdeviation{>–30
o
}
• MeanQRSaxisbetweendegreesand
degrees
-30,-90
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 238 —
A.
B.
C.
D.
Answer: While all of the tracings show rapid atrial activity, A, B and D represent atrial futter with atrial rates of 250-350 bpm. The
imposter is tracing C, which shows atrial tachycardia with 2:1 AV block. The atrial rate of 160 bpm is much slower than that of atrial
futter, and the ventricular rate of 80 bpm is exactly one-half the atrial rate, which helps to identify the presence of 2:1 AV block. In this
case, digitalis toxicity should be considered (although approximately one fourth of cases of atrial tachycardia with block occur in the
absence of digitalis use or toxicity).
239
Common Dilemmas
in ECG ¡nterpretation
Problem
Ischemic-looking ST segment elevation is present without
pathological Q waves in a patient with chest pain. Should
acute myocardial inIarction be coded?
Recommendation
No. Convex upward ST segment elevation without
pathological Q waves should be coded as item 65 (ST and/or
T abnormalities suggesting myocardial injury). Clinically,
this usually represents the early stages oI acute inIarction or
transient coronary spasm or occlusion. Nevertheless, in the
absence oI pathological Q waves (or pathological R waves
in the case oI posterior inIarction), acute myocardial
inIarction should not be coded.
240
ECG 38. 87-year-old female with dizziness:
241
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
242
ECG 38 was obtained Irom a 87-year-old Iemale with dizziness. The ECG shows sinus rhythm at 77 beats/minute with brieI sinus pauses
(asterisk) in which the PP interval is twice the basic PP interval. This Iinding indicates the presence oI sinoatrial exit block.
Codes: 07 Sinus rhythm
12 Sinoatrial exit block
243
Ouestions: ECG 38
1. ECG maniIestations oI Mobitz II sinoatrial (SA) exit block
include:
a. Lengthening oI the PR interval
b. Sinus pauses that are a multiple oI normal PP interval
c. Narrowing oI the QRS complex
d. Shortening oI the PP interval
2. The normal corrected QT intervals Ior heart rates oI 60 and 80
beats/minute are + 0.04 seconds and + 0.04 seconds,
respectively:
a. 0.38; 0.42
b. 0.44; 0.40
c. 0.42; 0.38
d. 0.40; 0.38
Answers: ECG 38
1. In Mobitz II SA exit block, sinus impulses occur at a constant
rate but occasionally Iail to capture the atria, resulting in
intermittent absence oI a P wave. The typical ECG Iinding is
a PP pause that is a multiple (2x, 3x, etc.) oI the basic PP
interval. Mobitz I SA exit block is suggested by the presence oI
recurring PP pauses ('group beating¨) with PP intervals less
than two times the basic PP interval. SA exit block is oIten a
component oI sick sinus syndrome, and is an important
consideration when evaluating the etiology oI a PP pause.
(Answer: b)
2. The easiest method oI calculating the corrected QT interval is to
assume a normal QT interval oI 0.40 + 0.04 seconds Ior a heart
rate oI 70 BPM, then add (or subtract) 0.02 seconds Ior every 10
BPM change in heart rate below (or above) 70 BPM. Thus, at
heart rates oI 60 BPM and 80 BPM, the corrected QT intervals
÷ 0.42 ¹ 0.04 seconds and 0.38 ¹ 0.04 seconds, respectively. At
a heart rate oI 50 BPM, the corrected QT interval ÷ (0.40) ¹ (2
x 0.02) ÷ 0.44 + 0.04 seconds. (Answer: b)
- («:·/ k:.::« ;2 - - («:·/ k:.::« ;2 - - («:·/ k:.::« ;2 - - («:·/ k:.::« ;2 -
8inoatrial {8A} exit block
First-degree: Conduction oI sinus impulses to the
atrium is (normal/delayed), but :1 response is
maintained
· First-degree SA exit block (is/is not) detectable on
the surIace ECG
delayed, 1
is not
Second-degree: Some sinus impulses Iail to the
atria
· Type I (Mobitz I):
Sinus P wave (true/Ialse)
' beating¨ with:
(1) (Shortening/lengthening) oI the PP interval
prior to absent P wave
(2) (Constant/variable) PR interval
(3) PP pause · normal PP interval
· Type II (Mobitz II): Constant PP interval Iollowed
by a pause that (is/is not) a multiple (2x, 3x, etc.)
oI the normal PP interval
capture
true
group
shortening
constant
2
is
1hird-degree:
· Complete Iailure oI conduction
· Cannot be diIIerentiated Irom complete
sinoatrial
sinus arrest
244
- POP OU¡Z -
)LQG7KH0LVWDNH
,QVWUXFWLRQV IdentiIy the incorrect ECG Ieature(s) Ior each ECG diagnosis listed below.
(&*'LDJQRVLVDQG)HDWXUHV 0LVWDNH
Hypothermia
· Sinus bradycardia
· PR, QRS, and QT prolonged
· Osborne ('J¨) wave: late upright terminal deIlection oI QRS
complex
· Atrial Iibrillation in 50-60°
Atrial Iibrillation occurs in 50-60°
CN8 disorder
· 'Classic changes¨ usually occur in the limb leads
Large upright or deeply inverted T waves
Prolonged QT interval (oIten marked)
Prominent U waves
· Other changes:
ST segment mimicking acute pericarditis or injury
ST depression may also occur
Abnormal Q waves mimicking MI
Almost any rhythm abnormality, including sinus tachycardia or
bradycardia, junctional rhythm, VPCs, ventricular tachycardia
'Classic changes¨ usually occur in
the precordial (not limb) leads
Myxedema
· Low QRS voltage in all leads
· Sinus bradycardia
· Peaked T waves
· PR interval may be prolonged
· Frequently associated with pericardial eIIusion
· Electrical alternans may occur
T waves are Ilattened or inverted
(not peaked)
245
Common Dilemmas
in ECG ¡nterpretation
Problem
Should leIt axis deviation be coded when leIt anterior
Iascicular block (LAFB) is present? Similarly, should right
axis deviation be coded when leIt posterior Iascicular block
(LPFB) is present?
Recommendation
No. A description oI axis is redundant in LAFB or LPFB.
II LAFB or LPFB is present, it is not necessary to code axis.
246
ECG 39. 1-year-old male with a heart murmur:
247
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
248
ECG 39 was obtained in a 1-year-old male with a heart murmur. The ECG shows sinus tachycardia with incomplete RBBB and leIt axis
deviation. This constellation oI Iindings is typical Ior an ostium primum atrial septal deIect. Electrical alternans is also present (asterisk). This
child subsequently underwent cardiac surgery to repair a large primum ASD.
Codes: 10 Sinus tachycardia
36 LeIt axis deviation (~ 30°)
38 Electrical alternans
44 RBBB, incomplete
79 Atrial septal deIect, primum
*
249
Ouestions: ECG 39
1. Primum atrial septal deIect results in ¸¸¸ axis deviation:
a. Right
b. LeIt
2. ECG Iindings suggestive oI right ventricular hypertrophy (RVH)
include:
a. LeIt axis deviation
b. Right atrial abnormality
c. R ~ S in V
1
d. R in aVL ~ 12 mm
e. Downsloping ST segments and T wave inversion in V
1
-V
3
Answers: ECG 39
1. Primum atrial septal deIect is associated with an rSr` complex in
lead V
1
and leIt axis deviation. In 15-40° oI cases, Iirst-degree
AV block is present. Advanced cases may demonstrate
biventricular hypertrophy. (Answer: b)
2. ECG Iindings associated with right ventricular hypertrophy
include right axis deviation, a dominant R wave in lead V
1
(R ~
S), right atrial abnormality, and repolarization abnormalities in
the right precordial leads. An R wave in lead aVL ~ 12 mm is
consistent with LVH, not RVH. (Answer: b, c, e)
- («:·/ k:.::« ;7 - - («:·/ k:.::« ;7 - - («:·/ k:.::« ;7 - - («:·/ k:.::« ;7 -
8inus tachycardia
· Rate ~ per minute
· P wave amplitude oIten (increases/decreases) and
PR interval oIten (lengthens/shortens) with
increasing heart rate
100
increases
shortens
Atrial septal defect, primum
· RSR` complex in lead
· (Right/leIt) axis deviation, in contrast to (right/leIt)
axis deviation in secundum ASD
· degree AV block in 15-40°
· Advanced cases have hypertrophy
· Primum ASDs represent 15° oI all ASDs, and are
due to deIicient tissue in the lower portion oI the
. These ASDs are usually (small/large), may
be accompanied by anomalous venous
drainage, and are associated with a cleIt anterior
valve leaIlet
V
1

LeIt, right
First
biventricular
septum, large
pulmonary
mitral
250
ECG 40. 75-year-old female with heart failure:
251
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
252
ECG 40 was obtained Irom a 75-year-old Iemale with heart Iailure. At Iirst glance, the ECG looks like an ectopic atrial rhythm at a rate oI
80 beats/minute with Iirst-degree AV block. However, on closer inspection, leads V
1
and V
2
show additional P waves immediately Iollowing
each QRS complex (arrows mark conducted P waves; arrowheads mark nonconducted P waves), consistent with atrial tachycardia at a rate oI
160 beats/minute with 2:1 AV block. In a patient with heart Iailure, this arrhythmia is commonly due to digitalis toxicity. Also noted are LVH
(R wave in aVL ¹ S wave in V
3
~ 20 mm in Iemales), nonspeciIic intraventricular conduction disturbance (QRS duration ÷ 0.11 seconds), and
ST-T wave changes in leads V
5
-V
6
secondary to LVH (i.e., 'strain¨ pattern).
Codes: 15 Atrial tachycardia
32 2:1 AV block
40 LeIt ventricular hypertrophy
49 NonspeciIic intraventricular conduction disturbance
67 ST and/or T wave abnormalities secondary to hypertrophy
71 Digitalis toxicity
253
Ouestions: ECG 40
1. Atrial tachycardia with block is associated with:
a. Mobitz Type I second-degree AV block
b. Mobitz Type II second-degree AV block
c. First-degree AV block
d. Complete heart block
2. Arrhythmias associated with digitalis toxicity include:
a. Ventricular Iibrillation
b. Ventricular tachycardia
c. Paroxysmal atrial tachycardia
d. Junctional tachycardia
e. AV block with accelerated junctional rhythm
I. Sinoatrial exit block
g. Sinus node arrest
Answers: ECG 40
1. Atrial tachycardia with block is oIten a maniIestation oI digitalis
toxicity, and results in a regular atrial rhythm with intermittent
nonconducted P waves due to second-degree AV block, which
can either Mobitz Type I or Type II. When 2:1 AV block is
present, it is diIIicult to distinguish between these mechanisms
based on surIace ECG alone. (Answer: a, b)
2. Digitalis toxicity can induce nearly every known arrhythmia.
Hypokalemia, hypomagnesemia, and hypercalcemia increase the
risk oI digitalis toxicity. (Answer: all)
- («:·/ k:.::« ;0 - - («:·/ k:.::« ;0 - - («:·/ k:.::« ;0 - - («:·/ k:.::« ;0 -
Atrial tachycardia
· Three or more consecutive (sinus/nonsinus) beats
at an atrial rate oI 100-240 bpm
· P wave is (always/sometimes) visualized
· QRS Iollows each P wave unless AV block is
present
nonsinus
sometimes
2° or 3°
AV block, 2:1
· Regular sinus or rhythm
· 2 waves Ior every QRS complex
· Can be Mobitz type I or type II 2° AV block
(true/Ialse)
ectopic atrial
P
true
Nonspecific intraventricular conduction
disturbance
· QRS ~ seconds in duration but morphology
does not meet criteria Ior LBBB or RBBB, RU
abnormal without widening oI the QRS
complex
0.11
notching
—254—
—POPOU¡Z—
PatternRecognItIon:DIgItaIIsEIIectvs.ToxIcIty
Instructions:DeterminewhichoItheIollowingECGsareconsistentwithdigitaliseIIectandwhichareconsistentwithdigitalistoxicity.
Choose All That Apply Answer
A. B. Digitalis effectsincludesaggingSTsegment
depressionwithupwardconcavity(choice
“c”), T wave changes (Ilat, inverted, or
biphasic),shorteningoItheQTinterval,and
PRlengthening.STchangesarediIIicultto
interpretinthesettingoILVH,RVH,or
bundlebranchblock;however,iItypical
saggingSTsegmentsarepresentandtheQT
intervalisshortened,digitaliseIIectshouldbe
considered.(Answer:c)
Digitalis toxicitycancausealmostanytypeoI
cardiacdysrhythmiaorconduction
disturbance,exceptbundlebranchblock
(choice“ ”).Examplesincludeatrial
tachycardiawithblock(choice“a”),atrial
IibrillationwithregularRRintervals(Irom
completeheartblockwithjunctionalescape
rhythm),second-orthird-degreeAVblock
(choice“b”),completeheartblockwith
acceleratedjunctionaloridioventricular
rhythm(choice“d”),andSVTwith
alternatingbundlebranchblock.Digitalis
toxicitymaybeexacerbatedbyhypokalemia,
hypomagnesemia,orhypercalcemia.Note:
ElectricalcardioversionoIatrialIibrillationis
contraindicatedinthesettingoIdigitalis
toxicityduetotheincreasedriskoIprotracted
asystoleorventricularIibrillation.
(Answer:a,b,d)
C. D.
E.
e
255
Don't Get Confusedl
Atrial Tachycardia with AV Block
P wave axis or morphology diIIerent Irom sinus node,
regular atrial rate oI 100-240 per minute, isoelectric intervals
between P waves in all leads, and second- or third-degree
AV block with nonconducted P waves
May be conIused wIth:
$WULDOIOXWWHU
Atrial tachycardia with AV block has a distinct isoelectric
baseline between P waves and an atrial rate oI 100-240 per
minute, whereas atrial Ilutter lacks an isoelectric baseline
(except in lead V
1
) and has an atrial rate oI 240-340 per
minute
256
ECG 41. Asymptomatic 61-year-old female:
257
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
258
ECG 41 was obtained in an asymptomatic 61-year-old Iemale. The ECG shows a normal sinus rhythm with a PR interval at the upper limit
oI normal (0.20 seconds). There is a prominent R wave in V
2
(asterisk) with subsequent loss in R wave voltage Irom V
2
to V
3
, which is due to
V
2
-V
3
electrode switch. This is otherwise a normal tracing.
Codes: 03 Incorrect electrode placement
07 Sinus rhythm
*
259
Ouestions: ECG 41
1. Both limb lead reversal and dextrocardia demonstrate:
a. Inversion oI the P-QRS-T in leads I and aVL
b. Abnormal R wave progression in V
1
-V
6
c. Right ventricular hypertrophy
d. Right atrial abnormality
2. Incorrect electrode placement oI one oI the precordial leads
oIten maniIests as unexplained loss oI R wave voltage in the
aIIected lead:
a. True
b. False
Answers: ECG 41
1. Limb lead reversal can be mistaken Ior dextrocardia, since both
conditions maniIest inversion oI the P-QRS-T complex in leads
I and aVL. Dextrocardia is associated with reverse R wave
progression in leads V
1
-V
6
, right ventricular hypertrophy, and
right atrial abnormality, none oI which are present in limb lead
reversal. (Answer: a)
2. Incorrect electrode placement in one oI the precordial leads
usually maniIests as unexplained loss oI R wave voltage in the
aIIected lead (e.g., V
2
), Iollowed by return oI normal R wave
progression in the remaining leads (e.g., V
3
-V
6
). (Answer: a)
- («:·/ k:.::« ;1 - - («:·/ k:.::« ;1 - - («:·/ k:.::« ;1 - - («:·/ k:.::« ;1 -
¡ncorrect electrode placement
Limb leuJ reteroul (reteroul of right unJ
left urm leuJo)
· Resultant ECG mimics dextrocardia with oI
the P-QRS-T in leads and aVL
· To distinguish between these conditions, look at
precordial leads: dextrocardia shows
(reverse/normal) R wave progression, while limb
lead reversal shows (reverse/normal) R wave
progression.
PrecorJiul leuJ reteroul: Unexplained
decrease in voltage in two consecutive leads
(e.g., V
1
, V
2
) with a return to normal progression in
the Iollowing leads
inversion
I
reverse
normal
R wave
260
- POP OU¡Z -
Pattern RecognItIon: CIInIcaI DIsorders
,QVWUXFWLRQV Determine the clinical diagnosis associated with each oI the Iollowing ECGs.
(&* 'LDJQRVLV $QVZHU
Plus reverse precordial R-wave progression
a. Atrial septal deIect, primum
b. Atrial septal deIect, secundum
c. Dextrocardia
d. Intracerebral hemorrhage
e. Limb lead reversal
I. Precordial lead reversal
g. Digitalis eIIect
h. Hypothermia
i. Pericardial eIIusion
'H[WURFDUGLD results in an inverted ('upside down¨) P-QRS-
T in leads I and aVL, and reverse R wave progression in the
precordial leads (decreasing R wave amplitude Irom leads
V
1
-V
6
). Inverted P-QRS-T in leads I and aVL with normal
precordial R wave progression suggests limb lead reversal.
(Answer: c)
3HULFDUGLDOHIIXVLRQ may present with electrical alternans
(alternation in the amplitude or direction oI P, QRS, and/or T
waves) and low voltage QRS, but neither Iinding is sensitive
or speciIic Ior the diagnosis: Only one-third oI patients with
QRS alternans have a pericardial eIIusion, and only 12° oI
patients with pericardial eIIusions have electrical alternans.
II electrical alternans involves the P-QRS-T ('total
alternans¨), eIIusion with tamponade is oIten present. Sinus
tachycardia is almost always present when pericardial
eIIusion progresses to cardiac tamponade. (Answer: i)
3UHFRUGLDOOHDGUHYHUVDO results in an unexplained decrease
in R wave voltage in two consecutive precordial leads (e.g.,
V
1
, V
2
), Iollowed by a return to normal R wave progression
(e.g., V
3
-V
6
). (Answer: I)
261
Common Dilemmas
in ECG ¡nterpretation
Problem:
The ECG shows an acute myocardial inIarction. Should any
other ECG diagnoses be coded?
Recommendation
Yes. It is also important to code item 65 (ST and/or T
abnormalities suggesting myocardial injury) when acute
myocardial inIarction is present. Also code item 65 when
ST segment depression is present in leads V
1
and V
2
in the
setting oI posterior MI.
262
ECG 42. 66-year-old male in the emergency room
with palpitations and syncope:
263
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULARRHYTHM8 RHYTHM8 RHYTHM8 RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
264
ECG 42 was obtained in a 66-year-old male who was taken to the emergency room with palpitations and syncope. The ECG shows a rapid
wide complex tachycardia at 146 beats/minute. The wide QRS duration (0.15 seconds) suggests a ventricular origin Ior the tachycardia; this
is conIirmed by the presence oI an underlying sinus tachycardia at approximately 120 beats/minute (arrows mark the P waves), resulting in AV
dissociation, and the presence oI ventricular capture complexes, maniIesting as Iusion complexes in the sixth beat on the rhythm strip and every
seventh beat thereaIter (asterisks). The QRS axis is rightward (measuring 98° by the computer), but does not meet criteria Ior right axis deviation
(~ 100°). Irregularity in the baseline in leads I and aVR is due to artiIact.
Codes: 04 ArtiIact
10 Sinus tachycardia (~ 100)
25 Ventricular tachycardia (~ 3 consecutive complexes)
35 AV dissociation
* *
*
265
Ouestions: ECG 42
1. ECG Iindings in this tracing Iavoring the diagnosis oI
ventricular tachycardia over supraventricular tachycardia
include:
a. AV dissociation
b. Concordance oI QRS complexes in V
1
- V
6
c. Fusion beats
d. Monophasic right bundle branch block pattern in V
1
e. QRS ~ 0.14 seconds
2. Fusion complexes during wide QRS tachycardia Iavor the
diagnosis oI supraventriclar tachycardia over ventricular
tachycardia:
a. True
b. False
3. The origin oI the ventricular tachycardia in this tracing is:
a. Right ventricle
b. LeIt ventricle
c. Unable to determine
Answers: ECG 42
1. Answer: All
2. Fusion complexes result Irom simultaneous activation oI the
ventricle Irom two diIIerent sources, resulting in a QRS complex
intermediate in morphology between the QRS complexes oI
each source. Although not a common Iinding, Iusion complexes
in the setting oI a wide QRS tachycardia are highly suggestive
oI ventricular tachycardia. (Answer: b)
3. In general, a positive QRS deIection in lead V
1
suggests a leIt
ventricular origin Ior ventricular tachycardia, while a negative
QRS in lead V
1
suggests a right ventricular origin. (Answer: b)
266
- («:·/ k:.::« ;z - - («:·/ k:.::« ;z - - («:·/ k:.::« ;z - - («:·/ k:.::« ;z -
Ventricular tachycardia
· Rapid succession oI three or more premature
ventricular beats at a rate ~ per minute
· RR intervals are usually regular but may be
irregular (true/Ialse)
· (Abrupt/gradual) onset and termination are evident
· AV is common
· Look Ior ventricular complexes and
beats as markers Ior VT
100
true
Abrupt
dissociation
capture, Iusion
Fusion complexes
· Due to simultaneous activation oI the ventricle
Irom sources, resulting in a QRS complex
that is in morphology between each source
2
intermediate
AV dissociation
· Atrial and ventricular rhythms are oI each
other
· Ventricular rate is (·/~) than the atrial rate
independent
~
267
Differential Diagnosis
LOW VOLTAGE ECG
(Amplitude oI the entire QRS complex (R¹S) · 10 mm
in all precordial leads and · 5 mm in all limb leads)
· Chronic lung disease
· Pericardial eIIusion
· Myxedema
· Obesity
· Pleural eIIusion
· Restrictive or inIiltrative cardiomyopathies
· DiIIuse coronary disease
268
ECG 43. 74-year-old diabetic male with sudden onset
of dyspnea:
269
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
270
ECG 43 was obtained Irom a 74-year-old diabetic male with sudden onset oI dyspnea. The ECG shows sinus rhythm at a rate oI 64
beats/minute with RBBB. There is an ectopic supraventricular beat (arrow), which most likely represents an atrial premature complex (small
deIormity in downslope oI T wave just preceding the premature QRS complex in leads V
5
-V
6
is probably a P wave |arrowheads|). Most notable
are the presence oI abnormal Q waves and marked ST segment elevation in the precordial leads, consistent with acute anterior MI with lateral
myocardial injury. Leads III and aVF show mild ST segment depression, which most likely represents reciprocal changes. The vertical lines
in each lead (asterisks) represent lead switch markers, not pacemaker spikes.

Codes: 07 Sinus rhythm
13 Atrial premature complexes
43 RBBB, complete
53 Anterior or anteroseptal MI (age recent or acute)
65 ST and/or T wave abnormalities suggesting myocardial injury
*
* *
* * *
* *
*
271
Ouestions: ECG 43
1. The age oI the myocardial inIarction on this ECG is:
a. Hours-to-days
b. Days-to-weeks
c. Weeks-to-months
2. Which oI the Iollowing statements are about right bundle branch
block (RBBB) are true:
a. RBBB impairs the ability to diagnose LVH on ECG
b. RBBB impairs the ability to diagnose Q wave myocardial
inIarction on ECG
c. RBBB impairs the ability to determine QRS axis
d. Most patients with RBBB have structural heart disease
Answers: ECG 43
1. Q waves usually develop in the hours-to-days aIter MI, and may
persist indeIinitely, regress, or inIrequently disappear. ST
elevation usually develops in seconds-to-minutes aIter MI and
resolves in minutes-to-hours aIter reperIusion oI the inIarct
artery. II reperIusion is not achieved, ST elevation resolves
slowly over hours-to-days. ST elevation persisting beyond 48
hours post-MI is an adverse prognostic marker. T wave
inversion begins beIore the ST segment returns to baseline. The
present ECG shows Q waves and ST elevation, but no T wave
inversion, suggesting an inIarct that is hours-to-days old.
(Answer: a)
2. Most patients with RBBB have either coronary artery disease
(most common), hypertensive heart disease, myocarditis,
cardiomyopathy, rheumatic heart disease, cor pulmonale (acute
or chronic), degenerative disease oI the conduction system
(Lenegre`s disease), or sclerosis oI the cardiac skeleton (Lev`s
disease). Patients with RBBB and anatomical LVH may not
maniIest increased QRS voltage; however, LVH can still be
diagnosed when voltage criteria are met. The Iirst 0.04 - 0.06
seconds oI the QRS is unaIIected by RBBB, and can be used to
identiIy QRS axis and abnormal Q waves oI myocardial
inIarction. (Answer: a, d)
272
- («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; -
RBBB, complete
· QRS duration ~ seconds
· Secondary R wave (R) in lead is usually
(shorter/taller) than the initial R wave
· Onset oI intrinsicoid deIlection in leads V
1
and V
2
~ seconds
· ST segment and T wave
in V
1
, V
2
· Wide slurred S wave in leads
· QRS axis is usually (normal/leItward/rightward)
0.12
V
1
taller
0.05
depression
inversion
I, V
5
, V
6
normal
8T and/or T wave changes suggesting
myocardial in]ury
· Acute ST segment (elevation/depression) with
upward (convexity/concavity) in the leads
representing the area oI inIarction
· T waves invert (beIore/aIter) ST segments return
to baseline
· Associated ST (elevation/depression) in the
noninIarct leads is common
· Acute wall injury oIten has horizontal or
downsloping ST segment depression with upright
T waves in V
1
-V
3
, with or without a prominent R
wave in these same leads
elevation
convexity
beIore
depression
posterior
273
- POP OU¡Z -
DIIIerentIaI DIagnosIs: QRS AmpIItude
,QVWUXFWLRQV For each diagnosis below, select all QRS amplitude changes that apply:
a. Low voltage QRS
b. Tall (large amplitude) QRS
c. Prominent R wave in V
1
d. QRS alternans (alternation in amplitude)
'LDJQRVLV $QVZHU
LeIt ventricular hypertrophy (LVH) Tall QRS. QRS alternans sometimes in hypertensive heart disease. (Answer: b, d)
LeIt bundle branch block (LBBB) Tall QRS. LBBB interIeres with determination oI QRS axis, ventricular hypertrophy, and MI. (Answer: b)
Thin body habitus Tall QRS (may lead to Ialse-positive diagnosis oI LVH). (Answer: b)
Right ventricular hypertrophy (RVH) Prominent R wave in V
1
. Right axis deviation and deep S waves in V
5
V
6
are common. (Answer: c)
DiIIuse coronary disease Low voltage QRS (inIrequent); QRS alternans (inIrequent). (Answer: a, d)
Right bundle branch block (RBBB) Prominent R wave in V
1
. (Answer: c)
Chronic lung disease (e.g., emphysema)
with pulmonary hypertension
Low voltage QRS; prominent R wave in V
1
(iI pulmonary hypertension with RVH is present). (Answer: a, c)
Pericardial eIIusion Low voltage QRS; QRS alternans in some. II electrical alternans involves the P-QRS-T ('total alternans),
pericardial eIIusion with cardiac tamponade is oIten present. (Answer: a, d)
Posterior myocardial inIarction Prominent R wave in V
1
and/or V
2
with ST depression and upright T waves. InIerior MI is common. (Answer: c)
Myxedema Low voltage QRS. Sinus bradycardia and Ilattened or inverted T waves are common. (Answer: a)
InIiltrative cardiomyopathy Low voltage QRS. PseudoinIarct pattern (abnormal Q waves) may occur. (Answer: a)
Obesity Low voltage QRS. Ability to detect ventricular hypertrophy based on voltage criteria is impaired. (Answer: a)
274
ECG 44. 57-year-old female with a routine ECG prior
to elective surgery:
275
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary
embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
276
ECG 44 was obtained in a 57-year-old Iemale on routine testing prior to elective surgery. The ECG shows sinus rhythm with changes in the
PP interval consistent with sinus arrhythmia (PP interval varies by 0.16 seconds). In addition, the QRS morphology is observed to change
during the recording; due to intermittent pre-excitation (intermittent WolII-Parkinson-White pattern). Except Ior the 3
rd
and 9
th
beats (asterisks),
all other beats demonstrate a short PR interval, delta wave (arrow), and prolonged QRS duration consistent with WPW pattern and conduction
across an accessory bypass tract. The 3
rd
and 9
th
beats occur early, when the accessory pathway is still reIractory (blocked), and demonstrate
normal AV conduction and QRS complexes.
Codes: 07 Sinus rhythm
08 Sinus arrhythmia
34 WolII-Parkinson-White pattern
277
Ouestions: ECG 44
1. In patients in WPW pattern on ECG, which Ieature is associated
with a low risk Ior developing rapid ventricular rate during atrial
Iibrillation:
a. The accessory pathway connects the leIt atrium and leIt
ventricle
b. Intermittent conduction over the accessory pathway in sinus
rhythm
c. Loss oI accessory pathway conduction during atrio-
ventricular reentry tachycardia
Answers: ECG 44
1. Patients with WPW pattern on their ECG are at risk Ior
developing rapid conduction over the accessory pathway during
atrial Iibrillation. This rapid conduction can result in a very
rapid ventricular rate and possibly syncope or even sudden
cardiac death. The rapidity oI accessory pathway conduction
bears no relationship to its location in the heart. Similarly,
when patients with WPW pattern develop typical
atrioventricular (orthodromic) reentry, preexcitation is lost on
ECG since the electrical impulse travels down the AV node and
His-Purkinje system, resulting in normal activation oI the
ventricle. (The impulse returns to the atrium over the accessory
pathway completing the reentrant circuit.) The presence oI
intermittent conduction over the accessory pathway in sinus
rhythm is a reliable marker that the accessory pathway is not
capable oI rapid conduction during atrial Iibrillation and
thereIore does not place the patient at risk Ior a rapid ventricular
rate with syncope or sudden cardiac death. (Answer: b)
- («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; - - («:·/ k:.::« ;; -
8inus arrhythmia
· (Sinus/nonsinus) P wave
· Longest and shortest PP intervals vary by ~
seconds or 10°
· Sinus arrhythmia diIIers Irom 'ventriculophasic¨
sinus arrhythmia, the latter oI which occurs in the
setting oI
Sinus
0.16
heart block
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 278 —
A.
B.
C.
D.
Answer: Tracings A, B, and D are examples of complete heart block: P waves bear no consistent relationship to the QRS complexes
and PP and RR intervals are constant. In these examples, the ventricular rhythm is maintained by a junctional (narrow complex) or
ventricular (wide complex) escape rhythm. Tracing C shows sinus rhythm with 2:1 AV block and is the imposter. Every other P wave
is conducted with a PR interval of 0.16 seconds.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 279 —
A.
B.
C.
D.
Answer: Tracings B, C, and D demonstrate a regular, narrow QRS tachycardia with the suggestion of retrograde P waves at the end
of each QRS complex. These rhythms are consistent with SVT, most likely reentry within the AV node or using a concealed accessory
pathway. Tracing A shows atrial fbrillation and is the imposter. It shows a narrow QRS tachycardia that is irregular with no clear atrial
activity. The irregular QRS intervals and the lack of clear P waves are consistent with atrial fbrillation.
280
ECG 45. 35-year-old male with syncope:
281
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
282
ECG 45 was obtained in a 35-year-old male with syncope and shows sinus rhythm with normally conducted APCs (asterisks). LVH (S wave
in aVR ~ 15mm; R wave in aVF ~ 21mm; R wave in V
5
¹ S wave in V
1
~ 40mm; R wave in V
6
~ 20mm) with associated ST-T abnormalities
are evident. Markedly increased QRS voltage and ST-T abnormalities in a young person with syncope suggest the diagnosis oI hypertrophic
cardiomyopathy (the inIerior and anterolateral Q waves are secondary to hypertrophic cardiomyopathy, not previous inIarction).
Codes: 07 Sinus rhythm
13 Atrial premature complexes
40 LeIt ventricular hypertrophy
67 ST and/or T wave abnormalities secondary to hypertrophy
85 Hypertrophic cardiomyopathy
* * *
*
283
Ouestions: ECG 45
1. Which oI the Iollowing statements about hypertrophic
obstructive cardiomyopathy are true?
a. LeIt atrial abnormality is Irequently seen
b. Right axis deviation occurs in ~ 30° oI cases
c. LVH is present in ~ 90° oI cases
d. Pathological Q waves occur in 20-30° oI cases
e. ST and T wave changes are the most common Iinding
I. Sinus node disease and AV block are common
g. Nonsustained VT is a risk Iactor Ior sudden death
2. Causes oI ST segment depression include:
a. Hyperkalemia
b. Hypokalemia
c. Digoxin
d. Quinidine
e. Mitral valve prolapse
3. Which causes oI ST segment depression in Question 2 are
associated with:
a Atrial Iibrillation with a regular ventricular response
b. Prominent U waves
4. LVH by voltage criteria is more likely to represent true
anatomical LVH in younger patients compared to older patients:
a True
b. False
Answers: ECG 45
1. Hypertrophic cardiomyopathy is an uncommon disorder
characterized by altered myocyte shape, size and alignment,
which along with increased myocardial Iibrosis, results in
marked ventricular hypertrophy, LV stiIIness, and diastolic
dysIunction. The vast majority oI patients have abnormal ECGs,
with LVH in 50-65°, leIt atrial abnormality in 20-40°, and
pathological Q waves (especially leads I, aVL, V
4
- V
5
) in 20-
30°. ST and T wave changes (repolarization abnormalities
secondary to LVH) are the most common ECG Iindings, while
right axis deviation is rare. The most Irequent cause oI mortality
is sudden death, with risk Iactors including young age and a
history oI syncope and/or asymptomatic ventricular tachycardia
on ambulatory monitoring. Sinus node disease and AV block
are uncommon maniIestations oI this disorder. (Answer: a, d,
e, g)
2. ST depression is a common maniIestation oI hypokalemia, along
with decreased T wave amplitude and prominent U waves.
284
Classical digitalis eIIect produces ST depression that pulls down
the Iirst portion oI the T wave to create a diphasic T wave,
initially negative and then positive. ST depression can also be
seen in patients taking quinidine, in conjunction with prolonged
QT interval, Ilat or inverted T waves, and a prominent U wave.
Approximately 20-40° oI patients with mitral valve prolapse
maniIest some degree oI ST depression and/or T wave inversion,
especially in the inIerior leads. ST segment depression is not a
usual maniIestation oI hyperkalemia, although ST segment
elevation can occur in advanced cases. (Answer: all)
3. Atrial Iibrillation with a regular ventricular response should
raise the suspicion oI digitalis toxicity. In this setting,
regularization oI the ventricular response is due to complete
heart block and accelerated junctional rhythm. Digitalis
toxicity may be exacerbated by hypokalemia, hypomagnesemia,
and hypercalcemia. Electrical cardioversion oI atrial Iibrillation
is contraindicated in the setting oI digitalis toxicity due to the
risk oI ventricular Iibrillation. (Answer to 3a ÷ c; Answer to 3b
÷ b, c, d, e)
4. Increased QRS voltage is commonly observed in young adults
with normal hearts. Many electrocardiographers are reluctant to
diagnose LVH by voltage criteria alone in patients under the age
oI 40, and require other changes to be present (e.g., strain
pattern, leIt axis deviation, delayed onset oI intrinsicoid
deIlection, poor R wave progression). (Answer: b)
- («:·/ k:.::« ;, - - («:·/ k:.::« ;, - - («:·/ k:.::« ;, - - («:·/ k:.::« ;, -
Hypertrophic cardiomyopathy
· (Right/leIt) atrial abnormality is common;
(right/leIt) atrial abnormality on occasion
· Majority have abnormal QRS complexes
(true/Ialse):
(Small/large) amplitude QRS
Large abnormal waves (can give
pseudoinIarct pattern in inIerior, lateral, and
anterior precordial leads)
Tall R wave with inverted T wave in V
1
simulating
NonspeciIic ST and/or T wave abnormalities are
common (true/Ialse)
Apical variant oI hypertrophic cardiomyopathy
has deep T wave inversions in leads
(Right/leIt) axis deviation in 20°
leIt
right
true
large
Q
RVH
Ialse
V
4
-V
6
leIt
285
Differential Diagnosis
PROLONGED OT ¡NTERVAL
(corrected QT interval ~ 0.42-0.46 seconds)
· Drugs (quinidine, procainamide, disopyramide,
amiodarone, sotalol, phenothiazine, tricyclics, lithium)
· Hypomagnesemia
· Hypocalcemia
· Marked bradyarrhythmias
· Intracranial hemorrhage
· Myocarditis
· Mitral valve prolapse
· Hypothyroidism
· Hypothermia
· Liquid protein diets
· Romano-Ward syndrome (normal hearing)
· Jervell and Lange-Nielson syndrome (deaIness)
286
ECG 46. 68-year-old male with fatigue and dyspnea:
287
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
288
ECG 46 was obtained in a 68-year-old male with Iatigue and dyspnea, and shows sinus arrest with a junctional rhythm at approximately 40
beats/minute. The slight irregularity in the early portion oI the rhythm strip is due to the presence oI an AV junctional premature complex
(asterisk). The sagging ST segment depression (arrowheads) is typical Ior digitalis eIIect (even though it could also be coded as nonspeciIic ST-T
abnormalities). Prominent U waves are present (arrows). This constellation oI Iindings is consistent with digitalis toxicity.
Codes: 11 Sinus pause or arrest
20 AV junctional premature complexes
22 AV junctional rhythm/tachycardia
69 Prominent U waves
70 Digitalis eIIect
71 Digitalis toxicity
*
289
Ouestions: ECG 46
1. ECG Iindings attributable to digitalis eIIect as opposed to
digitalis toxicity include:
a. Right bundle branch block
b. Paroxysmal atrial tachycardia with block
c. Atrial Iibrillation with regular ventricular response
d. Bidirectional ventricular tachycardia
e. Complete heart block
I. Sagging ST segment depression
g. Decreased T wave amplitude
h. Shortening oI the QT interval
i. U waves
j. Increased PR interval
k. LeIt bundle branch block
2. Findings on this ECG consistent with hyperkalemia include:
a. Flattened T waves
b. Absent P waves
c. Intraventricular conduction delay
d. Prominent U waves
Answers: ECG 46
1. Typical digitalis eIIects include prolonged PR interval, sagging
ST segment depression, decreased T wave amplitude, shortened
QT interval, and prominent U waves. Arrhythmias and
conduction disturbances associated with digitalis toxicity
include paroxysmal atrial tachycardia (PAT) with block, atrial
Iibrillation with a regular ventricular response, junctional
tachycardia, bidirectional ventricular tachycardia, and complete
heart block. Digitalis does not produce bundle branch block or
atrial Ilutter. (Answer: I, g, h, i, j)
2. The lack oI P waves and the presence oI IVCD are consistent
with the diagnosis oI hyperkalemia. However, normal T wave
amplitude speaks strongly against this diagnosis, especially
when hyperkalemia is acute. Prominent U waves are Irequently
observed in hypokalemia, not hyperkalemia. (Answer: b, c)
290
- («:·/ k:.::« ;( - - («:·/ k:.::« ;( - - («:·/ k:.::« ;( - - («:·/ k:.::« ;( -
8inus pause or arrest
· PP interval ~ seconds
· Resumption oI sinus rhythm at a PP interval that
(is/is not) a multiple oI the basic sinus PP interval
· II sinus rhythm resumes at a multiple oI the basic
PP, consider
1.6-2.0
is not
sinoatrial exit block
AV ]unctional rhythm
· Rate per minute
· QRS complex may be narrow or aberrant
(true/Ialse)
· Inverted P waves in leads and upright P waves
in leads are common
· RR interval oI escape rhythm is usually
(constant/variable)
60
true
II, III, aVF
I, aVL
constant
Digitalis toxicity
· Digitalis toxicity can cause almost any type oI
cardiac dysrhythmia or conduction disturbance
except
· Typical abnormalities include:
Paroxysmal tachycardia with block
Atrial Iibrillation with heart block
Second or third-degree block
Complete heart block with accelerated or
rhythm
Supraventricular tachycardia with bundle
branch block
bundle branch
block
atrial
complete
AV
junctional
idioventricular
alternating
291
- POP OU¡Z -
FInd The MIstake
,QVWUXFWLRQV IdentiIy the incorrect ECG Ieature(s) Ior each oI the ECG
diagnoses listed below
(&*)HDWXUHV 0LVWDNH
Atrial tachycardia with block
· Sinus P waves
· Atrial rate oI 150-240 per minute
· Isoelectric intervals between P waves in some but not
all leads
· Second- or third-degree AV block
· Rhythm is regular
Nonsinus P waves
are present;
isoelectric intervals
are present in all
leads
Multifocal atrial tachycardia
· Atrial rate ~ 100 per minute
· P waves with ~ 3 morphologies
· PR, RR intervals vary
· RP interval is constant
RP interval varies
(not constant)
Atrial flutter
· Rapid regular atrial undulations at 240-340 per minute
· Undulations in leads II, III, AVF, and V
1
are typically
inverted without an isoelectric baseline
In V
1
, Ilutter waves
are typically small
positive deIlections
with a distinct
isoelectric baseline
Atrial fibrillation
· Totally irregular atrial activity maniIests as undulations
oI varying amplitude, duration and morphology
· Ventricular rhythm is irregularly irregular
· Atrial activity may regularize with digitalis toxicity
Ventricular activity
may regularize with
digitalis toxicity,
but atrial activity
remains irregular
— 292 —
ECG 47. 68-year-old asymptomatic male:
I
V1 V4 aVR
aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II II II II
293
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
— 294 —
ECG 47 was obtained in a 68-year old asymptomatic male. In the first half of the tracing, the patient is in a sinus rhythm at approxi-
mately 77 bpm. After the third QRS complex, the distortion in the T-wave is caused by a blocked APC. In the second half of the tracing,
a second APC is noted; this one is conducted aberrantly, resulting in right bundle branch block QRS pattern. In the interim between the
first blocked APC and the second conducted APC, the sinus rhythm increased from 77 bpm to 81 bpm. The fact that the first APC was
blocked and the second one conducted (aberrantly) was a manifestation of Ashman’s Phenomenon. The tracing also shows left atrial
abnormality/enlargement and non-specific repolarization abnormalities, particularly noticeable in leads I, II, III, aVF, and V3.
Codes: 06 Left atrial abnormality / enlargement
07 Sinus rhythm
13 Atrial premature complexes
50 Functional (rate-related) aberrant intraventricular conduction
63 Nonspecific ST and/or T-wave abnormalities
I
V1 V4 aVR
aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II II II II
— 295 —
Ashman’s Phenomenon describes the situation whereby the repolarization of the right and left bundles is rate related. At a faster sinus
rate, the bundles repolarize more quickly and thus an APC is more likely to be conducted than when the sinus rate is slower at the time
of the APC. The diagram above depicts how at the slower rate of 77 bpm the atrial impulse was blocked in both the right and left bundles
(resulting in a blocked APC). However at the faster rate, the bundles repolarized more quickly and although the timing of the APC was
identical to the first one, this impulse was conducted through to the ventricles via the left bundle (the right bundle remained refractory).
77 bpm
II
II
81 bpm
R L
R L
296
ECG 48. 54-year-old male with chest pain:
ECG A ECG B
297
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary
embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
298
ECG 48A and 48B were obtained in a 54-year-old male with chest pain. ECG 85A shows an acute inIerior myocardial inIarction with ST-T
wave changes oI injury and diagnostic Q waves in leads II, III, and aVF. In addition, there is right axis deviation with a small R wave in leads
I and aVL, consistent with leIt posterior Iascicular block. The T wave depression in leads I, aVL, V
1
and V
2
may be due to ischemia, reciprocal
changes (associated with the inIerior injury), or posterior injury. In ECG 85B, right-sided chest leads are recorded V
1
is placed in the usual
V
2
position and the remaining chest leads are placed over the right chest which allows recording oI electrical activity as it passes through the
right ventricle. By recording right-sided chest leads in this patient, and injury pattern is observed in leads V
3
-V
6
consistent with acute right
ventricular injury.
Codes: 06 LeIt atrial abnormality/enlargement
07 Sinus rhythm
46 LeIt posterior Iascicular block
57 InIerior (age recent or acute)
65 ST and/or T wave abnormalities suggesting myocardial injury
ECG A ECG B

299
Ouestions: ECG 48
1. Right-sided chest leads are superior to the standard 12-lead
recording Ior identiIying which oI the Iollowing abnormalities
aIIecting the right ventricular:
a. Ischemia
b. InIarction
c. Injury
d. Conduction delay
Answers: ECG 48
1. Typically, the right ventricular contribution to the standard
12-lead ECG is minimal due to the large myocardial mass oI the
leIt ventricule and lead positioning over the leIt chest.
ThereIore, iI there is a concern that myocardial inIarction may
be involving the right ventricle, it is helpIul to place leads on the
right side oI the chest to allow more accurate recording oI the
right ventricle. (For right-sided chest leads, V
1
is placed in the
usual V
2
position, and V
3
R-V
6
R are placed in the same locations
as V
3
-V
6
but over the right chest.) However, the leads over the
right ventricle are still strongly inIluenced by activation oI the
leIt ventricle, which proceeds away Irom the right ventricular
leads, oIten resulting in a Q wave or QS complex even when
there is no evidence oI inIarction. Similarly, the diagnosis oI
ischemia is diIIicult because oI the inIluences oI the leIt
ventricle on right-sided chest lead recordings. Conduction delay
involving the right ventricle, such as right bundle branch block,
is still best recorded using the standard 12-lead ECG. In
contrast, right-sided chest leads are very useIul Ior the
identiIication oI right ventricular injury; 1 mm ST elevation
in lead V
4
R has ~ 90° sensitivity and speciIicity Ior right
ventricular involvement in the setting oI acute inIerior wall MI.
(Answer: c)
- («:·/ k:.::« ;2 - - («:·/ k:.::« ;2 - - («:·/ k:.::« ;2 - - («:·/ k:.::« ;2 -
Left posterior fascicular block
· (LeIt/right) axis deviation with mean QRS axis
between and degrees
· QRS duration between and seconds
· No other Iactor responsible Ior axis deviation
right
100, 180
0.08, 0.10
right
¡nferior M¡, probably acute or recent
· Abnormal Q waves and ST elevation in at least
two oI leads
· Associated ST depression is usually evident in
leads I, aVL, V
1
-V
3
(true/Ialse)
II, III, aVF
true
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 300 —
A.
B.
C.
D.
Answer: Tracings A and B have irregular QRS intervals with no clear atrial activity and are consistent with atrial fbrillation. Tracing
C shows atrial fbrillation with evidence of fbrillatory waves giving a more coarse appearance to the baseline when compared with
tracings A and B. Tracing D shows multifocal atrial tachycardia and is the imposter. It demonstrates irregular QRS intervals with each
QRS complex being preceded by a P wave with more than three different P wave morphologies present. The fnding of an irregular
narrow QRS complex tachycardia with three or more P wave morphologies is consistent with multifocal atrial tachycardia.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 301 —
A.
B.
C.
D.
Answer: Tracing A shows a markedly widened QRS complex and P waves that 'march through¨ the rhythm. The QRS prolongation
and AV dissociation allow diagnosis of ventricular tachycardia. In tracing C the QRS complexes are markedly prolonged consistent
with ventricular tachycardia, although no atrial activity can be identifed. In the middle of tracing C is a QRS complex of different
morphology, suggesting a 'fusion¨ complex, a fnding consistent with ventricular tachycardia. Tracing D demonstrates a relatively
narrow QRS tachycardia. However, atrial activity can be observed to be 'marching through¨ the tachycardia supporting the diagnosis
of ventricular tachycardia with AV dissociation. Tracing B shows sinus tachycardia with a P wave preceding each QRS complex and is
the imposter.
302
ECG 49. 28-year-old female with weakness:
303
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULARRHYTHM8 RHYTHM8 RHYTHM8 RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
304
ECG 49 was obtained Irom a 28 year-old Iemale with weakness. The ECG shows sinus rhythm at a rate oI 65 beats/minute. The corrected
QT interval is prolonged (0.52 seconds), primarily due to lengthening oI the ST segment (asterisk), which is characteristic oI hypocalcemia.
Baseline artiIact is seen in several leads, especially in V
1
.The patient was Iound to have a serum calcium level oI 5.9 mg/dL.
Codes: 04 ArtiIact
07 Sinus rhythm
66 ST and/or T waves suggesting electrolyte disturbances
68 Prolonged QT interval
77 Hypocalcemia
*
*
305
Ouestions: ECG 49
1. Hypocalcemia results in prolongation oI the QT interval due to:
a. QT interval and U wave Iusion
b. ST segment and T wave prolongation
c. Increased QT interval dispersion
d. ST segment prolongation
2 At a heart rate oI 50 BPM, the normal corrected QT interval ÷
+ 0.04 seconds
a. 0.36
b. 0.38
c. 0.42
d. 0.44
Answers: ECG 49
1. Hypocalcemia prolongs the QT interval by lengthening the ST
segment (without changing T wave duration). Hypocalcemia is
the only electrolyte abnormality associated with isolated ST
segment prolongation. (Answer: d)
2. The normal corrected QT interval varies inversely with heart
rate, and can be estimated by using 0.40 seconds as the normal
QT interval Ior a heart rate oI 70 BPM, then adding (or
subtracting) 0.02 seconds Ior every 10 BPM below (or above)
70 BPM. For a heart rate oI 50 BPM, the normal corrected QT
interval ÷ 0.04 ¹ (2 x 0.02 seconds) ÷ 0.44 + 0.04 seconds.
(Answer: d)

- («:·/ k:.::« ;7 - - («:·/ k:.::« ;7 - - («:·/ k:.::« ;7 - - («:·/ k:.::« ;7 -
Prolonged OT interval
· Corrected QT interval (QTc) ~ seconds,
where QTc ÷ QT interval divided by the square
root oI the preceding interval
· QT interval varies (directly/inversely) with heart
rate
· The normal QT interval should be (less
than/greater than) 50° oI the RR interval
0.42-0.46
RR
inversely
less than
Hypocalcemia
· Earliest and most common Iinding is prolonged
interval
· Occasional Ilattening, peaking, or inversion oI
waves
QT
T
306
ECG 50. 58-year-old male with lung cancer:
307
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
308
ECG 50 was obtained Irom a 58-year-old male with lung cancer. The ECG shows sinus rhythm at a rate oI 72 beats/minute. Most notable is the
presence oI a short QT interval (0.32 seconds) with a very short ST segment (arrows); in the setting oI a malignancy such as lung cancer, this Iinding
strongly suggests the presence oI hypercalcemia. At the time this ECG was obtained, the patient`s serum calcium was 13.5 mg/dL.
Codes: 07 Sinus rhythm
66 ST and/or T waves suggesting electrolyte disturbances
76 Hypercalcemia
309
Ouestions: ECG 50
1. ECG changes associated with hypercalcemia include:
a. Prolongation oI the QT interval
b. Shortening oI the ST segment
c. Flattening oI the T wave
d. Flattening oI the P wave
e. Increase in QRS duration
2. QT interval shortening can be seen with:
a. Hypocalcemia
b. Hypercalcemia
c. Hyperkalemia
d. Hypokalemia
e. Beta blockers
I. Digitalis
Answers: ECG 50
1. Hypercalcemia causes QT interval shortening, primarily due to
shortening oI the ST segment. There is little (iI any) eIIect on
the P wave, QRS complex, or T wave. (Answer: b)
2. Shortening oI the QT interval occurs with hypercalcemia,
hyperkalemia, digitalis, and beta-blockers. Hypocalcemia and
hypokalemia prolong the QT interval. (Answer: b, c, e, I)
- («:·/ k:.::« ,0 - - («:·/ k:.::« ,0 - - («:·/ k:.::« ,0 - - («:·/ k:.::« ,0 -
Hypercalcemia
· QT interval (lengthening/shortening), primarily
due to shortening oI the segment
· (Marked/little) eIIect on the P-QRS-T complex
shortening
ST
little
310
- POP OU¡Z -
EIectroIyte AbnormaIItIes and the ECG
,QVWUXFWLRQV Match the electrolyte disturbance with all ECG abnormalities that apply.
(OHFWURO\WH$EQRUPDOLW\ &KRRVH$OO7KDW$SSO\ $QVZHU
1. Hyperkalemia
2. Hypokalemia
3. Hypercalcemia
4. Hypocalcemia
a. Widened QRS
b. Prolonged ST segment
c. Prolonged QT interval
d. Shortened QT interval
e. Peaked T waves
I. Prominent U waves
1. EIIects oI K\SHUNDOHPLD on the ECG depend on serum K
¹
levels:
K
¹
÷ 5.5 - 6.5 mEq/L: Tall, peaked, narrow-based T waves, QT interval
shortening, and reversible leIt anterior or leIt posterior Iascicular block
K
¹
÷ 6.5 - 7.5 mEq/L: First-degree AV block, Ilattening and widening oI the
P wave, ST segment depression, and QRS widening
K
¹
~ 7.5 mEq/L: ECG oIten shows disappearance oI P waves (due to sinus
arrest or 'sinoventricular conduction¨), and LBBB, RBBB, or markedly
widened and diIIuse intraventricular conduction delay (sine wave pattern).
Arrhythmias and conduction disturbances include ventricular tachycardia,
ventricular Iibrillation, idioventricular rhythm, or asystole. (Answer: a, d, e)
2. EIIects oI K\SRNDOHPLD on the ECG include prominent U waves, ST segment
depression and Ilattened T waves (seen in 80° oI patients with K
¹
levels ·
2.7 mEq/L), increased P wave amplitude and duration, and occasional QT
prolongation. Arrhythmias and conduction disturbances include paroxysmal
atrial tachycardia (PAT) with block, Iirst-degree AV block, Type I second-
degree AV block, AV dissociation, VPCs, ventricular tachycardia, and
ventricular Iibrillation. (Answer: c, I)
3. EIIects oI K\SHUFDOFHPLD on the ECG include QT shortening (usually due to
shortening oI the ST segment without a change in the duration oI the T wave)
and occasional PR prolongation. Typically, there is no eIIect on the P, QRS,
or T wave. (Answer: d)
4. The primary eIIect oI K\SRFDOFHPLD on the ECG is prolonged QT interval
which is due to ST segment prolongation without a change in the duration oI
the T wave. (Answer: b, c)
311
- POP OU¡Z -
DIIIerentIaI DIagnosIs: QT IntervaI
,QVWUXFWLRQV Determine whether the diagnoses below are associated with a long QT interval or a short QT interval.
'LDJQRVLV $QVZHU
Hypocalcemia Long QT (earliest and most common Iinding), due to prolongation oI the ST segment
without a change in T wave duration.
Hypercalcemia QT shortening (usually Irom shortening oI ST segment). Prolongation oI PR interval is
sometimes seen.
Quinidine eIIect Long QT. Prominent U waves and nonspeciIic ST and T wave changes are common. QRS
widening may occur.
Hypomagnesemia Long QT.
Intracranial hemorrhage Long QT (oIten marked). Prominent U waves and large upright or deeply inverted T
waves in the precordial leads are common.
Mitral valve prolapse Long QT. May also see Ilattened or inverted T waves in II, III, aVF (sometimes in V
1
, V
2
),
ST depression (sometimes in leIt precordial leads), and prominent U waves.
Myocarditis Long QT. Q waves and ST elevation sometimes occur and mimic acute MI.
Hyperkalemia QT shortening. Tall, peaked, narrow-based T waves are common.
Hypothermia Long QT, due to prolongation oI ST segment without a change in T wave duration (only
hypothermia and hypocalcemia do this). Osborne (J) waves, prolongation oI PR interval,
and QRS widening also occur.
Romano Ward Syndrome Long QT (congenital disorder with normal hearing). Jervell and Lange-Nielson syndrome
presents with long QT and congenital deaIness.
Digitalis eIIect QT shortening. Sagging ST depression with upward concavity, T wave changes (Ilat,
inverted, or biphasic), prominent U wave, and PR prolongation are common.
312
ECG 51. 82-year-old male with hypertension:
313
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
314
ECG 51 was obtained in an 82-year-old male with hypertension. The ECG shows sinus rhythm with a conducted atrial premature complex
(APC) (arrow) and a nonconducted APC (arrowhead). First-degree AV block, nonspeciIic intraventricular conduct deIect, and LVH with ST-T
abnormalities are also present. Voltage-based criteria Ior LVH on this tracing include an R wave in aVL ¹ S wave in V
3
~ 28 mm (Cornell
criteria), and an S wave in V
1
¹ R wave in V
5
or V
6
~ 35 mm.
Codes: 07 Sinus rhythm
13 Atrial premature complexes
29 AV block, 1°
40 LeIt ventricular hypertrophy
49 NonspeciIic intraventricular conduction disturbance
67 ST and/or T wave abnormalities secondary to hypertrophy
315
Ouestions: ECG 51
1. The pause Iollowing an atrial premature complex (APC) is
typically a noncompensatory pause:
a. True
b. False
2. Aberrantly conducted APCs are characterized by:
a. Initial QRS vector opposite in direction to initial QRS vector
oI normally conducted beats
b. LBBB conIiguration
c. RBBB conIiguration
Answers: ECG 51
1. APCs are usually Iollowed by a noncompensatory pause, in
which the PP interval containing the APC is less than twice the
basic PP interval. In contrast, ventricular premature complexes
(VPCs) are usually Iollowed by a Iully compensatory pause (PP
interval containing the VPC is twice the basic PP interval).
(Answer: a)
2. Aberrant conduction oI APCs maniIests as variable widening or
distortion oI the normal QRS. The initial QRS vector is in the
same direction as the normally-conducted beats, while the more
terminal portion oI the QRS may be in a diIIerent direction. The
longer reIractory period oI the right bundle (compared to the leIt
bundle) increases the likelihood that an APC will conduct down
the leIt bundle, resulting in RBBB morphology. (Answer: c)
316
- («:·/ k:.::« ,1 - - («:·/ k:.::« ,1 - - («:·/ k:.::« ,1 - - («:·/ k:.::« ,1 -
LVH by voltage only
&RUQHOO&ULWHULD(most accurate): R wave in aVL
¹ S wave in V
3
~ mm in males or ~ mm
in Iemales
· 2WKHUFRPPRQO\XVHGYROWDJHEDVHGFULWHULD
Precordial leads (one or more)
(1) R wave in V
5
or V
6
¹ S wave in V
1
~ mm iI age ~ 40 years
~ mm iI age 30-40 years
~ mm iI age 16-30 years
(2) Maximum R wave ¹ S wave in precordial
leads ~ mm
(3) R wave in V
5
~ mm
(4) R wave in V
6
~ mm
Limb leads (one or more)
(1) R wave in lead I ¹ S wave in lead II ~
mm
(2) R wave in lead I ~ mm
(3) S wave in aVR ~ mm
(4) R wave in aVL ~ mm
(5) R wave in aVF ~ mm
· 1RQYROWDJHUHODWHGFULWHULDIRU/9+
(LeIt/right) atrial abnormality
(LeIt/right) axis deviation
Onset oI intrinsicoid deIlection ~ seconds
Small or absent R waves in leads
Absent waves in leads I, V
5
, V
6
Abnormal waves in leads II, III, aVF
Prominent waves, especially in leads with
large R and T waves
R wave amplitude in V
6
(greater than/less than)
V
5
, provided there are dominant R waves in
these leads
28, 20
35
40
60
45
26
20
26
14
15
12
21
leIt
leIt
0.05
V
1
-V
3
Q
Q
U
greater than
- («:·/ k:.::« ,1 - - («:·/ k:.::« ,1 - - («:·/ k:.::« ,1 - - («:·/ k:.::« ,1 -
8T and/or T wave changes secondary
to ¡VCD or hypertrophy
· LJH: ST (elevation/depression) & T wave
inversion when QRS is mainly positive (leads );
subtle ST (elevation/depression) & upright T waves
when the QRS is mainly negative (leads V
1
, V
2
)
· RJH: ST segment depression & T wave inversion
in leads and sometimes in leads II, III, aVF
· LBBB: ST segment & T wave displacement
(opposite to/ in same direction as) the major QRS
deIlection
· RBBB: Uncomplicated RBBB has little ST
displacement (true/Ialse). T wave vector is
(opposite to/in same direction as) the terminal
slurred portion oI the QRS
depression
I, V
5
, V
6
elevation
V
1
-V
3
opposite to
true
opposite to
317
Don't Get Confusedl
Multifocal Atrial Tachycardia
Atrial rate ~100 per minute with ~ 3 P wave morphologies
and varying PR, RR, and RP intervals
May be conIused wIth

6LQXVWDFK\FDUGLDZLWKPXOWLIRFDO$3&V
Demonstrates one dominant atrial pacemaker (i.e., the sinus
node). In multiIocal atrial tachycardia, QR dominant atrial
pacemaker (i.e., no dominant P wave morphology) is
present.
$WULDOILEULOODWLRQIOXWWHU
Atrial Iibrillation/Ilutter lacks an isoelectric baseline. In
contrast, multiIocal atrial tachycardia demonstrates a distinct
isoelectric baseline and P waves.
318
ECG 52. 53-year-old male with severe chest pressure
who lost consciousness during this ECG:
I
aVR
V1 V4
II
aVL
V2
V5
III
II
aVF V3
V6
319
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
320
ECG 52 was obtained in a 53-year-old male who presented with severe chest and neck pressure and lost consciousness during the
acquisition oI this 12-lead ECG. The ECG shows chaotic, irregular deIlections oI varying amplitude without distinct P waves, QRS
complexes, or T waves, consistent with ventricular Iibrillation/ventricular Ilutter at a rate oI 248 beats/minute.
Codes: 28 Ventricular Iibrillation
I aVR
V1 V4
II
aVL V2
V5
III
II
aVF V3
V6
321
Ouestions: ECG 52
1. The likelihood oI successIul resuscitation out oI ventricular
Iibrillation decreases by approximately ° per minute Irom
onset oI the dysrhythmia:
a. 2°
b. 5°
c. 7.5°
d. 10°
2. The two most Irequent causes oI ventricular Iibrillation are:
a. Aortic stenosis
b. Drug-induced or congenital long QT
c. Coronary artery disease
d. Pulmonary embolism
e. Cardiomyopathy (including dilated and hypertrophic
etiologies)
Answers: ECG 52
1. Ventricular Iibrillation (VF) is a lethal dysrhythmia unless it is
promptly terminated. Electrocardioversion is nearly always
successIul at restoring sinus rhythm when VF is shocked within
the Iirst minute. The success rate oI cardioversion Ialls oII
rapidly with elapsed time. Overall, the rate oI survival Irom VF
in the community has been reported to vary between 4° and
33°, depending upon the rapidity oI which the emergency
medical personnel are able to attend to the victim. (Answer: d)
2. Coronary atherosclerosis and its consequences (myocardial
ischemia or inIarction) are responsible Ior approximately 80°
oI sudden cardiac death in the United States. Cardiomyopathy
(ischemic, non-ischemic, and hypertrophic) is the second most
common precipitating Iactor. The degree oI leIt ventricular
impairment is closely correlated with the risk oI sudden cardiac
death. Pulmonary embolism, aortic stenosis, and long QT
syndromes are also associated with increased risk oI ventricular
Iibrillation, but are less Irequent causes compared to coronary
artery disease and cardiomyopathy. (Answer: c, e)
- («:·/ k:.::« ,z - - («:·/ k:.::« ,z - - («:·/ k:.::« ,z - - («:·/ k:.::« ,z -
Ventricular fibrillation
Extremely rapid and (regular/irregular) ventricular
rhythm with:
· Chaotic, irregular deIlections oI
(constant/varying) amplitude and duration
· (Absence/presence) oI distinct P waves, QRS
complexes, and T waves
irregular
varying
absence
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 322 —
A. B. C. D.
Answer: Tracings A, C, and D are examples of normal variant early repolarization ST segment elevation, with a concave upward
confguration of the ST elevation ending with a symmetrical upright T wave. Tracing B is shows a lateral myocardial injury pattern and
is the imposter. In contrast to early repolarization, the confguration of the ST segment elevation of acute myocardial injury is convex
upward.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 323 —
A.
B.
C.
D.
Answer: Tracings A, B, and C demonstrate a regular, narrow QRS tachycardia with possible atrial activity at the end of the QRS com-
plex in tracing C but no obvious atrial activity in tracings A or B. These regular, narrow QRS tachycardias with either P waves at the
end of the QRS or no discernible atrial activity are consistent with SVT. Tracing D shows atrial futter with 2:1 AV conduction and is
the imposter. The futter waves are best seen after each QRS complex. The futter waves, which are negative, show an irregular rela-
tionship to the preceding QRS complex and therefore are not T waves but rather futter waves following the QRS.
324
ECG 53. 59-year-old female with palpitations:
325
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—326—
ECG53 was obtained Irom a 59-year-old Iemale with palpitations. The ECG shows sinus rhythm (asterisk on sinus beat) at a rate oI 90
beats/minutewithoccasionalAPCs(arrowhead)andVPCs(arrow).InthemiddleoIthetracing(doubleasterisk),thereisa4-beatrunoIatrial
tachycardiaatarateoI150beats/minute.
Codes: 07 Sinusrhythm
13 Atrialprematurecomplexes
15 Atrialtachycardia
23 Ventricularprematurecomplexes
327
Ouestions: ECG 53
1. Characteristics oI atrial tachycardia include:
a. Atrial rate between 120-180 per minute
b. Regular rhythm
c. P waves similar to sinus rhythm
2. Which oI the Iollowing statement about atrial premature
contractions are true:
a. QRS complex is always similar in morphology to the QRS
complex during sinus rhythm
b. PR may be normal, increased, or decreased
c. The post-extrasystolic pause is usually noncompensatory
d. The QRS morphology oI aberrantly conducted APCs is most
oIten an RBBB pattern
Answers: ECG 53
1. Atrial tachycardia is a regular rhythm with nonsinus P waves at
rates oI 100- hould not be
conIused with multiIocal atrial tachycardia, which is an irregular
rhythm with 3 P wave morphologies that can be mistaken Ior
atrial Iibrillation. (Answer: a, b)
2. An atrial premature complexes (APC) is characterized by the
presence oI a P wave that is abnormal in conIiguration and
premature relative to the normal PP interval. The QRS complex
is usually similar in morphology to the QRS complex present
during sinus rhythm. However, with aberrantly conducted APCs,
the QRS morphology is most oIten RBBB pattern due to the
longer reIractory period oI the right bundle compared to the leIt
bundle, but it can be LBBB pattern or variable. The PR interval
oI APCs can be normal, increased, or decreased, and the post-
extrasystolic pause is usually noncompensatory (i.e., the interval
Irom the preceding normal P wave to the normal P wave
Iollowing the APC is less than two normal PP intervals).
(Answer: b, c, d)
240 per minute. Atrial tachycardia s
328
- («:·/ k:.::« ,; - - («:·/ k:.::« ,; - - («:·/ k:.::« ,; - - («:·/ k:.::« ,; -
Atrial premature complexes
· P wave is (normal/abnormal) in conIiguration
· QRS complex is (similar/diIIerent) in
morphology to the QRS complex present during
sinus rhythm
· PR interval may be normal, increased, or
decreased (true/Ialse)
· The post-extrasystolic pause is usually
(compensatory/noncompensatory)
abnormal
similar
true
noncompensatory
Atrial tachycardia
· Three or more consecutive (sinus/nonsinus)
beats at an atrial rate oI 100-240 bpm
· P wave is (always/sometimes) visualized
· QRS Iollows each P wave unless AV block
is present
nonsinus
sometimes
2° or 3°
- («:·/ k:.::« ,; - - («:·/ k:.::« ,; - - («:·/ k:.::« ,; - - («:·/ k:.::« ,; -
Ventricular premature complexes,
uniform, fixed coupling
· A wide, notched or slurred complex that is
premature relative to the normal RR interval and
is not preceded by a wave
· QRS duration is almost always ~ seconds
· Initial direction oI the QRS is oIten (similar
to/diIIerent Irom) the QRS during sinus rhythm
· Secondary ST & T wave changes in the
(same/opposite) direction as the major deIlection
oI the QRS (i.e., ST depression & T wave
inversion in leads with a dominant wave;
ST elevation and upright T wave in leads with a
dominant wave or complex)
· Coupling interval is constant or varies by ·
seconds
· Morphology oI VPCs in any given lead is (the
same/diIIerent)
· Retrograde capture oI atria may occur
(true/Ialse)
· A Iull pause (PP interval containing the
VPC is twice the normal PP interval) is usually
evident
QRS
P
0.12
diIIerent Irom
opposite
R
S, QS
0.08
the same
true
compensatory
329
- POP OU¡Z -
Rhythm RecognItIon: HR > 100; Narrow QRS; IrreguIar RR IntervaI
,QVWUXFWLRQV Determine the cardiac rhythm Ior each oI the Iollowing ECGs.
(&* 'LDJQRVLV
Answer: Atrial Iibrillation. Description: Absent P waves, with totally irregular
atrial activity represented by Iibrillatory (I) waves oI varying amplitude, duration,
and morphology causing random oscillation oI the baseline. Ventricular rhythm is
typically irregularly irregular, and occurs at a rate oI 100-180 per minute in the
absence oI drugs. Atrial activity is best seen in leads V
1
, V
2
, II, III, and aVF.
Digoxin toxicity can cause regularization oI the QRS, representing complete heart
block with junctional tachycardia. Note: In the absence oI AV nodal blocking
drugs, a ventricular rate · 100 per minute suggests coexistent AV conduction
system disease. Conditions mimicking atrial Iibrillation include multiIocal atrial
tachycardia, paroxysmal atrial tachycardia with block, or atrial Ilutter with variable
AV block.
Answer: MultiIocal atrial tachycardia (MAT). Description: Irregular atrial rhythm
with at least three diIIerent P wave morphologies (originating Irom separate atrial
Ioci) at an atrial rate ~ 100 per minute with varying PP and PR intervals. P waves
may be blocked (not Iollowed by a QRS), or may be conducted with a narrow or
aberrant (wide) QRS complex. Can be conIused with atrial Iibrillation/Ilutter or
sinus tachycardia with multiIocal APCs. MAT is usually associated with some
Iorm oI lung disease (e.g., COPD, cor pulmonale, hypoxia, aminophylline therapy).
Answer: Atrial Ilutter with variable AV block. Description: Rapid, regular atrial
undulations (Ilutter or 'F¨ waves) usually at a rate oI 240-340 per minute. Flutter
waves are typically inverted in leads II, III and aVF, and maniIest small positive
upright deIlections in V
1
; 'atypical Ilutter¨ can show upright F waves in the
inIerior leads. QRS complexes may be narrow or wide (iI underlying aberrancy or
bundle branch block). AV conduction ratio (ratio oI Ilutter waves to QRS
complexes) is usually a Iixed, even number (e.g., 2:1, 4:1), but variable conduction
sometimes occurs (as in the present tracing). Flutter waves sometime deIorm the
QRS, ST, T waves to mimic intraventricular conduction delay or myocardial
ischemia/injury.
V1
330
ECG 54. 26-year-old male with palpitations:
331
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary
embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—332—
ECG54wasobtainedinan26-year-oldmalewithpalpitations.TheECGshowsanatrialtachycardiaatapproximately140beats/minutewith
variableAVconductionandgroupbeating.ThePwavemorphologyisnegativeinleadsII,III,andaVF(arrows),indicatinganatrialIocus
remoteIromthesinusnode(normalsinusPwavemorphologyispositiveinleadsII,III,andaVF).PacingspikesareobservedbeIoreeachQRS
complex(arrowheads),butnopacingspikeispresentbeIorethePwaves,consistentwithadualchamberpacemakerthatissensingtheatrium
andpacingtheventricle.(Theventricularleadisintherightventricularapex,thuspacingtheventriclewiththeexpectedpatternIorthispacing
locationoIleItbundlebranchblockwithleItaxisdeviation.)TheuniqueIindingonthisECGisthegroupbeatingplusPwavesthatarenot
IollowedbyapacedQRScomplex.Atinitialglance,thismaybeinterpretedasaIailureoIpacemakeroutput.However,closerinspection
demonstratesgradualprolongationoItheAVdelaybetweenPwaveandthepacemakerspike.Inaddition,theatrialtachycardiarateisrapid
(140beats/minute)andmostlikelyabovetheprogrammedupperratelimitIorthepacemaker.ThepacemakerisdemonstratingaIeaturetermed
“upperratebehaviorpacing,”inwhichtheventricularratecannotexceedtheupperprogrammedrateIorthepacemakereventhoughtheatrial
rateismorerapid.Tomaintaintheventricularrateatorundertheupperprogrammedrate,AVWenckebachoccurs,asdepictedonthisECG.
Thisisnormalpacemakerbehavior.
Codes: 15 Atrialtachycardia
92 Dual-chamberpacemaker(DDD)
333
Ouestions: ECG 54
1. Which oI the Iollowing statements about pacemakers are true:
a. DVI pacemakers pace only the ventricle, but senses both the
atrium and ventricle
b. VOO pacemakers pace the ventricle asynchronously
c. VVI-R is a rate-responsive ventricular pacemaker
d. DDD pacemakers can Iunction in either a triggered or
inhibited mode
2. A dual chamber (DDD) pacemaker senses:
a. The ventricle only
b. The atrium only
c. The atrium and the ventricle
d. Neither the atrium nor the ventricle
3. A normally-Iunctioning DDD pacemaker results in:
a. An atrial paced complex Iollowed by a native QRS aIter an
AV interval less than the programmed AV interval oI the
pacemaker
b. An atrial paced complex Iollowed by a ventricular paced
complex at the programmed AV interval
c. A native P wave Iollowed by a paced ventricular complex
at the programmed AV interval
d. A native P wave Iollowed by a native QRS at rates above
the programmed pacemaker rate
Answers: ECG 54
1. Pacemakers are identiIied by a 3-letter pacemaker code. The
Iirst letter indicates the chamber SDFHG: atrial (A), ventricular
(V), or both (D). The second letter indicates the chamber
VHQVHG: atrial (A), ventricular (V), or neither (O). The third
letter indicates the pacing PRGH triggered (T), inhibited (I),
dual (D), or asynchronous (O). A rate-responsive pacemaker is
indicated by a Iourth letter, R. All statements in question 1 are
correct except 'a¨, since a DVI pacemaker paces both the
atrium and ventricle but senses only the ventricle. (Answer: b,
c, d)
2. DDD pacemakers sense and pace the right atrium and ventricle.
This results in inhibition or triggering oI pulse generator
impulses on the atrial and/or ventricular channels. (Answer: c)
3. A normally-Iunctioning DDD pacemaker can show various
combinations oI atrial paced beats and/or native P waves
Iollowed by ventricular paced beats and/or native QRS
complexes. The exact combination depends on the programmed
AV interval/pacemaker rate and underlying rhythm. All Iour
statements are correct. (Answer: all)
334
- («:·/ k:.::« ,; - - («:·/ k:.::« ,; - - («:·/ k:.::« ,; - - («:·/ k:.::« ,; -
Atrial tachycardia
· Three or more consecutive (sinus/nonsinus) beats
at an atrial rate oI 100-240 bpm
· P wave is (always/sometimes) visualized
· QRS Iollows each P wave unless AV block is
present
nonsinus
sometimes
2° or 3°
Dual chamber, atrial-sensing
pacemaker
· For atrial sensing, need to demonstrate inhibition
oI (atrial/ventricular) output and/or triggering oI
the (atrial/ventricular) stimulus in response to
intrinsic atrial depolarization
· Includes and possibly VAT or VDD
pacemakers
atrial
ventricular
DDD
—335—
—POPOU¡Z—
PatternRecognItIon:A-VInteractIons
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. Fusioncomplex
b. Canbeseenwithventricular
tachycardia
c. ResultsIromsimultaneousactivation
oIventricleIrom2sources
d. Echobeat
e. FormoInonsustainedreentry
I. Capturecomplex
g. SuggestdiagnosisoISVTinsettingoI
wideQRStachycardia
h. Occurswhenatrialimpulsestimulates
theventricleduringVT
i. Atrialandventricularrhythmsoccur
independantoIeachother
j. AVdissociation
k. Ventriculophasicsinusarrhythmia
Ventricular capture complexoccurswhenatrial
impulsestimulatestheventricleduringventricular
tachycardia.The“captured”ventricleresultsina
QRScomplexsimilartothatduringsinusrhythm.
ThepresenceoIaventricularcapturecomplex(es)
inthesettingoIawideQRStachycardiastrongly
suggeststhediagnosisoIventriculartachycardia.
(Answer:b,I,h)
AV dissociationoccurswhenatrialandventricular
rhythmsactindependentlyoIeachother.Inmost
cases,theventricularrateisequaltoorIasterthan
theatrialrate,eitherduetoaccelerationoIa
subsidiarypacemakerabovetheatrialrateor
slowingoItheatrialratebelowtheintrinsicrateoI
thesubsidiaryventricularpacemaker.Also
appliestojunctionalrhythms.(Answer:b,i,j)
Ventriculophasic sinus arrhythmiaoccursduring
partialorcompleteAVblockwhenthePPinterval
containingaQRScomplexisshorterthanthePP
intervalwithoutaQRScomplex.(Answer:k)
336
ECG 55. 73-year-old female on routine ECG:
337
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction
disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary
embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
—338—
ECG 55
pacemakerwiththeventricularleadintheleItventricleinsteadoIthenormallocationintherightventricularapex.Therhythmissinusata
rateoI83beats/minute,andthereisapacingspikebeIoreeachQRScomplexbutnotbeIorethePwave(arrows).Thisisconsistentwithadual
chamberpacemakerthatisproperlysensingtheatriumandpacingtheventricle.Normalventricularleadplacementintherightventricularapex
maniIestsrightbundlebranchmorphologywithleItaxisdeviationECG.Instead,theventricularleadisintheleItventricleneartheapexthus
maniIestsarightbundlebranchmorphologyandrightaxisdeviation.Inthispatienttheventricularpacingleadwasinadvertentlypassedthrough
apatentIoramenovaleintotheleItatrium,throughthemitralvalve,andintotheleItventricle.
Codes: 07 Sinusrhythm
92 Dual-chamberpacemaker(DDD)
was obtained in a 73-year-old Iemale on routine ECG. The ECG demonstrates a unique clinical presentation oI a permanent
339
Ouestions: ECG 55
1. Which QRS morphology is associated with location oI the
ventricular pacing catheter in the right ventricular apex:
a. RBBB ¹ RAD
b. RBBB ¹ LAD
c. LBBB ¹ RAD
d. LBBB ¹ LAD
Answers: ECG 55
1. When the ventricles are activated by an impulse originating in
the right ventricle, the leIt ventricle is activated by septal
activation, avoiding the normal leIt bundle branch conduction
system and giving rise to leIt bundle branch morphology on the
surIace ECG. This occurs with right-sided VPCs, ventricular
tachycardia, and pacing Irom the right ventricle. Any electrical
impulse that starts in the apex oI the heart activates the
ventricles away Irom the inIerior leads and gives rise to leIt axis
deviation ('superior axis¨). In contrast, activation oI the
ventricles Irom the leIt or right ventricular outIlow tract (i.e.,
just below the pulmonary or aortic valve) activates the heart
toward the inIerior leads and give rise to a normal axis or right
axis deviation that is markedly positive in the inIerior leads
('inIerior axis¨). (Answer: d)
- («:·/ k:.::« ,, - - («:·/ k:.::« ,, - - («:·/ k:.::« ,, - - («:·/ k:.::« ,, -
Dual chamber, atrial-sensing
pacemaker
· For atrial sensing, need to demonstrate inhibition
oI (atrial/ventricular) output and/or triggering oI
the (atrial/ventricular) stimulus in response to
intrinsic atrial depolarization
· Includes and possibly VAT or VDD
pacemakers
atrial
ventricular
DDD
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 340 —
A.
B.
C.
D.
Answer: Tracings A, B and C represent supraventricular tachycardia, with no clear P waves or atrial activity present. Tracing D shows
atrial futter with 2:1 AV block and is the imposter. Here the deeply negative futter waves preceding the QRS are also evident in the
late QRS complex and ST segment of the preceding beat. In fact, the slightly later appearance of the futter wave superimposed on the
S wave at the right of the tracing (compared to the left portion of the tracing) helps to further confrm the diagnosis of atrial futter.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 341 —
A.
B.
C.
D.
Answer: Tracings A, C, and D demonstrate a narrow QRS complex rhythm with irregular QRS intervals and no discrete atrial (P
wave) activity. These fndings are consistent with atrial fbrillation. Tracing B shows sinus rhythm with frequent APCs and is the im-
poster. It shows an irregular rhythm with one dominant P wave preceding most of the QRS complexes. The early QRS complexes also
have a preceding P wave and are consistent with atrial premature complexes.
342
ECG 56. 58-year-old female with heart failure:
343
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
344
ECG 56 was obtained in a 58-year-old Iemale with heart Iailure. The ECG shows sinus bradycardia at 58 beats/minute and LVH ® wave in
I ~ 14 mm; R wave in aVL ~ 12 mm; arrows) with associated ST-T abnormalities. While some degree oI QRS widening is oIten present with
LVH, the QRS in this tracing measures 0.12 seconds, consistent with nonspeciIic IVCD. Evidence Ior an old inIerior myocardial inIarction
(arrowheads) is present.
Codes: 09 Sinus bradycardia (·60)
40 LeIt ventricular hypertrophy
49 NonspeciIic intraventricular conduction disturbance
58 InIerior Q wave MI (age indeterminate or old)
67 ST and/or T wave abnormalities secondary to hypertrophy
345
Ouestions: ECG 56
1. ECG leads in the present tracing that demonstrate LVH by
voltage criteria include:
a. R wave in I ¹ S wave in II
b. R wave in V
5
or V
6
¹ S wave in lead V
1
c. R wave in I
d. S wave in aVR
e. R wave in aVL
I. R wave in aVF
2. ECG Iindings associated with LVH include:
a. ST elevation in leads V
1
- V
3
b. ST segment depression and T wave inversion in leads I,
aVL, V
4
- V
6
c. Prominent U waves
Answers: ECG 56
1. In the present tracing, voltage criteria Ior LVH is satisIied by the
presence oI R waves in leads I and aVL ~ 14 mm and 12 mm,
respectively. Criteria not satisIied on this ECG include an R
wave in lead V
5
or V
6
¹ S wave in lead I ~ 35 mm; an R wave
in lead I ¹ S wave in lead II ~ 26 mm; an S wave in aVR ~ 15
mm; and an R wave in aVF ~ 21 mm. (Answer: c, e)
2. Non-voltage criteria Ior LVH include ST segment depression
and T wave inversion in leads V
5
and V
6
, ST elevation in the
right precordial leads, and prominent U waves. Other non-
voltage-based Iindings include leIt atrial abnormality, leIt axis
deviation, nonspeciIic intraventricular conduction delay, delayed
intrinsicoid deIlection, poor R wave progression, absent Q
waves in the leIt precordial leads, and abnormal Q waves in the
inIerior leads (due to leIt axis deviation). LVH may cause a
'pseudoinIarct¨ pattern on ECG: poor R wave progression with
ST elevation in V
1
-V
3
can mimic anteroseptal MI, and inIerior
Q waves can mimic inIerior MI. (Answer: all)
- («:·/ k:.::« ,( - - («:·/ k:.::« ,( - - («:·/ k:.::« ,( - - («:·/ k:.::« ,( -
Nonspecific intraventricular conduction
disturbance
· QRS ~ seconds in duration but morphology
does not meet criteria Ior LBBB or RBBB, RU
abnormal without widening oI the QRS
complex
0.11
notching
Left ventricular hypertrophy 8T-T
changes
· Voltage criteria Ior LVH and one or more ST-T
abnormalities:
ST segment and T wave deviation in
(same/opposite) direction to the major deIlection
oI QRS
ST segment (elevation/depression) in leads I,
aVL, III, aVF, and/or V
4
-V
6
Subtle (· 1-2 mm) ST (elevation/depression) in
leads V
1
-V
3
Inverted waves in leads I, aVL, V
4
-V
6
(Absent/prominent) U waves
opposite
depression
elevation
T
prominent
346
ECG 57. 55-year-old woman with a history of dilated
cardiomyopathy:
347
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
348
ECG 57 was obtained Irom a 55-year-old woman with a history oI dilated cardiomyopathy. The ECG shows sinus tachycardia, leIt atrial
abnormality (arrowhead), and LBBB with secondary ST-T abnormalities. The rhythm strip at the bottom oI the tracing shows a ventricular
premature complex (arrow) Iollowed by a compensatory pause; the Iirst beat aIter the compensatory pause (asterisk) shows a normal sinus beat
without LBBB, establishing the diagnosis oI rate-related LBBB.
Codes: 06 LeIt atrial abnormality/enlargement
10 Sinus tachycardia
23 Ventricular premature complexes
47 LBBB, complete
50 Functional (rate-related) aberrant intraventricular conduction
*
349
Ouestions: ECG 57
1. Intermittent leIt bundle branch block (LBBB) can be
tachycardia- or bradycardia-dependent:
a. True
b. False
2. In the setting oI LBBB, myocardial injury/inIarction is
suggested by the presence oI ¸¸¸ mm oI discordant ST segment
elevation in leads V
1
-V
4
:
a. 2
b. 3
c. 4
d. 5
Answers: ECG 57
1. Intermittent LBBB is more common at Iast heart rates
(tachycardia-dependent) than at slow heart rates, but may be
bradycardia-dependent as well. The ventricular premature
complex in the present ECG (arrow) results in a compensatory
pause; this allows the reIractory leIt bundle branch to recover,
resulting in normal QRS conduction Ior a single beat. Sinus
tachycardia resumes on the Iollowing beat, resulting in a shorter
cycle length and resumption oI leIt bundle branch block.
(Answer: a)
2. In the setting oI LBBB, discordant ST segment elevation (ST
elevation in a direction opposite to the major QRS vector) ~ 5
mm in height is worrisome Ior ischemia. Concordant ST
segment elevation (ST segment elevation in the same direction
as the major QRS vector) ~ 1 mm is a more speciIic Iinding Ior
transmural ischemia. (Answer: d)
- («:·/ k:.::« ,I - - («:·/ k:.::« ,I - - («:·/ k:.::« ,I - - («:·/ k:.::« ,I -
8inus tachycardia {>100}
· Rate ~ per minute
· P wave amplitude oIten (increases/decreases) and
PR interval oIten (increases/decreases) with
increasing heart rate
100
increases
shortens
Left atrial abnormality/enlargement
· Notched P wave with a duration ~ seconds in
leads II, III or aVF, RU
· Terminal negative portion oI the P wave in lead V
1
~ 1 mm deep and ~ seconds in duration
0.12
0.04
—350—
—POPOU¡Z—
PatternRecognItIon:IntraventrIcuIarConductIonDIsturbances
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. Rightbundlebranchblock
b. QRSaxisisusuallynormal
c. DoesnotinterIerewithECGdiagnosisoI
ventricularhypertrophyorQ-waveMI
d.LeItanteriorIascicularblock
e. CanresultinIalse-positivediagnosisoI
LVHbasedonvoltagecriteriausingonly
leadsIoraVL
I. CanmaskthepresenceoIinIeriorwallMI
g. LeItposteriorIascicularblock
h. CanmaskthepresenceoIlateralwallMI
i. Leastprevalentconductionabnormality
j. LeItbundlebranchblock
k. CommonlyassociatedwithsecondaryST
&Tchangesinoppositedirectiontomain
QRScomplex
Right bundle branch block(RBBB)resultsinaprolonged
QRSduration(~0.12seconds)withdelayedonsetoI
intrinsicoiddeIlection(beginningoIQRStopeakoIR
wave~0.05seconds);secondaryRwave(R)inV
1
andV
2
(rsR’orrSR’),withRusuallytallerthantheinitialRwave
andsecondaryTwaveinversion+downslopingST
segments;andwide,slurredSwavesinleadsI,V
5
andV
6
.
MeanQRSaxisisdeterminedbytheinitialunblocked
0.06-0.08secondsoItheQRS,andshouldbenormalunless
leItanteriorIascicularblockorleItposteriorIascicular
blockispresent.RBBBdoesnotinterIerewiththe
diagnosisoIventricularhypertrophyorQ-waveMI.
(Answer:a,b,c,kinleadsV
1
andV
2
).
Left bundle branch block(LBBB)resultsinaprolonged
QRS(~0.12seconds);delayed(~0.05seconds)onsetoI
intrinsicoiddeIlectioninleadsI,V
5
andV
6
;andbroad
monophasicRwavesinleadsI,V
5
,andV
6
thatareusually
notchedorslurred.OtherchangesincludesecondaryST
andTwavechangesoppositeindirectiontothemajorQRS
deIlection(STdepressionandTwaveinversioninleadsI,
V
5
,V
6
;STelevationanduprightTwavesinV
1
andV
2
),
andrSorQScomplexesintherightprecordialleads.The
axisisusuallynormal,butleItaxisdeviationmaybe
present.LBBBinterIereswithidentiIicationoIQRSaxis,
ventricularhypertrophy,andacuteMI.(Answer:b,j,k)
351
- POP OU¡Z -
DIIIerentIaI DIagnosIs: PrecordIaI R-Wave ProgressIon
,QVWUXFWLRQV For each diagnosis below, select all precordial R-wave progression changes that apply:
· Early R-wave progression (tall R wave in V
1
V
2
; R/S wave amplitude ~ 1)
· Poor R-wave progression (precordial transition zone |R/S wave amplitude ÷ 1| in V
5
or V
6
)
· Reverse-R wave progression (decreasing R-wave amplitude across precordial leads)
'LDJQRVLV $QVZHU
Hypertrophic cardiomyopathy Poor R-wave progression. Q waves in I, aVL, V
4
-V
6
(Irom septal hypertrophy) may lead to pseudoinIarct pattern.
LeIt ventricular hypertrophy (LVH) Poor R-wave progression. May be accompanied by ST elevation in V
1
-V
3
to mimic anteroseptal MI, or Q waves
in II, III, aVF to mimic inIerior MI.
LeIt anterior Iascicular block (LAFB) Poor R-wave progression. LAFB can result in pseudoinIarct pattern, mask inIerior MI, and cause Ialse-positive
diagnosis oI LVH based on voltage criteria using only leads I or aVL.
Right ventricular hypertrophy (RVH) Early R-wave progression. Right axis deviation and deep S waves in V
5
V
6
are common. Severe RVH may cancel
out QRS Iorces Irom the LV and underestimate the presence oI LVH.
Anterior MI Poor R-wave progression; may be only maniIestation oI prior MI (no anterior Q-waves).
Posterior MI Early R-wave progression. ST depression and upright T waves in V
1
V
2
and inIerior MI are common.
Right bundle branch block (RBBB) Early R-wave progression. R` taller than r-wave in V
1
and T wave inversion in V
1
V
2
are usual.
Chronic lung disease (e.g., emphysema) Poor R-wave progression. Q waves are sometimes seen in right/mid-precordial or inIerior leads, resulting in
pseudoinIarct pattern.
WolII-Parkinson-White syndrome
(leIt-sided accessory pathway)
Early R-wave progression when the accessory pathway connects the leIt atrium and ventricle. Can lead to Ialse-
positive or Ialse-negative diagnosis oI ventricular hypertrophy, MI, or bundle branch block.
Duchenne`s muscular dystrophy Early R-wave progression.
Dextrocardia Reverse R-wave progression. Inverted (upside-down) P-QRS-T in leads I and aVL is the key to diagnosis.
352
ECG 58. 61-year-old asymptomatic female:
353
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
354
ECG 58 was obtained in a 61-year-old asymptomatic Iemale. The P, QRS, and T waves are inverted in leads I and aVL (asterisks) and upright
in aVR. These Iindings are can be seen both in incorrect limb lead electrode placement and dextrocardia. The normal R wave progression in
the precordial leads is consistent with limb lead reversal; dextrocardia maniIests reverse R wave progression. The axis is diIIicult to determine
due to incorrect electrode placement, but is probably normal. First-degree AV block is also present.
Codes: 03 Incorrect electrode placement
07 Sinus rhythm
29 AV block, 1°
*
*
355
Ouestions: ECG 58
1. Limb lead reversal results in a "mirror-image" oI the normal P-
QRS-T in leads ¸¸¸¸ and ¸¸¸¸¸:
a. I and II
b. I and aVL
c. II and III
d. aVL and aVR
2. In contrast to dextrocardia, limb lead reversal is associated with
reverse R wave progression in leads V
1
-V
6
:
a. True
b. False
Answers: ECG 58
1. Limb lead reversal results in inversion oI the P-QRS-T in leads
I and aVL. This gives the mistaken impression oI right axis
deviation, and may be conIused with mirror-image dextrocardia.
(Answer: b)
2. Dextrocardia and limb lead reversal both result in apparent right
axis deviation and inversion oI the P, QRS, and T waves in leads
I and aVL. Dextrocardia is associated with reverse R wave
progression in leads V
1
-V
6
; limb lead reversal shows normal
precordial R wave progression. (Answer: b)
- («:·/ k:.::« ,2 - - («:·/ k:.::« ,2 - - («:·/ k:.::« ,2 - - («:·/ k:.::« ,2 -
¡ncorrect electrode placement
Limb lead reversal (reversal of right and left arm
leads)
· Resultant ECG mimics dextrocardia with oI
the P-QRS-T in leads and aVL
· To distinguish between these conditions, look at
precordial leads: dextrocardia shows
(reverse/normal) R wave progression, while limb
lead reversal shows (reverse/normal) R wave
progression.
Precordial lead reversal: Unexplained decrease in
voltage in two consecutive leads (e.g., V
1
, V
2
)
with a return to normal progression in the Iollowing
leads
inversion
I
reverse
normal
R wave
356
ECG 59. 59-year-old male with chest pain and cough
of several days duration:
357
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
358
ECG 59 was obtained in a 59-year-old male with chest pain and cough oI several days duration. The ECG shows sinus rhythm at 87
beats/minute. DiIIuse ST segment elevation that is upwardly concave (arrows) is noted in nearly all leads. Some PR depression is apparent in
leads II, III, aVF, and V
3
(arrowheads). Electrical alternans is most obvious in the lead II rhythm strip. Peaked T waves (~ 6 mm in height) are
also noted in the inIerior leads (asterisks). These Iindings are consistent with acute pericarditis with pericardial eIIusion. Extensive myocardial
inIarction (leIt main or dominant leIt circumIlex occlusion) is also a possibility, but the several day history oI chest pain makes this diagnosis
unlikely.
Codes: 07 Sinus rhythm
38 Electrical alternans
83 Pericardial eIIusion
84 Acute pericarditis
*
*
*
359
Ouestions: ECG 59
1. ST elevation can be seen in pericarditis in all leads except:
a. aVF
b. aVR
c. III
d. V
1
2. DiIIuse loss oI QRS voltage in the setting oI pericarditis most
likely suggests:
a. Amyloidosis
b. Obesity
c. Pericardial eIIusion
d. Associated myocardial inIarction
Answers: ECG 59
1. ST segment elevation associated with acute pericarditis is
typically diIIuse and upwardly concave. All leads can (and oIten
do) show ST elevation except aVR, which typically shows ST
depression. (Answer: b)
2. Amyloidosis, obesity, and diIIuse myocardial disease related to
previous inIarction can cause loss oI QRS voltage. However, in
the setting oI pericarditis, the most likely cause is the
development oI a pericardial eIIusion. (Answer: c)
- («:·/ k:.::« ,7 - - («:·/ k:.::« ,7 - - («:·/ k:.::« ,7 - - («:·/ k:.::« ,7 -
Electrical alternans
· Alternation in the and/or oI the P, QRS
and/or T waves
amplitude,
direction
8T and/or T wave changes suggesting
acute pericarditis
· Classic evolutionary pattern consists oI stages
Stage 1: Upwardly concave ST segment
in almost all leads
Stage 2: ST junction (J point) returns to
baseline and T wave amplitude begins
to (increase/decrease)
Stage 3: T waves (invert/remain upright)
Stage 4: ECG (does/does not) return to normal
· Other clues to acute pericarditis:
Sinus
PR early (PR elevation in aVR)
(High/low) voltage QRS
Electrical alternans iI pericardial is present
4
elevation
decrease
invert
does
tachycardia
depression
low
eIIusion
Peaked T waves
· T wave ~ mm in the limb leads or ~
mm in the precordial leads
6, 10
— 360 —
Answer: Tracings A, B, and C demonstrate ST segment elevation with ST segments that are convex upwards with inverted T waves.
These fndings are consistent with myocardial injury. Tracing D shows concave upward ST segment elevation consistent with early
repolarization and is the imposter.
A. B. C. D.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— POP QUIZ —
Find The Imposter
Instructions: Three of the following ECG tracings have a common diagnosis. Identify the common diagnosis and fnd the imposter.
— 361 —
A.
B.
C.
D.
Answer: Tracings B, C, and D show atrial fbrillation with irregular QRS intervals and no discreet P waves. Tracing A shows atrial
futter with variable AV conduction and is the imposter. The tracing has regular atrial activity at a rate of approximately 300 beats per
minute. This atrial activity is negative with a 'saw tooth¨ pattern and consistent with atrial futter. The atrial activity has a variable
relationship with the preceding QRS complex and thus represents atrial activity and not a T wave.
362
ECG 60. 53-year-old male with chest fluttering and
dyspnea:
363
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
364
ECG 60 was obtained in a 53-year-old male complaining oI chest Iluttering and dyspnea. The ECG shows atrial Ilutter, which is most apparent
in the latter portion oI the lead II rhythm strip and in leads V
4
-V
6
(arrows mark Ilutter waves). Variable second-degree AV block is noted, at
times resulting in a rapid (1:1) ventricular response with aberrant conduction (asterisk). During the tachycardia, the patient shows evidence Ior
RBBB and leIt posterior Iascicular block, which are transient Iindings related to the tachycardia and not essential Ior coding (although including
these diagnoses would probably be given neutral credit).
Codes: 18 Atrial Ilutter
50 Functional (rate-related) aberrant intraventricular conduction
*
365
Ouestions: ECG 60
1. True statements about atrial Ilutter include:
a. Ventricular response rates may vary
b. The interval between Ilutter waves may vary
c. Flutter rate is usually 240-340 bpm
d. Carotid sinus massage Irequently restores normal sinus
rhythm
2. The most common AV conduction rate in atrial Ilutter is:
a. 1:1
b. 2:1
c. 3:1
d. 4:1
e. ~ 4:1
3. QRS complexes in tachycardia-induced aberrancy are more
likely to maniIest:
a. LeIt bundle branch block (LBBB) morphology
b. Right bundle branch block (RBBB) morphology
Answers: ECG 60
1. Atrial Ilutter maniIests as rapid regular atrial undulations (Ilutter
or 'F¨ waves) at a rate oI 240-340 per minute. (In contrast,
atrial Iibrillation maniIests totally irregular atrial Iibrillatory (I)
waves oI varying amplitude, duration and morphology.) AV
conduction ratio (ratio oI Ilutter waves to QRS complexes) is
usually Iixed, but may vary, resulting in an irregular ventricular
response, which is oIten due to two levels oI block (e.g., 2:1 and
4:1 AV block) or concealed conduction. Atrial Ilutter typically
responds to carotid sinus massage with a decrease in ventricular
rate, which returns to baseline upon termination oI this
maneuver; restoration oI normal sinus rhythm with carotid sinus
massage is rare. (Answer: a, c)
2. Atrial Ilutter most commonly presents as 2:1 AV block.
Conduction ratios oI 1:1 (which may be mistaken Ior ventricular
tachycardia) and 3:1 are uncommon. In untreated patients, AV
block ~ 4:1 suggests coexistent AV conduction system disease.
(Answer: b)
3. Aberrant intraventricular conduction occurs when a
supraventricular impulse Iinds one oI the bundle branches
conductive and the other reIractory. Since the right bundle
typically has a longer action potential and reIractory period than
the leIt bundle, QRS complexes in aberrancy usually maniIest
RBBB morphology. (Answer: b)
366
- («:·/ k:.::« (0 - - («:·/ k:.::« (0 - - («:·/ k:.::« (0 - - («:·/ k:.::« (0 -
Atrial flutter
· Rapid (regular/irregular) atrial undulations ('F¨
waves) at a rate oI per minute
· Flutter rate may (increase/decrease) in the presence
oI Types IA, IC or III antiarrhythmic drugs
· Flutter waves in leads II, III, AVF are typically
(inverted/upright) (with/without) an isoelectric
baseline
· Flutter waves in lead V
1
are typically small
(positive/negative) deIlections (with/without) a
distinct isoelectric baseline
· QRS complex may be normal or aberrant
(true/Ialse)
· AV conduction ratio (ratio oI Ilutter waves to QRS
complexes) is usually (Iixed/variable)
Conduction ratios oI 1:1 and 3:1 are
(common/uncommon)
In untreated patients, AV block ~ suggests
the coexistence oI AV conduction disease
regular
240-340
decrease
inverted,without
positive, with
true
Iixed
uncommon
4:1
367
- POP OU¡Z -
VT or Not VT: That Is the QuestIon
,QVWUXFWLRQV In the setting oI a wide QRS tachycardia, decide
whether the ECG Ieatures below Iavor ventricular tachycardia or
SVT with aberrancy.
(&*)HDWXUH
97RU697ZLWK
$EHUUDQF\
QRS duration during tachycardia ·
0.14 seconds iI RBBB morphology
or · 0.16 seconds iI LBBB
morphology (assuming QRS is
narrow during sinus rhythm)
SVT
Some QRS deIlections in precordial
leads are positive and some are
negative (discordance)
SVT
RSR` V
1
: R wave is taller than R` VT
QRS morphology similar to sinus
rhythm or aberrantly conducted
APCs
SVT
Tachycardia initiated by VPCs VT
AV dissociation present VT
Capture beats present VT
Fusion beats present VT
368
ECG 61. 6-year-old female with a heart murmur:
369
GENERAL FEATURE8
* 01. Normal ECG
* 02. Borderline normal ECG or normal variant
* 03. Incorrect electrode placement
* 04. ArtiIact
P WAVE ABNORMAL¡T¡E8
* 05. Right atrial abnormality/enlargement
* 06. LeIt atrial abnormality/enlargement
8UPRAVENTR¡CULAR RHYTHM8
* 07. Sinus rhythm
* 08. Sinus arrhythmia
* 09. Sinus bradycardia (·60)
* 10. Sinus tachycardia (~100)
* 11. Sinus pause or arrest
* 12. Sinoatrial exit block
* 13. Atrial premature complexes
* 14. Atrial parasystole
* 15. Atrial tachycardia
* 16. Atrial tachycardia, multiIocal
* 17. Supraventricular tachycardia, paroxysmal
* 18. Atrial Ilutter
* 19. Atrial Iibrillation
JUNCT¡ONAL RHYTHM8
* 20. AV junctional premature complexes
* 21. AV junctional escape complexes
* 22. AV junctional rhythm/tachycardia
VENTR¡CULAR RHYTHM8
* 23. Ventricular premature complexes
* 24. Ventricular parasystole
* 25. Ventricular tachycardia (≥ 3 consecutive
complexes)
* 26. Accelerated idioventricular rhythm
* 27. Ventricular escape complexes or rhythm
* 28. Ventricular Iibrillation
AV CONDUCT¡ON ABNORMAL¡T¡E8
* 29. AV block, 1°
* 30. AV block, 2°-Mobitz type I (Wenckebach)
* 31. AV block , 2°-Mobitz type II
* 32. AV block, 2:1
* 33. AV block, 3°
* 34. WolII-Parkinson-White pattern
* 35. AV dissociation
ABNORMAL¡T¡E8 OF OR8 AX¡8
* 36. LeIt axis deviation (~ 30°)
* 37. Right axis deviation (~ ¹100°)
* 38. Electrical alternans
OR8 VOLTAGE ABNORMAL¡T¡E8
* 39. Low voltage
* 40. LeIt ventricular hypertrophy
* 41. Right ventricular hypertrophy
* 42. Combined ventricular hypertrophy
¡NTRAVENTR¡CULAR CONDUCT¡ON
ABNORMAL¡T¡E8
* 43. RBBB, complete
* 44. RBBB, incomplete
* 45. LeIt anterior Iascicular block
* 46. LeIt posterior Iascicular block
* 47. LBBB, complete
* 48. LBBB, incomplete
* 49. NonspeciIic intraventricular conduction disturbance
* 50. Functional (rate-related) aberrant intraventricular
conduction
O-WAVE MYOCARD¡AL ¡NFARCT¡ON8
* 51. Anterolateral (age recent or acute)
* 52. Anterolateral (age indeterminate or old)
* 53. Anterior or anteroseptal (age recent or acute)
* 54. Anterior or anteroseptal (age indeterminate or old)
* 55. Lateral (age recent or acute)
* 56. Lateral (age indeterminate or old)
* 57. InIerior (age recent or acute)
* 58. InIerior (age indeterminate or old)
* 59. Posterior (age recent or acute)
* 60. Posterior (age indeterminate or old)
REPOLAR¡ZAT¡ON ABNORMAL¡T¡E8
* 61. Normal variant, early repolarization
* 62. Normal variant, juvenile T waves
* 63. NonspeciIic ST and/or T wave abnormalities
* 64. ST and/or T wave abnormalities suggesting
myocardial ischemia
* 65. ST and/or T wave abnormalities suggesting
myocardial injury
* 66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
* 67. ST and/or T wave abnormalities secondary to
hypertrophy
* 68. Prolonged QT interval
* 69. Prominent U waves
8UGGE8TED CL¡N¡CAL D¡8ORDER8
* 70. Digitalis eIIect
* 71. Digitalis toxicity
* 72. Antiarrhythmic drug eIIect
* 73. Antiarrhythmic drug toxicity
* 74. Hyperkalemia
* 75. Hypokalemia
* 76. Hypercalcemia
* 77. Hypocalcemia
* 78. Atrial septal deIect, secundum
* 79. Atrial septal deIect, primum
* 80. Dextrocardia, mirror image
* 81. Chronic lung disease
* 82. Acute cor pulmonale including pulmonary embolus
* 83. Pericardial eIIusion
* 84. Acute pericarditis
* 85. Hypertrophic cardiomyopathy
* 86. Central nervous system disorder
* 87. Myxedema
* 88. Hypothermia
* 89. Sick sinus syndrome
PACED RHYTHM8
* 90. Atrial or coronary sinus pacing
* 91. Ventricular demand pacemaker (VVI), normally
Iunctioning
* 92. Dual-chamber pacemaker (DDD)
* 93. Pacemaker malIunction, not constantly capturing
(atrium or ventricle)
* 94. Pacemaker malIunction, not constantly sensing
(atrium or ventricle)
370
ECG 61 was obtained in a 6-year-old Iemale with a heart murmur. The ECG shows sinus rhythm at 98 beats/minute. Incomplete RBBB
(asterisk marks the rSR` complex in V
1
, which is 0.10 seconds in duration) with secondary ST-T changes, right atrial abnormality (arrow), and
right axis deviation are also present. These Iindings are consistent with ostium secundum atrial septal deIect, which was conIirmed by
echocardiography.
Codes: 05 Right atrial abnormality/enlargement
07 Sinus rhythm
37 Right axis deviation (~ ¹100°)
44 RBBB, incomplete
78 Atrial septal deIect, secundum
*
371
Ouestions: ECG 61
1. Secundum atrial septal deIect results in ¸¸¸¸ axis deviation:
a. LeIt
b. Right
2. Causes oI right axis deviation include:
a. Right bundle branch block
b. Right ventricular hypertrophy
c. Lateral myocardial inIarction
d. Ostium secundum ASD
e. Dextrocardia
I. Chronic lung disease (e.g., emphysema)
Answers: ECG 61
1. Secundum atrial septal deIect is typically associated with right
axis deviation, incomplete RBBB, and right atrial enlargement.
(Answer: b)
2. Right axis deviation can be seen as a normal variant, but is more
oIten associated with COPD, cor pulmonale, right ventricular
hypertrophy (RVH), lateral MI, leIt posterior Iascicular block
(LPFB), dextrocardia, lead reversal, ostium secundum ASD
(ostium primum ASD is associated with leIt axis deviation), and
WolII-Parkinson-White syndrome. Right bundle branch block
does not cause right axis deviation unless complicated by LPFB.
Right axis deviation (QRS axis 90° to 180°) must be
distinguished Irom right VXSHULRU axis (-90° to -180°), which can
be caused by RVH with or without leIt anterior Iascicular block,
leIt anterior Iascicular block with lateral MI, or COPD.
(Answer: all except a)
- («:·/ k:.::« (1 - - («:·/ k:.::« (1 - - («:·/ k:.::« (1 - - («:·/ k:.::« (1 -
Atrial septal defect, secundum
· Incomplete (RBBB/LBBB)
· (Right/leIt) axis deviation + (right/leIt) ventricular
hypertrophy
· (Right/leIt) atrial abnormality in 30°
· degree AV block in · 20°
· Secundum ASDs represent 70-80° oI all ASDs, and
are due to deIicient tissue in the region oI the
RBBB
Right, right
Right
First
Iossa ovalis
372
- POP OU¡Z -
Pattern RecognItIon: ECGJCIInIcaI CorreIatIon
,QVWUXFWLRQV Match the ECG with the most likely clinical presentation.
(&* &KRRVH6LQJOH%HVW$QVZHU $QVZHU
a. Acute hemiparesis, papilledema
b. Dyspnea, constipation, impaired
memory, Iatigue
c. Red-green color blindness,
nausea, vomiting
d. Acute oliguria 2° to
rhabdomyolysis
e. Murmur in a Down`s Syndrome
patient
I. Acute exacerbation oI chronic
bronchitis
g. Prolonged exposure to extreme
cold
h. Dyspnea and pulses paradoxus
in a renal Iailure patient
i. Acute onset oI dyspnea in a
patient with a DVT
0XOWLIRFDODWULDOWDFK\FDUGLD (MAT) results in an irregular rhythm
at a rate ~ 100 per minute with at least three diIIerent P wave
morphologies and varying PP and PR intervals. MAT is usually
associated with some Iorm oI lung disease (COPD, cor pulmonade,
hypoxia, heart Iailure), and can be precipitated by aminophylline.
This ECG was obtained in a 67-year-old smoker patient with
palpitations Iollowing acute exacerbation oI chronic bronchitis.
(Answer: I)
+\SRWKHUPLD is associated with Osborne ('J¨) waves, which are late,
upright, terminal deIlections oI the QRS complex that become more
pronounced as temperature declines. (Notching simulating Osborne
waves may be seen in early repolarization.) Other ECG Iindings in
hypothermia include sinus bradycardia, prolongation oI PR, QRS,
and QT intervals, and atrial Iibrillation (in 50-60°). AV junctional
rhythm, VT, and VF may occur. This patient was Iound
unconscious Iollowing prolonged exposure to extreme cold.
(Answer: g)
2VWLXPSULPXPDWULDOVHSWDOGHIHFW$6' represents 15-20° oI
ASDs, and is due to deIicient tissue in the lower portion oI the atrial
septum. Primum ASDs are usually large, may be accompanied by
anomalous pulmonary venous drainage, and are associated with cleIt
anterior mitral valve leaIlet, mitral regurgitation, and Down`s
syndrome. ECG Iindings include RSR` in V
1
, incomplete RBBB,
and leIt axis deviation (in contrast to right axis deviation with
ostium secundum ASD). First-degree AV block occurs in 15-40°,
and biventricular hypertrophy is common in advanced cases.
(Answer: e)
373
Don't Forgetl
· An S
1
S
2
S
3
pattern (S wave in leads I, II, and III) is
present in up to 20° oI healthy adults
· Parkinsons tremor (~ 300 per minute) may be
mistaken Ior atrial Ilutter
· II sinus bradycardia is present at a rate · 40 per
minute, think oI 2:1 sinoatrial exit block
· P wave amplitude oIten increases and PR interval
oIten shortens with increasing heart rate (e.g., during
exercise)
· The post-extrasystolic pause oI normally conducted
APCs is usually QRQFRPSHQVDWRU\ (i.e., PP interval
containing the APC is less than two times the normal
PP interval)
· In nonconducted (blocked) APCs, P waves are oIten
hidden in the preceding T wave search Ior a
deIormed T wave immediately preceding a PP pause
to identiIy the presence oI a nonconducted atrial
premature beat
—374—
ECG62. 80-year-oldmalewithepisodesof
lightheadedness:
—375—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconduction
disturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonary
embolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—376—
ECG62wasobtainedIroman80-year-oldmalewithepisodesoIlightheadedness.TheECGshowssinusrhythmatarateoI60beats/minute.
Sinusarrhythmia(variabilityinPPintervalsexceeds0.16seconds,especiallyaIterthepause)andasinuspauselasting2.4seconds(asterisk)
arepresent.SinoatrialexitblockshouldnotbecodedsincethePPpauseisnotamultiple(2x,3x,etc.)oIthenormalPPinterval.Thesinus
pauseandsymptomsoIlightheadednessareconsistentwithsicksinussyndrome.EarlyRwaveprogression(transitionpointbetweenV
1
and
V
2
)isalsonoted.
Codes: 07 Sinusrhythm
08 Sinusarrhythmia
11 Sinuspauseorarrest
89 Sicksinussyndrome
*
—377—
Ouestions:ECG62
1. ThemostcommoncauseoIasinus(PP)pauseis:
a. Sinoatrialexitblock
b. Ventricularprematurecomplex(VPC)
c. Blockedatrialprematurecomplex(APC)
d. High-gradeAVblock
2. ThelongestandshortestPPintervalsinsinusarrhythmiavary
bymorethan:
a. 0.08seconds
b. 0.16seconds
c. 10°
d. 5°
Answers:ECG62
1. A blocked APC is the most common cause oI a sinus pause.
Close scrutiny oI the T wave at the beginning oI the pause
Irequently reveals some deIormity caused by the premature
atrialbeat.(Answer:c)
2. Sinusarrhythmiaresultsingradual(sometimesabrupt)phasic
change in the PP interval, with the longest and shortest PP
intervalsvaryingby~0.16secondsor10°.(Answer:b,c)
—(«:·/k:.::«(z— —(«:·/k:.::«(z— —(«:·/k:.::«(z— —(«:·/k:.::«(z—
8inuspauseorarrest
• PPinterval~seconds
• ResumptionoIsinusrhythmataPPintervalthat
(is/isnot)amultipleoIthebasicsinusPPinterval
• IIsinusrhythmresumesatamultipleoIthebasic
PP,considerblock
1.6-2.0
isnot
sinoatrialexit
8inusarrhythmia
• (Sinus/nonsinus)Pwave
• LongestandshortestPPintervalsvaryby~
secondsor°
• SinusarrhythmiadiIIersIrom“ventriculophasic”
sinusarrhythmia,thelatteroIwhichoccursinthe
settingoI
Sinus
0.16
10
heartblock
8icksinussyndrome
• Markedsinus
• arrestorexitblock
• Bradycardiaalternatingwith
• AtrialIibrillationwithventricularresponse
precededorIollowedbysinusbradycardia,sinus
arrest,orsinoatrialexitblock
• ProlongedsinusnodetimeaIteratrial
prematurecomplexoratrialtachyarrhythmias
• AVjunctionalrhythm
• AdditionalconductionsystemdiseaseisoIten
present,includingAVblock,IVCD,orbundle
branchblock(true/Ialse)
bradycardia
Sinus,sinoatrial
tachycardia
slow
recovery
escape
true
—378—
ECG63. 47-year-oldfemalewithpalpitations:
—379—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconduction
disturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonary
embolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—380—
ECG63wasobtainedIroma47-year-oldIemalewithpalpitations.TheECGshowssinusrhythmatarateoI84beats/minutewithIrequent
atrialprematurecomplexes,someoIwhichconductednormally(narrowQRS)(arrowheads),othersoIwhichconductaberrantly(wideQRS)
(arrows).TheintermittentRBBBpatternisaresultoIaberrantintraventricularconduction,nottruebundlebranchblock.NonspeciIicST-T
changesareevident,andleItatrialabnormalityispresentinthesinusbeatsinleadV
1
.
Codes: 06 LeItatrialabnormality/enlargement
07 Sinusrhythm
13 Atrialprematurecomplexes
50 Functional(rate-related)aberrantintraventricularconduction
63 NonspeciIicSTand/orTwaveabnormalities
—381—
Ouestions:ECG63
1. In the setting oI a wide complex premature beat, Iactors that
Iavoranatrialoriginoveraventricularorigininclude:
a. Compensatorypause
b. PresenceoIothernormallyconductedAPCs
c. PresenceoIotheraberrantlyconductedAPCs
d. Initial QRS Iorces in the same direction as anormally
conductedbeat
2. TheQRSconIigurationtypicallyseenwithaberrantlyconducted
APCsis:
a. LBBBpattern
b. RBBBpattern
Answers:ECG63
1. Factors Iavoring an aberrantly conducted atrial premature
complex(APC)overaventricularprematurecomplex(VPC)
includethepresenceoIothernormallyconductedoraberrant
APCs,andinitialQRSIorcesinthesamedirectionasanormal
sinusbeat.APCstypicallyresetthesinusnode,resultingina
non-compensatorypause(i.e,PPintervalcontainingtheAPCis
lessthantwicethenormalPPinterval).Incontrast,VPCsare
usually accompanied by a Iull compensatory pause (i.e., PP
intervalcontainingtheVPCistwicethenormalPPinterval).
(Answer:b,c,d)
2. AberrantlyconductedAPCsarecharacterizedbyPwavesthat
are abnormal in conIiguration and occur early relative to the
normalPPinterval,andvariablewidening/distortionoItheQRS
complex. The longer reIractory period oI the right bundle
compared to the leIt bundle increases the likelihood that an
APC will conduct down the leIt bundle, resulting in QRS
morphologywithRBBBconIiguration.(Answer:b)
—(«:·/k:.::«(;— —(«:·/k:.::«(;— —(«:·/k:.::«(;— —(«:·/k:.::«(;—
Atrialprematurecomplexes,aberrantly
conducted
• Pwaveis(normal/abnormal)inconIiguration
• QRScomplexis(similar/diIIerent)inmorphology
totheQRScomplexpresentduringsinusrhythm,
andusuallymaniIests(RBBB/LBBB)pattern
• PRintervalmaybenormal,increased,ordecreased
(true/Ialse)
• Thepost-extrasystolicpauseisusually
(compensatory/noncompensatory)
abnormal
diIIerent
RBBB
true
noncompensatory
Leftatrialabnormality
• NotchedPwavewithaduration~ secondsin
leadsII,IIIoraVF,or
• TerminalnegativeportionoIthePwaveinleadV
1
~1mmdeepand~ secondsinduration
0.12
0.04
—382—
ECG64. 72-year-oldmalewithchronicheartfailure:
—383—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconduction
disturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonary
embolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—384—
ECG64wasobtainedIroma72-year-oldmalewithchronicheartIailure.TheECGshowsanarrowQRScomplexrhythmatarateoI78
beats/minutewithoutPwaves,consistentwithacceleratedjunctionalrhythm.InthesettingoIchronicheartIailure,thisisoItencausedby
digitalistoxicity.Lowvoltageisevidentinthelimbleads(QRSamplitude·5mm),whichmaybeduetopleuraleIIusion,pericardialeIIusion,
orrestrictive,inIiltrative,orsevereischemiccardiomyopathy.
Codes: 22 AVjunctionalrhythm/tachycardia
71 Digitalistoxicity
—385—
Ouestions:ECG64
1. ThePwaveinajunctionalrhythm:
a. FollowstheQRScomplex
b. IsburiedintheQRScomplex
c. PrecedestheQRScomplex
2. Acceleratedjunctionalrhythmwithunderlyingcompleteheart
blockisacommonmaniIestationoI:
a. Sicksinusrhythm
b. Acuterespiratorydecompensation
c. AcutemyocardialinIarction
d. Digitalistoxicity
3. Duringacceleratedjunctionalrhythm:
a. Pwaves(whenevident)areusuallyinvertedinleadsII,III,
andaVF
b. TheQRScomplexisaberrantlyconducted
c. Rateexceeds100perminute
d. PRintervalisprolonged
Answers:ECG64
1. DependingonthesiteoIoriginoIthejunctionalrhythmwithin
theAVnode,thePwavecanprecede,beburiedin,orIollow
theQRScomplex.(Answer:all)
2. DigitalistoxicitycancauseawidevarietyoIarrhythmiasand
conduction disturbances, including paroxysmal atrial
tachycardia with block, second- or third-degree AV block,
acceleratedjunctionaloridioventricularrhythmwithcomplete
heartblock,andsupraventriculartachycardiawithalternating
bundlebranchblock.RegularizationoItheventricularresponse
in atrial Iibrillation is oIten indicates the development oI
completeheartblock.Digitalistoxicitymaybeexacerbatedby
hypokalemia,hypomagnesemia,orhypercalcemia.(Answer:d)
3. Because the AV node lies at the base oI the rightatrium,
electricalactivationoItheatriausuallyproceedsinaninIerior
to superior direction, resulting in inverted P waves in the
inIerior leads. (In contrast, the sinoatrial node activates the
atriuminasuperiortoinIeriordirection,resultinginuprightP
waves in the inIerior leads.) Other Ieatures oI junctional
rhythmsincludeQRScomplexesthataretypicallynarrow(but
maybewideiIaberrancyorpre-existingbundlebranchblock)
and occur at rates ~ 60 per minute. P waves usually occur
within0.12secondsbeIoreoraItertheQRScomplex.(Answer:
a)
—386—
—(«:·/k:.::«(;— —(«:·/k:.::«(;— —(«:·/k:.::«(;— —(«:·/k:.::«(;—
AcceleratedAV]unctionalrhythm
• Rate~perminute
• QRScomplexmaybenarroworaberrant
(true/Ialse)
• InvertedPwavesinleadsanduprightPwaves
inleadsarecommon
• Pwavemayprecede,beburiedin,orIollowthe
QRS(true/Ialse)
60
true
II,III,aVF
I,aVL
true
Lowvoltage
• AmplitudeoItheentireQRScomplex(R¹S)·
mminallprecordialleadsand·mminall
limbleads
10
5
Digitalistoxicity
• DigitalistoxicitycancausealmostanytypeoI
cardiacdysrhythmiaorconductiondisturbance
except
•Typicalabnormalitiesinclude:
Paroxysmaltachycardiawithblock
AtrialIibrillationwithheartblock
Secondorthird-degreeblock
Completeheartblockwithacceleratedor
rhythm
Supraventriculartachycardiawithbundle
branchblock
bundlebranch
block
atrial
complete
AV
junctional
idioventricular
alternating
—387—
—POPOU¡Z—
RhythmRecognItIon:HR<100;NarrowQRS;IrreguIarRRIntervaI
Instructions:DeterminethecardiacrhythmIoreachoItheIollowingECGs.
ECG Diagnosis
Answer:Sinoatrialexitblock,MobitzTypeI.Description:Somewhat
irregularsinusrhythmwithoccasionalabsenceoIaPwave,causedbyIailure
oIsinusimpulsestointermittenlycapturetheatria.UnlikeMobitzTypeII
SAexitblock,thereisshorteningoIthePPintervaluptothepause,andthe
PPpauseisless thantwicethenormalPPinterval.PRintervalisconstant.
OItenamaniIestationoIthesicksinussyndrome.
Answer:Sinoatrialexitblock,MobitzTypeII.Description:Regularsinus
rhythmwithoccasionalabsenceoIaPwave,causedbyIailureoIsinus
impulsestointermittentlycapturetheatria.PPintervalsbeIoreandaIterthe
pauseareconstant,andthePPpauseisamultiple(e.g.,2x,3x)oIthenormal
PPinterval.PRintervalisconstant.OItenamaniIestationoIthesicksinus
syndrome.
Answer:2
"
degreeAVblock,MobitzTypeII.Description:Regularsinus
oratrialrhythmwithintermittentnonconductedPwavesandnoevidenceIor
atrialprematurity.PRintervalintheconductedbeatsisconstant,andtheRR
intervalcontainingthenonconductedPwaveisequaltotwoPPintervals.
TypeIIAVblockusuallyoccurswithinorbelowthebundleoIHis,andis
associatedwithawideQRSin80°oIcases.
—388—
ECG65. Rhythmstripfroma62-year-oldmalewith
chestpain:
—389—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconduction
disturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonary
embolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—390—
ECG65 is a 3-lead rhythm strip obtained Irom a 62-year-old male with chest pain. The Iirst Iour beats are sinus beats at a rate oI 98
beats/minute. Sinus rhythm is Iollowed by the onset oI ventricular tachycardia (arrowhead), which rapidly degenerates into ventricular
Iibrillation.TheSTelevationinleadV
5
(arrow)isconsistentwithacutemyocardialinjury.ThepatientwassuccessIullydeIibrillated.
Codes: 07 Sinusrhythm
25 Ventriculartachycardia
28 VentricularIibrillation
65 STand/orTwaveabnormalitiessuggestingmyocardialinjury
—391—
Ouestions:ECG65
1. Drugscommonlyassociatedwithproarrhythmiainclude:
a. Amiodarone
b. Flecainide
c. Quinidine
d. PropaIenone
2. FactorsassociatedwithincreasedriskoIventriculartachycardia
orsuddencardiacdeathaItermyocardialinIarctioninclude:
a. LeItventriculardysIunction
b. Heartratevariability
c. Syncope
d. Nonsustainedventriculartachycardia
Answers:ECG65
1. Quinidine(byprolongingtheQTinterval),andIlecainideand
propaIenone(byprolongingventricularconduction,i.e.,QRS
complex) increase the risk oI proarrhythmia. Amiodarone is
associated with hypothyroidism, hyperthyroidism, pulmonary
toxicity, hepatic toxicity, skin discoloration, and severe
bradyarrhythmias.Proarrhythmiawithventriculartachycardia,
however, is less common with amiodarone, but still occurs.
(Answer:all)
2. LeIt ventricular ejection Iraction · 40°, nonsustained
ventricular tachycardia, syncope, and reduced heart rate
variability are risk Iactors Ior ventricular tachycardia and
sudden cardiac death Iollowing acute myocardial inIarction.
Sinus bradycardia and maintained beat-to-beat heart rate
variability(sinusarrhythmia)areassociatedwithreducedrisk
statusaIterMI.(Answer:a,c,d)
—(«:·/k:.::«(,— —(«:·/k:.::«(,— —(«:·/k:.::«(,— —(«:·/k:.::«(,—
Ventriculartachycardia
• RapidsuccessionoIthreeormorepremature
ventricularbeatsatarate~perminute
• RRintervalsareusuallyregularbutmaybe
irregular(true/Ialse)
• (Abrupt/gradual)onsetandterminationareevident
• AViscommon
• LookIorventricularcomplexesand
beatsasmarkersIorVT
100
true
abrupt
dissociation
capture,Iusion
Ventricularfibrillation
• Extremelyrapidand(regular/irregular)ventricular
rhythmwith:
Chaotic,irregulardeIlectionsoI
(constant/varying)amplitudeandduration
(Absence/presence)oIdistinctPwaves,QRS
complexes,andTwaves
irregular
varying
absence
—392—
—POPOU¡Z—
ToTreatorNottoTreat,ThatIstheQuestIon
Instructions:SelectthebestIormoItreatmentIoreachconditionsuggestedbytheIollowingECGs.
ECG Choose Single Best Answer Answer
34y.o.Iemale:top(baseline2weeksago);
bottom(nowduringpalpitations)
a. Notreatment
b. Digoxin
c. Digoxinantibody
d. Adenosine
e. Stopaminophylline
I. Procainamide(IV)
g. Pericardiocentesis
h. Glucose¹insulin
Approximately50°oIpatientswithWolII-Parkinson-White
(WPW)syndromemaniIesttachyarrhythmias,oIwhich80°isAV
reentranttachycardia,15°atrialIibrillation,and5°atrialIlutter.
Atrial fibrillation in WPW(seeninthisECG)isassociatedwitha
QRSthatvariesinwidth(generallywide),resultinginarapid,
irregular,wideQRScomplextachycardiathatresemblesVTandcan
degenerateintoVF.The12-leadECGduringsinusrhythmshowsa
shortPRintervalwithinitialslurringoItheQRS(deltawave)dueto
pre-excitationoItheventriclesIromconductionoveranaccessory
AVpathway(bundleoIKent).TreatmentoIatrialIibrillationin
WPWconsistsoIIVprocainamideorelectricalcardioversion
(Answer:I)
Pulsusparadoxus,severedyspnea,hypotension
CausesoIelectrical alternansincludepericardialeIIusion,severe
leItventricularIailure,hypertension,coronaryarterydisease,
rheumaticheartdisease,andsupraventricularorventricular
tachycardia.Onlyone-thirdoIpatientswithQRSalternanshavea
pericardialeIIusion,andonly12°oIpatientswithpericardial
eIIusionshaveelectricalalternans.Theclinicalhistoryinthiscase
suggestscardiactamponadewithimpendinghemodynamiccollapse,
whichshouldbetreatedwithemergencypericardiocentesis.
(Answer:g)
ThisECGshowsanarrowcomplexSVTatarateoI155perminute,
consistentwithAV nodal reentrant tachycardia(AVNRT).TheP
waveisburiedintheQRScomplex.AVNRTisoIteninitiatedby
APCs,andaccountsIor60-70°oISVTs.Carotidsinusmassage
Irequentlyterminatesthetachycardia.AdenosineishighlyeIIective
atinterruptingthereentrantloopandrestoringsinusrhythm.
(Answer:d)
—393—
—POPOU¡Z—
PatternRecognItIon:AntIarrhythmIcDrugEIIectvs.ToxIcIty
Instructions:DeterminewhichoItheIollowingECGsareconsistentwithantiarrhythmicdrugeIIectandwhichareconsistentwith
antiarrhythmicdrugtoxicity.
Choose All That Apply Answer
A. B. Antiarrhythmic drug effectissuggestedby
mildincreaseinQTinterval,prominentU
waves(oneoItheearliestIindings),
nonspeciIicSTand/orTwavechanges,ora
decreaseinatrialIlutterrate.(Answer:none)
Antiarrhythmic drug toxicityissuggestedby
markedprolongationoItheQTinterval
(choice“d”),wideningoItheQRScomplex
(choice“c”),AVblock,markedsinus
bradycardia,sinusarrest(choice“a”),
sinoatrialexitblock,orventricular
arrhythmiasincludingtorsadedepointes
(choice“e”).PeakedTwaves(choice“b”)or
markedSTdepressionwithdeeplyinvertedT
waves(choice“I”)arenotassociatedwith
antiarrhythmicdrugtoxicity.(Answer:a,c,d,
e)
C. D.
E. F.
—394—
ECG66. 51-year-oldfemalewithorthopneaand
paroxysmalnocturnaldyspnea:
—395—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—396—
ECG66wasobtainedina51-year-oldIemalewithahistoryoIorthopneaandparoxysmalnocturnaldyspnea.TheECGshowssinusrhythm
withpredominantly2:1AVblock(arrowheadsmarkPwaves),leItbundlebranchblock(LBBB)withsecondaryST-Tchanges,andrightaxis
deviation.CloseinspectionrevealsevidenceIorMobitzTypeI(Wenckebach)second-degreeAVblock(asterisk)—thethirdPwaveconducts
atanormalPRinterval,theIourthPwaveataprolongedPRinterval,andtheIiIthPwave(hiddenintheTwave)isblocked.TheQwavesand
STelevationinleadsV
1
-V
3
aremostlikelyduetoLBBB,ratherthanacuteanteroseptalMI(LBBBoItenresultsinapseudoinIarctpattern).
Codes: 07 Sinusrhythm
30 AVblock,2
o
-MobitztypeI(Wenckebach)
32 AVblock,2:1
37 Rightaxisdeviation(~¹100
o
)
47 LBBB,complete
*
① ② ③ ④ ⑤
—397—
Ouestions:ECG66
1. Right axis deviation is deIined by a QRS axis rightward
between:
a. 60
o
-100
o
b. 90
o
-180
o
c. 100
o
-270
o
d. 110
o
-270
o
2. InthesettingoI2:1AVblock,thepresenceoIawidecomplex
QRSmakesthemechanismoIAVblockmorelikelytobe:
a. MobitzTypeI
b. MobitzTypeII
Answer:ECG66
1. RightaxisdeviationisdeIinedasaQRSaxisbetween100
o
and
270
o
.(Answer:c)
2. It is oIten diIIicult to distinguish Mobitz I Irom Mobitz II
second-degree AV block when 2:1 AV block is present
throughout the tracing. II classic Mobitz I (Wenckebach) is
presentonanotherECGoronmonitoringstrips,themechanism
oIblockisprobablyMobitzI.IIabnormalQRSconductionis
present (e.g., LBBB or biIascicular block), Mobitz II is more
likely.(Answer:b)
—(«:·/k:.::«((— —(«:·/k:.::«((— —(«:·/k:.::«((— —(«:·/k:.::«((—
AVblock,2
o
-MobitzType¡
{Wenckebach}
• ProgressiveprolongationoItheintervaland
shorteningoItheintervaluntilaPwaveis
blocked
• RRintervalcontainingthenonconductedPwaveis
(lessthan/equalto/greaterthan)thesumoItwoPP
intervals
• ResultsinbeatingduetothepresenceoI
nonconductedPwaves
PR
RR
lessthan
group
LBBB,complete
• QRSduration~ seconds
• OnsetoIintrinsicoiddeIlectioninleadsI,V
5
,V
6
~
seconds
• BroadmonophasicRwavesinleads,which
areusuallynotchedorslurred
• SecondaryST&Twavechangesinthe
(same/opposite)directiontothemajorQRS
deIlection
• or complexintherightprecordialleads
• LBBB(does/doesnot)interIerewithdetermination
oIQRSaxisandthediagnosesoIventricular
hypertrophyandacuteMI
0.12
0.05
I,V
5
,V
6
opposite
rSorQS
does
—398—
—POPOU¡Z—
PatternRecognItIon:AVConductIonAbnormaIItIes
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. ReIlectsprolongedconductionIrom
thesinusnodetoatrialtissue
b. 1
N
AVblock
c. Canbeseeninnormalindividuals
d. 2
N
AVblock,TypeI
e. Groupedbeatingdueto
nonconductedPwaves
I. BlockusuallyoccursatleveloIAV
node
g. MorecommonininIeriorMIthan
anteriorMI
h. 2
N
AVblock,TypeII
i. Blockusuallywithinorbelow
bundleoIHis
j. Blockmayimprovewithcarotid
sinusmassageandworsenwith
atropine
k. CanbeeitherMobitzTypeIorII
l. Atrialandventricularrhythmsare
independentoIeachother
m. 3
N
AVblock
1
N
AV blockrepresentsdelayIromtheonsetoIatrial
depolarizationtotheonsetoIventricular
repolarization,andmaniIestsasaPRinterval~0.20
seconds.EachPwaveisIollowedbyaQRS
complex.Causesincludehighvagaltone,drugs,
acuterheumaticIever,myocarditis,andcongenital
heartdisease;occasionallyseeninnormals.(Answer:
b,c,I,g)
Mobitz Type I (Wenkebach) 2
o
AV blockresultsina
regularsinusoratrialrhythmwithintermittent
nonconductedPwaves(resultingin“grouped
beating”),andprogressiveprolongationoIthePR
intervalandshorteningoItheRRintervaluntilaP
waveisblocked;theRRintervalcontainingthe
nonconductedPwaveislessthantwoPPintervals.
BlockusuallyoccurswithintheAVnode,andis
associatedwithanarrowQRScomplex.AVblock
mayimprovewithmaneuversthatincreaseheartrate
(e.g.,atropine)andworsenwithmaneuversthat
reduceheartrate(e.g.,carotidsinusmassage).
Sometimesseeninnormals.(Answer:c,d,e,I,g)
Mobitz Type II 2
o
AV blockresultsinaregularsinus
oratrialrhythmwithintermittentnonconductedP
waves,aconstantPRintervalintheconductedbeats,
andanRRintervalcontainingthenonconductedP
waveequaltotwoRRintervals.Blockusuallyoccurs
withinorbelowthebundleoIHis,andisassociated
withawideQRScomplex.AVblockmayworsen
withmaneuversthatincreaseheartrateandimprove
withmaneuversthatreducerate.(Answer:e,h,i,j)
—399—
DifferentialDiagnosis
R¡GHTAX¡8DEV¡AT¡ON{> +100
o
}
• Rightventricularhypertrophy
• Verticalheart
• Chronicobstructivepulmonarydisease
• Pulmonaryembolus
• LeItposteriorIascicularblock
• LateralwallmyocardialinIarction
• Dextrocardia
• Limbleadreversal
• OstiumsecundumatrialseptaldeIect
—400—
ECG67. Rhythmstripfroma54-year-oldfemalewith
lightheadedness:
—401—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—402—
ECG67isa3-leadrhythmstripobtainedIroma54-year-oldIemalewithlightheadedness.TheECGshowsventricularpacingwithintermittent
IailuretocaptureandIailuretosense:FailuretocaptureresultsinpacemakerspikesnotIollowedbyQRScomplexes(arrowheads),andIailure
tosenseresultsinprematurepacemakerspikes(arrows)relativetotheV-VintervaloIthepacemaker(separationbetweentheIirstandsecond
pacemakerspikes),thekeytimingintervalIorthepacemaker.TheintrinsicrhythmissinusatarateoI88beats/minute(Pwavesbestseenin
leadII)withcompleteheartblockandaventricularescaperhythmatarateoI29beats/minute.Thesinusandventricularescaperhythmsare
independentoIeachother,resultinginAVdissociation.(TheRBBBpatternisduetoabnormalventricularactivationIromtheventricularescape
rhythm,nottruebundlebranchblock.)LeItatrialenlargementisalsopresent.N÷nativebeat;P÷pacedbeat.
Codes: 06 LeItatrialabnormality/enlargement
07 Sinusrhythm
27 Ventricularescapecomplexesorrhythm
33 AVblock,3°
35 AVdissociation
93 PacemakermalIunction,notconstantlycapturing(atriumorventricle)
94 PacemakermalIunction,notconstantlysensing(atriumorventricle)
N P P N N P
—403—
Ouestions:ECG67
1. Twiddler’ssyndromeis:
a. Lightheadedness associated with atrial contraction against
closedatrio-ventricular(AV)valveswithVVIpacemakers
b. Displacement oI a pacemaker lead caused by patient
manipulationoIthesubcutaneousleadwires
c. AIormoIpacemaker-mediatedtachycardiaIirstdescribed
byDr.FelixTwiddler
2. Paced ventricular beats with RBBB morphology isconsistent
with:
a. PerIoration oI the pacemaker lead across the septum and
intotheleItventricle
b. AleItventricularepicardiallead
c. Normalleadplacementintherightventricularapex
Answers:ECG67
1. Twiddler’s syndrome reIers to patient manipulationoI
pacemakerleadwires,resultinginrotationoIthepulsegenerator
in the pocket lead and dislodgement with Iailure to capture
and/or sense. Pacemaker syndrome reIers to episodic
lightheadedness Irom enhanced baroreIlex response to atrial
contractionagainstclosedAVvalves.Thisisusuallyassociated
withcannon“a”wavesinthejugularpulse,andoccursmainly
with VVI pacemakers. No novel syndromes have been
attributedtoaDr.Twiddler.(Answer:b)
2. Normally-positioned pacemaker leads in the rightventricular
apexshow pacedQRScomplexeswithLBBBpattern.Paced
beats with RBBB morphology should raise concern that the
pacingleadhasenteredtheleItventricle,eitherIromperIoration
oItheseptumor,inunusualcases,passageoIthecatheteracross
an atrial septal deIect or patent Ioramen ovale. RBBB
morphology can also be seen in patients with leIt ventricular
epicardialleadsplacedyearsagoviathoracotomy.(Answer:a,
b)
—404—
—(«:·/k:.::«(I— —(«:·/k:.::«(I— —(«:·/k:.::«(I— —(«:·/k:.::«(I—
Pacemakermalfunction,notconstantly
sensing{atriumorventricle}
• Pacemakersintheinhibitedmode:PacemakerIails
tobe byanappropriateintrinsic
depolarization
• Pacemakersinthetriggeredmode:PacemakerIails
tobetriggeredbyanappropriate
depolarization
• PrematuredepolarizationsmaynotbesensediI
theyIallwithintheprogrammedperiodoIthe
pacemaker,orhaveinsuIIicientatthesensing
electrodesite
inhibited
intrinsic
reIractory
amplitude
Pacemakermalfunction,notconstantly
capturing{atriumorventricle}
• FailureoIpacemakerstimulustobeIollowedbya
• Ruleout“pseudo-malIunction”(i.e.,pacerstimulus
IallsintotheperiodoIventricle)
depolarization
reIractory
—405—
—POPOU¡Z—
PatternRecognItIon:PacemakerMaIIunctIon
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. Failuretocapture
b. Causesincludelead
displacement,leadIracture,and
increasedpacingthreshold
c. Failuretosense
d. Occurswithlowamplitude
signals
e. FailuretoIire
I. OversensingTwaves
g. Myopotentialinhibition
h. Pacemaker-mediatedtachycardia
(PMT)
i. Can becorrectedby increasing
thepost-ventricularatrial
reIractoryperiod(PVARP)
j. Proper pacing (no malIunction)
Oversensing of T wavesoccurswhenTwavesaremistaken
IorRwaves,whichresetsthepacemakerclockandresultsin
IailureoIthepacemakertodischargeattheappropriatetime.
Theventricularstimulusescape(V-A)intervalistimedIrom
theTwave,insteadoItheRwave.Thisproblemcanbe
correctedbyreprogrammingthesensitivityoIthechamber
thatisoversensing.(Answer:I)
Oversensing of myopotentials (myopotential inhibition)
occurswhenmyopotentials(muscularpotentialsIromarm
movements)areinappropriatelysensedascardiacpotentials,
whichresetsthepacemakerclockandinhibitspacemaker
output.PacedRRintervalstendtobeirregular.This
problemismorecommonwithunipolarpacemakers.
(Answer:g)
Pacemaker-mediated tachycardia(PMT)occurswithatrial-
sensingdualchamberpacemakers,andmaniIestsasrapid
pacingatorneartheprogrammedupperratelimit.PMTis
duetoarepetitivecycleoIventricularpacedbeat(orVPC)
ÚretrogradeatrialactivityÚatrialsensingÚventricular
pacedbeat,andcanusuallybecorrectedbyincreasingthe
post-ventricularatrialreIractoryperiod(PVARP)oIthe
pacemaker.(InthisECG,retrogradePwavesdeIormthe
downslopeoI theT waves.)(Answer: h, i)
—406—
ECG68. 18-year-oldasymptomaticmale:
—407—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—408—
ECG68wasobtainedina18-year-oldasymptomaticmalebeingscreenedIorparticipationinhighschoolbasketball.ThemostnotableIeature
oI the ECG is the negative P-QRS-T in leads I and aVL (asterisks), which may be seen in both dextrocardia and limb lead reversal. The
diminishing(reverse)Rwaveamplitude(arrows)acrosstheprecordium(V
1
-V
6
)conIirmsthediagnosisoIdextrocardia.Rightaxisdeviation
andnonspeciIicST-Tabnormalitiesarealsopresent.
Codes: 07 Sinusrhythm
37 Rightaxisdeviation(~¹100°)
63 NonspeciIicSTand/orTwaveabnormalities
80 Dextrocardia,mirrorimage
*
*
—409—
Ouestions:ECG68
1. Dextrocardiaisassociatedwith:
a. QTprolongation
b. Lowvoltageinthelimbleads
c. InvertedP,QRS,andTwavesinleadsIandaVL
d. ProminentRwavevoltageintheleItprecordialleads(V
4
-
V
6
)
2. Isolated dextrocardia (dextrocardia without inversion oI other
viscera) is almost invariably associated with other serious
congenitalcardiacmalIormations:
a. True
b. False
Answers:ECG68
1. Dextrocardia is a rare condition characterized by congenital
malpositioningoItheheartintherightsideoIthechest.ECG
IeaturesincludeinversionoItheP-QRS-TinleadsIandaVL,
anddecreasingRwaveamplitudeIromleadsV
1
-V
6
.(Answer:
c)
2. In mirror-like dextrocardia, the most common Iorm oI
dextrocardia,theabdominalandthoracicviscera(inadditionto
the heart) are transposed to the side opposite their usual
locations (dextrocardia with “situs inversus”). This Iorm oI
dextrocardiaisgenerallynotassociatedwithseverecongenital
cardiac abnormalities (other than the malposition, which does
notaIIectcardiacIunction).In isolateddextrocardia,theheart
isrotatedtotherightsideoIthechestbutothervisceraremain
in their usual locations. This type oI dextrocardia is almost
alwaysassociatedwithseriouscongenitalcardiacabnormalities,
resulting in clinical diIIiculties in inIancy or early childhood.
(Answer:a)
—(«:·/k:.::«(2— —(«:·/k:.::«(2— —(«:·/k:.::«(2— —(«:·/k:.::«(2—
Rightaxisdeviation
• MeanQRSaxisbetweenanddegrees 101,270
Dextrocardia,mirrorimage
• P-QRS-Tinleadsareinvertedor“upside
down”
• DecreasingwaveamplitudeIromleadsV
1
-V
6
• Dextrocardiaandcanbothproduceanupside
downP-QRS-TinleadsIandaVL.Todistinguish
betweentheseconditions,lookattheRwave
patterninV
1
-V
6
:
ReverseRwaveprogressionsuggests
(dextrocardia/leadreversal)
NormalRwaveprogressionsuggests
(dextrocardia/leadreversal)
I,aVL
R
leadreversal
dextrocardia
leadreversal
—410—
ECG69. 76-year-oldasymptomaticfemale:
—411—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—412—
ECG69 was obtained Irom a 76-year-old asymptomatic Iemale, and shows atrial Iibrillation with appropriate ventricular demand pacing
(asterisks)at50beats/minute.NonspeciIicrepolarizationabnormality is notedinnativeQRScomplexes.SaggingSTsegmentdepression
(arrows)isconsistentwithdigitaliseIIect.
Codes: 19 AtrialIibrillation
63 NonspeciIicSTand/orTwaveabnormalities
70 DigitaliseIIect
91 Ventriculardemandpacemaker(VVI),normallyIunctioning
*
* * *
—413—
Ouestions:ECG69
1. ThediagnosisoIventriculardemand(VVI)pacingrequires:
a. InhibitionoIatrialoutputinresponsetonativeatrialactivity
b. Variablepacingrates
c. RetrogradeVAconduction
d. Inhibition oI ventricular output in response to an intrinsic
QRScomplex
Answers:ECG69
1. Aventriculardemand(VVI)pacemakersensesandpacesonly
in the ventricle, and is oblivious to native atrial activity. II
constantventricularpacingisnotedthroughoutthetracing,itis
impossibletodistinguishventriculardemandIromasynchronous
ventricularpacing.Thus,thediagnosisoIventriculardemand
pacingrequiresevidenceoIappropriateinhibitionoIpacemaker
outputinresponsetoanativeQRS(atleastone).Retrograde
VAconductionmayoccur,butisnotrequiredIorthediagnosis.
ThepacingrateoIaVVIpacemakerisgenerallyconstantatthe
programmedpacingrate;incontrast,VVI-RpacingallowsIor
variablepacingratesinresponsetophysiologicneeds.(Answer:
d)
—(«:·/k:.::«(7— —(«:·/k:.::«(7— —(«:·/k:.::«(7— —(«:·/k:.::«(7—
Ventriculardemandpacing
• PacemakerstimulusIollowedbyaQRScomplex
thathas(thesame/diIIerent)morphologycompared
totheintrinsicQRS
• MustdemonstrateoIpacemakeroutputin
responsetointrinsicQRS
diIIerent
inhibition
Digitaliseffect
• STsegmentdepressionwithupward
(concavity/convexity)
• TwaveIlat,inverted,or
• QTinterval(shortened/prolonged)
• Uwaveamplitude(increased/decreased)
• PRinterval(shortened/lengthened)
Sagging
concavity
biphasic
shortened
increased
lengthened
—414—
—POPOU¡Z—
PatternRecognItIon:PacemakerMaIIunctIon
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. Failuretocapture
b. Causesincludelead
displacement,leadIracture,and
increasedpacingthreshold
c. Failuretosense
d. FailuretoIire
e. OversensingTwaves
I. Myopotentialinhibition
g. Pacemaker-mediatedtachycardia
(PMT)
h. Can becorrectedby increasing
thepost-ventricularatrial
reIractoryperiod(PVARP)
i. Proper pacing (no malIunction)
Failure to captureoccurswhenapacingspike(atrialor
ventricular)isnotIollowedbyanappropriatedepolarization.
Causesincludeleaddisplacement,perIoration,increased
pacingthreshold(IromMI,Ilecainide,amiodarone,
hyperkalemia),leadIractureorinsulationbreak,pulse
generatorIailure(Irombatterydepletion),orinappropriate
reprogramming.FailuretocapturemustbediIIerentiated
Irom“pseudo-malIunction,”inwhichthepacerstimulusIalls
intoreIractoryperiodoIventricle.(Answer:a,b)
Failure to senseoccurswhenthepacemakerisnotinhibited
byanappropriateintrinsicdepolarization,resultinginan
extraearlyasynchronouspacingspike.Pacemakertimingis
notresetbyintrinsicorectopicbeats,resultinginapaced
rhythmthatcompeteswiththeintrinsicrhythm.Failureto
senseoccurswithlowamplitudesignals(especiallyVPCs),
inappropriateprogrammingoIpacemakersensitivity,andall
causesoIIailuretocapture,above.Reprogrammingthe
sensitivityoIthepacemakeroItencorrectstheproblem.
(Answer:b,c)
Properventriculardemandpacingisseen(nomalIunction).
(TheperIoratedverticallinebetweentheIirstandsecond
beatsisaleadswitchindicator,notapacemakerspike.)
(Answer:i)
—415—
—POPOU¡Z—
FIndTheMIstake
Instructions:IdentiIytheincorrectECGIeature(s)IoreachECGdiagnosislistedbelow.
ECG Diagnosis and Features Mistake
Antiarrhythmicdrugeffect
• ProminentUwaves(oneoItheearliestIindings)
• ProlongedQTinterval
• NonspeciIicSTand/orTwavechanges
• WideningoItheQRScomplex
• AVblock
WideningoItheQRScomplexand
AVblockareconsistentwithdrug
toxicity(notdrugeIIect)
Pericarditis
• ClassicevolutionaryST-TpatternconsistsoI4stages:1)DiIIuse
upwardlyconcaveSTelevation;2)Twavesinvert;3)STjunction
returnstobaseline&Twaveamplitudedecreases;4)ECGreturns
tonormal
• Othercluesincludesinustachycardia,PRdepressionlate,andlow
voltageQRS
STjunctionusuallyreturnsto
baselinebeIore(notaIter)Twaves
invert;PRdepressionoccursearly
(notlate)
Digitaliseffect
• SaggingSTsegmentdepressionwithupwardconvexity
• TwaveIlat,inverted,orbiphasic
• QTintervalshortened
• Uwaveamplitudeincreased
• PRintervallengthened
STsegmentshaveupward
concavity(notconvexity)
Digitalistoxicity
• Typicalabnormalitiesincludeparoxysmalatrialtachycardiawith
block,atrialIibrillationwithcompleteheartblock,second-or
third-degreeAVblock,completeheartblockwithaccelerated
junctionaloridioventricularrhythm,andbundlebranchblock
Isolatedbundlebranchblockisnot
amaniIestationoIdigitalistoxicity
—416—
ECG70. 49-year-oldwomanwithdryskin,weakness,
coldintolerance,constipation&weightgain:
—417—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—418—
ECG70wasobtainedina49-year-oldwomanwithcomplaintsoIdryskin,weakness,coldintolerance,constipation,andweightgain.The
ECGshowssinusbradycardiawithleItaxisdeviation,relativelylowvoltageQRScomplexes(whichdonotquitemeetcriteriaIorIormalcoding
oIlowvoltage),ageindeterminateoroldinIeriormyocardialinIarction,andminornonspeciIicST-Tabnormalities.InthecontextoItheclinical
presentation,theseECGIindingsareconsistentwithmyxedema.ThiswomanhadapasthistoryoIinIeriorMIandwasshowntobeproIoundly
hypothyroid.
Codes: 09 Sinusbradycardia(·60)
58 InIeriorQwaveMI(ageindeterminateorold)
87 Myxedema
—419—
Ouestions:ECG70
1. ThediIIerentialdiagnosisIorlowvoltageECGincludes:
a. SarcoidosisoItheheart
b. Myxedema
c. CongestiveheartIailure
d. PericardialeIIusion
e. PleuraleIIusion
I. Amyloidheart
g. COPD
h. DiIIusecoronaryarterydisease
i. Obesity
j. Pectusexcavatum
Answers:ECG70
1. The amplitude oI the QRS complex is oIten decreased by
conditionsthatincreasetheamountoIbodytissue(obesity),air
(COPD,pneumothorax),Iluid(pericardialorpleuraleIIusion),
Iibrous tissue (coronary artery disease) or other inIiltrative
substances (sarcoid, amyloid, myxedema) between the
myocardium and surIace ECG electrodes. Pectus excavatum
(Iunnel chest) oIten increases QRS amplitude. (Answer: all
exceptj)
—(«:·/k:.::«I0— —(«:·/k:.::«I0— —(«:·/k:.::«I0— —(«:·/k:.::«I0—
Lowvoltage,limbandprecordialleads
• AmplitudeoItheentireQRScomplex(R¹S)·
mminallprecordialleadsand·mminall
limbleads
10
5
¡nferiorM¡,ageindeterminateor
probablyold
• AbnormalQwaves(with/without)STelevationin
atleasttwooIleads
without
II,III,aVF
Myxedema
• (High/low)QRSvoltageinallleads
• Sinus(tachycardia/bradycardia)
• TwaveIlattenedor(upright/inverted)
• PRintervalmaybe(shortened/prolonged)
• Frequentlyassociatedwithpericardial
• Electricalalternansmayoccur(true/Ialse)
Low
bradycardia
inverted
prolonged
eIIusion
true
—420—
—POPOU¡Z—
PatternRecognItIon:ECGJCIInIcaICorreIatIon
Instructions:MatchtheECGtothemostlikelyclinicalpresentation.
ECG Choose Single Best Answer Answer
a. Severeheadache,papilledema
b. Dyspnea,constipation,impaired
memory,Iatigue
c. Red-green colorblindness,
nausea,vomiting
d. Acuteoliguria2°to
rhabdomyolysis
e. MurmurinaDown’sSyndrome
patient
I. AcuteexacerbationoIchronic
bronchitis
g. Prolongedexposuretoextreme
cold
h. Dyspneaandpulsesparadoxus
inarenalIailurepatient
i. AcuteonsetoIdyspneaina
patientwithaDVT
ClassicECGchangesoIcerebral or subarachnoid hemorrhage
usuallyoccurintheprecordialleads,andconsistoIlargeuprightor
deeplyinvertedTwavesandaprolongedQTinterval.Other
changesmayincludeprominentUwaves,Twavenotchingwithloss
oIamplitude,STsegmentelevationordepression,orabnormalQ
wavesmimickingMI.ThisECGwasobtainedinapatientwitha
rupturedBerryaneurysmandincreasedintracranialpressure.
(Answer:a)
Peaked T wavesaredeIinedbyTwaveamplitudeexceeding6mm
inthelimbleadsor10mmintheprecordialleads.Causesinclude
hyperkalemia(morecommonwhenriseinserumpotassiumis
acute),acuteMI,intracranialbleeding,LVH,RVH,andLBBB.
Thispatientpresentedwithacuteoliguria2°torhabdomyolysisand
aserumK
+
oI8meq/L.(Answer:d)
QRS (electrical) alternansmaybeseeninassociationwith
pericardialeIIusion,severeleItventricularIailure,hypertension,
coronaryarterydisease,rheumaticheartdisease,and
supraventricularorventriculartachycardia.ThisECGwasobtained
IromarenalIailurepatientwithuremicpericarditisandcardiac
tamponade.(Answer:h)
— 421 —
DifferentialDiagnosis
LEFT AX¡8DEV¡AT¡ON{> – 30°}
• LeItanteriorIascicularblock(iIaxis~–45°)
• InIeriorwallMI
• LeItbundlebranchblock
• LeItventricularhypertrophy
• OstiumprimumatrialseptaldeIect
• Chroniclungdisease(e.g.,emphysema)
• Hyperkalemia
—422—
ECG71. 53-year-oldmalewithpalpitations:
—423—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—424—
ECG71wasobtainedIroma53year-oldmalewithpalpitations.TheECGbeginswithsinusrhythmatarateoI72beats/minute.AIterthe
8
th
sinusbeat,thereisanonconductedatrialprematurecomplex(bestseeninleadV
1
,arrow)thatinitiatesarunoIatrialIibrillation(asterisk).
AlthoughtherhythminitiallyresemblesatrialIlutter,itquicklybecomesmorechaoticandtypicaloIatrialIibrillation.ThisECGemphasizes
theimportanceoIreviewingtheentirerhythmstrip.
Codes: 07 Sinusrhythm
13 Atrialprematurecomplexes
19 AtrialIibrillation
*
—425—
Ouestions:ECG71
1. InadditiontoatrialIibrillation,causesoIanirregularlyirregular
rhythminclude:
a. AtrialIlutterwithvariableAVblock
b. AVnodalreentranttachycardia(AVNRT)
c. Atrialtachycardiawith2:1block
d. MultiIocalatrialtachycardia
e. Acceleratedjunctionalrhythm
I. SinusrhythmwithIrequentAPCs
2. AtrialIibrillationwithaventricularresponse~200perminute
suggests:
a. Tachy-bradysyndrome(sicksinussyndrome)
b. Concealedbypasstract
c. Digitalistoxicity
d. WolII-Parkinson-Whitesyndrome
Answers:ECG71
1. MultiIocalatrialtachycardiaisanirregularrhythmwith~3P
wavemorphologies,varyingPR,RR,andRPintervals,anda1:1
relationship between P waves and QRS complexes. Sinus
rhythmwithIrequentAPCscanresembleMAT,butadominant
sinusPwaveisevident.AtrialIlutterwithvariableAVblock
results in sawtooth Ilutter waves and an irregularly irregular
ventricular response. Atrial tachycardia with 2:1 AV block
results in a regular rhythm with 2 P waves Ior every QRS
complex.AVNRTandacceleratedjunctionalrhythmarealmost
alwaysregularrhythms.(Answer:a,d,I)
2. Patients with WolII-Parkinson-White (WPW) syndrome are
capable oI conducting atrial impulses antegrade across their
bypasstractsatveryrapidrates,resultinginventricularratesin
atrial Iibrillation up to 300-350 per minute. Patients with
concealed bypass tracts conduct retrograde (not antegrade)
acrosstheirbypasstracts;ventricularratesinatrialIibrillation
aresimilartonormalpatients(100-180perminute).Ventricular
rates ~ 200 per minute rarely occur in other clinical settings.
(Answer:d)
—426—
—(«:·/k:.::«I1— —(«:·/k:.::«I1— —(«:·/k:.::«I1— —(«:·/k:.::«I1—
Atrialprematurecomplexes
• Pwaveis(normal/abnormal)inconIiguration
• QRScomplexis(similar/diIIerent)inmorphology
totheQRScomplexpresentduringsinusrhythm
• PRintervalmaybenormal,increased,or
decreased(true/Ialse)
• Thepost-extrasystolicpauseisusually
(compensatory/noncompensatory)
abnormal
similar
true
noncompensatory
Atrialfibrillation
• wavesareabsent
• Atrialactivityistotallyandrepresentedby
Iibrillatory(I)wavesoIvaryingamplitudes,
durationandmorphology
• Atrialactivityisbestseenintheand
leads
• Ventricularrhythmis(regularly/irregularly)
irregular
• toxicitymayresultinregularizationoIthe
RRintervalduetocompleteheartblockwith
junctionaltachycardia
• Ventricularrateisusuallyperminuteinthe
absenceoIdrugs
ThinkiItheventricularrateis~200per
minuteandtheQRSis~0.12seconds
P
irregular
rightprecordial,
inIerior
irregularly
Digitalis
100-180
WolII-Parkinson-
White
—427—
CommonDilemmas
inECG¡nterpretation
Problem
Atrial Iibrillation is present with intermittent episodes oI
atrial Ilutter. Should atrial Iibrillation or atrial Ilutter be
coded?
Recommendation
AtrialIibrillationshouldbecoded,notatrialIlutter.Atrial
Iibrillation oIten maniIests as “Iib/Ilutter;” however, on
Iormaltesting,youmustchooseoneortheother.Thebest
strategy in this setting is to code atrial Iibrillation; atrial
IluttershouldbereservedIortracingsthatshowcontinuous
atrialIlutterwithoutinterspersedepisodesoIIibrillation.
—428—
ECG72. 52-year-oldmalewithchestpain:
—429—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—430—
ECG72wasobtainedIroma52-year-oldmalewithchestpain.TheECGshowsatrialIibrillationwithmarkedST-Twavechanges(arrows)
consistentwithacutemyocardialinjurytotheinIerior,posterior,andanterolateralwalls(whichwilllikelyevolveintoanextensiveQwaveMI).
Inaddition,ST-Twavechangesconsistentwithmyocardialischemiaareevidentinthehighlateralleads(IandaVL).Thecoarsebaseline
IluctuationnotedinleadV
2
(arrowhead)iscompatiblewithartiIact.RegularizationoItheatrialIibrillationinthelasthalIoIthetracing(asterisk)
isconsistentwithAVblockwithanAVjunctionalescaperhythmsecondarytodigitalistoxicity.Rightaxisdeviationisalsopresent.
Codes: 04 ArtiIact
19 AtrialIibrillation
21 AVjunctionalescapecomplexes
37 Rightaxisdeviation(~¹100
N
)
64 STand/orTwaveabnormalitiessuggestingmyocardialischemia
65 STand/orTwaveabnormalitiessuggestingmyocardialinjury
71 Digitalistoxicity
*
—431—
Ouestions:ECG72
1. ThemostlikelycauseoIatallRwaveinleadV
1
inthesetting
oIinIeriormyocardialinjuryis:
a. Rightventricularhypertrophy
b. Rightbundlebranchblock
c. Normalvariant
d. PosteriorMI
2. WhatisthelikelyageoIthemyocardialinIarctiononthisECG:
a. Hours
b. Days
c. Weeks
3. WhatisresponsibleIorthechangeinQRSmorphologybetween
the4thand5thbeatsinthebottomrowoItheECGrecord:
a. Fusionbeat
b. Leadchange
c. ArtiIact
d. Aberrancy
4. Right axis deviation in this tracing is due to leIt posterior
Iascicularblock:
a. True
b. False
5. Findingsinthistracingconsistentwithhyperkalemiainclude:
a. AtrialIibrillation
b. STelevation
c. TallTwaves
6. ThemostlikelycauseIortheSTdepressioninIandaVLis:
a. Ventricularaneurysm
b. Lateralwallmyocardialischemia
c. Localizedpericarditis
d. ReciprocalchangessecondarytoacutemyocardialinIarction
e. DigitaliseIIect
7. WhatisthecauseoIthebaselineundulationsinV
2
:
a. CoarseatrialIibrillation
b. Flutterwaves
c. TremorduetoParkinson’sdisease
d. ArtiIact
—432—
Answers:ECG72
1. PosteriorMIisthemostlikelycauseoIatallRwaveinleadV
1
inthesettingoIinIeriormyocardialinjury.DuetothelossoI
posteriorQRSIorces,unopposedanteriorQRSIorcesmaniIest
aprominentRwaveinleadsoverlyingtheanteriorwall,suchas
leadV
1
and/orV
2
.(Answer:d)
2. ThedevelopmentoIQwavesandevolutionarychangesintheT
wave and ST segment can be used to approximate the age oI
myocardialinIarction:
& T waves: The development oI large upright T waves is
oIten the earliest maniIestations oI acute MI, occurring
within minutes and lasting Ior minutes to hours. T wave
inversion, which begins while ST segments are still
elevated,maylastIormonthstoyears,persistindeIinitely,
orregresstononspeciIicTwavechanges.
& ST segment:STelevationusuallydevelopsintheminutes
tohoursIollowingacuteMI.Resolutionmayoccurwithin
hours,butusuallyrequiresaIewdaysIorcompletereturnto
baseline. Persistence beyond 4 weeks should raise the
suspicionoIventricularaneurysm.
& && & Q waves:AbnormalQwavesusuallydevelopintheIirst
several hours to days Iollowing acute inIarction. In most
patients,theypersistindeIinitely;onoccasion,Qwavesmay
regresstonolongermeetcriteriaIorabnormalQwaves.In
Iewerthan15°oIpatients,Qwavesdisappearentirely.
In the present ECG, inIerior and anterolateral Q waves
accompaniedbyconvexupwardSTsegmentelevationsuggest
themyocardialinIarctionisacute.(Answer:a)
3. The abnormal QRS morphology seen in the IiIth beat in the
bottom row oI the ECG record is due to lead change midway
throughtheinscriptionoItheQRSmorphology.TheIirsthalI
oItheQRScomplexrepresentsrecordingIromaVF;thesecond
halIrepresentsrecordingIromV
3
.(Answer:b)
4. BeIore right axis deviation can be attributed to leIt posterior
Iascicular block (LPFB), other causes oI right axis deviation
must be excluded, including lateral wall MI, right ventricular
hypertrophy, and pulmonary emphysema. The presence oI
lateralMIinthistracingprecludesthediagnosisoILPFB,which
isadiagnosisoIexclusion.(Answer:b)
5. Although this patient is not hyperkalemic, elevated potassium
levelscaninduceECGchangesthatmimicacuteMI.Findings
inthisECGthatcanalsobeseeninhyperkalemiaincludetallT
wavesandSTelevation.However,theTwavesinhyperkalemia
are usually peaked and narrow, and ST elevation is usually
diIIuseanddoesnotshowreciprocalSTsegmentdepression,as
seenhereinleadsIandaVL.(Answer:b,c)
6. The ST segment depression in leads I and aVL is most likely
duetohighlateralwallischemia,althoughreciprocalchanges
are possible. In general, ST depression associated with ST
elevation in other leads is a marker Ior a larger region oI
jeopardizedmyocardium.DigitalismaycauseSTdepression,
butistypicallydiIIuseandnotconIinedtotwoleadsasinthe
presenttracing.PericarditisandventricularaneurysmcauseST
segmentelevation,notdepression.(Answer:b)
—433—
7. The most likely cause oI baseline undulation in lead V
2
is
artiIact,probablyduetoalooselead.CoarseatrialIibrillation
isunlikelysinceIineatrialIibrillationispresentthroughoutthe
restoIthetracing.Variabilityinthepeak-to-peakintervalsoI
the undulations makes atrial Ilutter unlikely, and the lack oI
artiIact in the limb leads makes tremor due to Parkinson’s
diseaseunlikely.(Answer:d)
—(«:·/k:.::«Iz— —(«:·/k:.::«Iz— —(«:·/k:.::«Iz— —(«:·/k:.::«Iz—
Atrialfibrillation
• wavesareabsent
• Atrialactivityistotallyandrepresentedby
Iibrillatory(I)wavesoIvaryingamplitudes,
durationandmorphology
• Atrialactivityisbestseenintheand
leads
• Ventricularrhythmis(regularly/irregularly)
irregular
• toxicitymayresultinregularizationoIthe
RRintervalduetocompleteheartblockwith
junctionaltachycardia
• Ventricularrateisusuallyperminuteinthe
absenceoIdrugs
ThinkiItheventricularrateis~200per
minuteandtheQRSis~0.12seconds
P
irregular
rightprecordial,
inIerior
irregularly
Digitalis
100-180
WolII-Parkinson-
White
—(«:·/k:.::«Iz— —(«:·/k:.::«Iz— —(«:·/k:.::«Iz— —(«:·/k:.::«Iz—
AV]unctionalescapecomplexes
• QRScomplexoccursasaphenomenonin
responsetodecreasedsinusimpulseIormationor
conduction,orhigh-degreeAVblock
• Rateistypicallyperminute
• Atrialmechanismmaybesinusrhythm,
paroxysmalatrialtachycardia,atrialIlutter,oratrial
Iibrillation(true/Ialse)
• QRSmorphologyis(similarto/diIIerentIrom)the
sinusorsupraventricularimpulse
secondary
40-60
true
similarto
PosteriorM¡,recentorprobablyacute
• InitialRwave~ secondsinleads and
with:
Rwaveamplitude(greaterthan/lessthan)S
waveamplitude,andSTsegment
(elevation/depression)with(upright/inverted)T
waves
• PosteriorMIisusuallyseeninthesettingoIacute
inIeriorMI(true/Ialse)
• RVH,WPWandRBBB(do/donot)interIerewith
theECGdiagnosisoIposteriorMI
0.04,V
1
V
2
greaterthan
depression,upright
true
do
PeakedTwaves
• Twave~mminthelimbleadsor~
mmintheprecordialleads
6,10
—434—
ECG73. 79-year-oldasymptomaticmale:
—435—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—436—
ECG73wasobtainedIroma79-year-oldasymptomaticmale.TheECGshowssinusrhythm,leItandrightatrialabnormalities(arrows),and
QwavesmeetingcriteriaIorageindeterminate anterior,anterolateral,andinIeriormyocardialinIarctions(arrowheads).NonspeciIicST-T
abnormalitiesarepresent(thesubtleSTsegmentelevationdoesnotmeet1mmintheinIeriorleadsandisnotdiagnosticoIaneurysmoracute
injury).ThecorrectedQTintervalisprolonged(0.48seconds).
Codes: 05 Rightatrialabnormality/enlargement
06 LeItatrialabnormality/enlargement
07 Sinusrhythm
52 AnterolateralQwaveMI(ageindeterminateorold)
54 AnteriororanteroseptalQwaveMI(ageindeterminateorold)
58 InIeriorQwaveMI(ageindeterminateorold)
63 NonspeciIicSTand/orTwaveabnormalities
68 ProlongedQTinterval
—437—
Ouestions:ECG73
1. ConditionsassociatedwithpathologicalQwavesthatcanmimic
myocardialinIarctioninclude:
a. Pericarditis
b. WolII-Parkinson-Whitesyndrome
c. LeItbundlebranchblock
d. COPD
e. Pneumothorax
I. Severerightventricularhypertrophy
g. Cardiomyopathy
h. InIiltrativediseasesoIthemyocardium(e.g.,tumor,sarcoid)
i. Pulmonaryembolism
2. DrugsthatcanprolongtheQTintervalinclude:
a. Amiodarone
b. Sotalol
c. Disopyramide
d. Tricyclicantidepressants
e. Lithium
I. Procainamide
g. Quinidine
h. Phenothiazines
3. ThelikelyageoItheMIinthepresentECGis:
a. Minutestohours
b. Hourstodays
c. Monthstoyears
4. ThepresenceoIQwavescanbeusedtodistinguishtransmural
IromsubendocardialmyocardialinIarction:
a. True
b. False
5. The absence oI Q waves can be used to distinguish
subendocardialIromtransmuralmyocardialinIarction:
a. True
b. False
—438—
Answers:ECG73
1. WhileabnormalQwavesaremostcommonlyassociatedwith
myocardial inIarction (MI), several other conditions may
produceabnormalQwavesonECG,includingWPWsyndrome,
leIt bundle branch block (LBBB), COPD, pneumothorax,
cardiomyopathy,pulmonaryembolismandothers.IntheWPW
syndrome, negative delta-waves can occur and mimic MI. In
leItbundlebranchblock,QScomplexesinleadsV
1
-V
4
(oIten
accompaniedby1-2mmoISTelevation)canbemistakenIor
anteroseptal MI. In COPD, Q waves usually occur in the
inIeriorand/orright/midprecordialleads;otherIindingsinclude
poorRwaveprogression,Ppulmonale,lowvoltageQRS,and
S
1
S
2
S
3
pattern.PneumothoraxcancausealossoIRwavesinthe
right precordial leads (QS complex), and along with the
presenceoIsymmetricalTwaveinversioncanmimicanterior
MI. In hypertrophic cardiomyopathy, abnormal Q waves are
Irequently seen in leads I, aVL, V
4
- V
6
due to septal
hypertrophy.AbnormalQwavesmayalsobeseenininIiltrative
diseases oI the myocardium when electrically-active tissue is
replacedbyIibroustissueorelectrically-inertsubstances(e.g.,
amyloid). Finally, Q waves may be seen in lead III and
sometimes in aVF in pulmonary embolism, which can be
accompanied by ST and T waves changes and conIused with
acuteinIeriorMI;however,unlikeinIeriorMI,Qwavesinlead
IIarerare.(Answer:Allexcepta,I)
2. Many drugs increase ventricular repolarization to cause
prolongation oI the QT interval, especially Type IA
antiarrhythmics(quinidine,procainamide,disopyramide),sotalol
andamiodarone.SigniIicantQTprolongationincreasestherisk
oI torsade de pointes, syncope, and sudden cardiac death.
(Answer:All)
3. ThedevelopmentoIQwaves,andevolutionarychangesinthe
TwaveandSTsegmentcanbeusedtoapproximatetheageoI
myocardialinIarction:
& T waves: The development oI large upright T waves is
oIten the earliest maniIestations oI acute MI, occurring
within minutes and lasting Ior minutes to hours. T wave
inversion, which begins while ST segments are still
elevated,maylastIormonthstoyears,persistindeIinitely,
orregresstononspeciIicTwavechanges.
& ST segment:STelevationusuallydevelopsintheminutes
tohoursIollowingacuteMI.Resolutionmayoccurwithin
hours,butusuallyrequiresaIewdaysIorcompletereturnto
baseline. Persistence beyond 4 weeks should raise the
suspicionoIventricularaneurysm.
& && & Q waves:AbnormalQwavesusuallydevelopintheIirst
several hours to days Iollowing acute inIarction. In most
patients, they persist indeIinitely, but may regress to no
longer meet the criteria Ior abnormal Q waves; in some
patients(·15°),Qwavesdisappearentirely.
In the ECG in question, the presence oI inIerior Q waves
accompaniedbyisoelectricSTsegmentsanduprightTwaves
suggestthattheinIarctionismonthsoryearsinage,notacute.
(Answer:c)
—439—
4. Q waves were once thought to be the hallmark oI transmural
inIarction,butpathologicalstudieshaveconIirmedthatQwaves
canoccurinsubendocardialinIarctionaswell.ThepresenceoI
aQwavecannotbeusedtoreliablydistinguishtransmuralIrom
subendocardialMI.(Answer:b)
5. Non-Q-wave MI can be seen in both transmural inIarction
(especially when the culprit vessel is the leIt circumIlex
coronaryartery)andsubendocardialinIarction.(Answer:b)
—(«:·/k:.::«I;— —(«:·/k:.::«I;— —(«:·/k:.::«I;— —(«:·/k:.::«I;—
AnterolateralM¡,ageindeterminateor
probablyold
• AbnormalQwaves(with/without)STsegment
elevationinleads
without
V
4
-V
6
AnteriorM¡,ageindeterminateor
probablyold
• rSinlead,IollowedbyeitherQSorQR
complexes(with/without)STsegmentelevationin
leadsor(increasing/decreasing)Rwave
amplitudeIromV
2
-V
5
V
1
without,V
2
-V
4
decreasing
¡nferiorM¡,ageindeterminateor
probablyold
• AbnormalQwaves(with/without)STelevationin
atleasttwooIleads
without
II,III,aVF
—440—
ECG74. 80-year-oldunconsciousfemale:
—441—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—442—
ECG 74 was obtained Irom an 80-year-old unconscious Iemale. The ECG shows a regular, wide QRS complex rhythm at a rate oI 57
beats/minutewithnoprecedingPwaves,consistentwithacceleratedidioventricularrhythm.TheextremelywideQRScomplexes(0.24seconds
inleadV
1
)(asterisk)haveanearlysine-wave-likeappearance,suggestiveoIhyperkalemia.ThetallTwavesinleadsV
3
-V
6
(arrows)arealso
consistentwithhyperkalemia.NeitherbundlebranchblocknormyocardialinIarctionshouldbecodedinthesettingoIidioventricularrhythm.
ThepatientwasIoundtohaveaserumK
¹
leveloI8.5mmol/L.
Codes: 26 Acceleratedidioventricularrhythm
74 Hyperkalemia
*
—443—
Ouestions:ECG74
1. Hyperkalemia is associated with all oI the IollowingECG
Iindingsexcept:
a. First-degreeAVblock
b. LeItanteriorIascicularblock
c. ProlongedQTinterval
d. Sinusarrest
e. TallpeakedTwaves
I. Intraventricularconductiondisturbance(IVCD)
Answers:ECG74
1. HyperkalemiaresultsinsigniIicantslowingoIatrial,AVnodal,
and ventricular conduction, maniIesting as sinus arrest, Iirst-
degreeAVblock,IVCD,bundlebranchblockand/orIascicular
block. Tall peaked T waves, Ilattening oI the P wave,
idioventricularrhythm,ventriculartachycardia,andventricular
Iibrillationmayalsooccur.Hyperkalemiaincreasesthespeed
oIventricularrepolarization,resultinginshorteningoItheQT
interval.(Answer:c)
—(«:·/k:.::«I;— —(«:·/k:.::«I;— —(«:·/k:.::«I;— —(«:·/k:.::«I;—
Acceleratedidioventricularrhythm
• Highlyirregularventricularrhythm(true/Ialse)
• VentricularrateoIperminute
• QRSmorphologyissimilarto
• Ventricularcomplexes,beats,and
AVarecommon
Ialse
60-110
VPCs
capture,Iusion
dissociation
Hyperkalemia
• K
+
¬5.5-ô.5mEq/L
Tall,peaked,narrowbasedwaves
QTinterval(shortening/lengthening)
(Reversible/irreversible)leItanterioror
posteriorIascicularblock
• K
+
¬ô.5-7.5mEq/L
degreeAVblock
FlatteningandwideningoIthewave
STsegment(depression/elevation)
widening
• K
+
>7.5mEq/L
DisappearanceoIwaves
LBBB,RBBB,ormarkedlywidenedanddiIIuse
intraventricularconductiondelayresemblinga
wavepattern
Arrhythmiasandconductiondisturbances
includingVT,VF,idioventricularrhythm,
asystole(true/Ialse)
T
shortening
Reversible
First
P
depression
QRS
P
sine
true
—444—
—POPOU¡Z—
PatternRecognItIon:ECGJCIInIcaICorreIatIon
Instructions:MatchtheECGwiththemostlikelyclinicalpresentation.
ECG Choose Single Best Answer Answer
NormalECG2weeksearlier
a. Acutehemiparesis,papilledema
b. Dyspnea,constipation,impaired
memory,Iatigue
c. Red-greencolorblinders,nausea,
vomiting
d. Acuteoliguria2°to
rhabdomyolysis
e. MurmurinaDown’sSyndrome
patient
I. AcuteexacerbationoIchronic
bronchitis
g. Prolongedexposuretoextremecold
h. Dyspneaandpulsesparadoxusina
renalIailurepatient
i. AcuteonsetoIdyspneainapatient
withaDVT
Large pulmonary embolicauseelevatedpulmonaryarterypressures,
rightventriculardilation/strain,andclockwiserotationoItheheart.
AssociatedECGchangesincludeS
1
Q
3
orS
1
Q
3
T
3
(occursin30°
andlastsIor1-2weeks),incompleteorcompleterightbundlebranch
block(occursin25°andlasts·1week),andinvertedTwavesin
therightprecordialleads(Iromrightventricularstrain;canlastIor
months).OtherECGIindingsincluderightaxisdeviation,
nonspeciIicSTandTwavechanges,andPpulmonale.Arrhythmias
andconductiondisturbancesincludesinustachycardia(most
common),atrialIibrillation,atrialIlutter,atrialtachycardia,and
Iirst-degreeAVblock.(Answer:i)
Sinus bradycardiaresultsinsinusPwavesatarate·60perminute.
Causesincludehighvagaltone(normals|especiallyduringsleep|,
trainedathletes,Bezold-JarischreIlex,pulmonaryembolism),
myocardialinIarction(usuallyinIerior),drugs,hypothyroidism,
hypothermia,obstructivejaundice,hyperkalemia,increased
intracranialpressure,andsicksinussyndrome.ThisECGwas
obtainedinapatientwithdyspnea,constipation,impairedmemory,
andIatiguesecondarytohypothyroidism.(Answer:b)
Atrial tachycardia with blockresultsinnonsinusPwaves,regular
atrialrate(usually150-240perminute),isoelectricintervalsbetween
Pwaves(incontrasttoatrialIlutter),andnonconductedPwaves
(Iromsecond-degreeAVblock).DigoxintoxicityisresponsibleIor
75°oIcasesandorganicheartdiseaseIor25°.ThisECGwas
obtainedinapatientwhodevelopedred-greencolorblindnessand
GIcomplaintsIromdigitalistoxicity.(Answer:c)
—445—
—POPOU¡Z— —POPOU¡Z— —POPOU¡Z— —POPOU¡Z—
2:1AVBIock:MobItzTypeIorII
Instructions:DecideiItheECGIeatureslistedbelowIavorMobitz
TypeI(Wenkebach)orMobitzTypeIIsecond-degreeAVblock.
ECG Feature Mobitz Type I or II
2:1blockdevelopsduringinIeriorMI TypeI
TypeIonanotherpartoIECG TypeI
HistoryoIsyncope TypeII
NarrowQRScomplex TypeI
AVblockworsensinresponseto
maneuversthatincreaseheartrate&
AVconduction(e.g.,atropine,
exercise)
TypeII
AVblockworsensinresponseto
maneuversthatreduceheartrate&
AVconduction(e.g.,carotidsinus
massage)
TypeI
—446—
ECG75. 76-year-oldfemalewithseveresubsternal
chestpressure:
—447—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—448—
ECG75wasobtainedina76-year-oldIemalewithseveresubsternalchestpressure,diaphoresis,andpallor.TheECGshowssinusrhythm,
leItbundlebranchblock,andleItaxisdeviation.ConcordantSTsegmentelevationisapparentinleadsV
5
andV
6
(arrows),consistentwithacute
myocardialinjury.However,sincepathologicalQwavesarenotpresent,QwavemyocardialinIarctionshouldnotbecoded.
Codes: 07 Sinusrhythm
36 LeItaxisdeviation(~-30°)
47 LBBB,complete
65 STand/orTwaveabnormalitiessuggestingmyocardialinjury
—449—
Ouestions:ECG75
1. ThemostspeciIicECGIindingIoracutemyocardialinjuryin
thesettingoILBBBis:
a. ST segment elevation ~ 1 mm opposite in direction
(discordant)tothemajorQRSdeIlection
b. QwavesinleadsV
1
-V
3
c. ConcordantSTsegmentdepression
d. STsegmentelevationinthesamedirection(concordant)as
themajorQRSdeIlection
2. LeItbundlebranchblock(LBBB):
a. InterIereswiththeECGdiagnosisoIRVH
b. InterIereswiththeECGdiagnosisoILVH
c. Does not interIere with the ECG diagnosis oI myocardial
inIarction
Answers:ECG75
1. AcutemyocardialinIarctionisverydiIIiculttodiagnosisinthe
settingoILBBB,andtheusualcriteriadonotapply.Qwaves
are oIten present in the anteroseptal leads and cannot be
considered pathological. ST and T wave changes opposite in
direction to the major QRS complex are secondary to LBBB,
andlackspeciIicityIoracuteischemia.ConcordantSTsegment
elevation ~ 1 mm is an unusual Iinding in LBBB, and is
generally considered to be a sign oI acute myocardial injury.
(Answer:d)
2. LeIt bundle branch block (LBBB) interIeres with the ECG
diagnosis oI right and leIt ventricular hypertrophy and
myocardial inIarction. Since more than 80° oI patients with
LBBBhaveincreasedLVmassonecho,Iorpracticalpurposes,
LBBB can be consideredamarkerIorLVH.However,LVH
shouldnotbecodedunlessvoltagecriteriaarepresent.
(Answer:a,b)
—450—
—(«:·/k:.::«I,— —(«:·/k:.::«I,— —(«:·/k:.::«I,— —(«:·/k:.::«I,—
LBBB,completewith8T-Twaves
suggestiveofacutemyocardialin]ury
orinfarction
• STelevation~ mmconcordantto(same
directionas)themajordeIlectionoItheQRS
• STdepression~ mminV
1
,V
2
,orV
3
• STelevation~ mmdiscordantwith(opposite
directionto)themajordeIlectionoItheQRS
1
1
5
8Tand/orTwavechangessuggesting
myocardialin]ury
• AcuteSTsegment(elevation/depression)with
upward(convexity/concavity)intheleads
representingtheareaoIinIarction
• Twavesinvert(beIore/aIter)STsegmentsreturnto
baseline
• AssociatedST(elevation/depression)inthe
noninIarctleadsiscommon
• AcutewallinjuryoItenhashorizontalor
downslopingSTsegmentdepressionwithuprightT
wavesinV
1
-V
3
,withorwithoutaprominentR
waveinthesesameleads
elevation
convexity
beIore
depression
posterior
—451—
—POPOU¡Z—
MakeTheDIagnosIs
Instructions:Determinetheclinicaldisorderthatbestcorrespondstothe
ECGIeatureslistedbelow(seeanswersheetIoroptions).
ECG Features Answer
• Abnormallytall,symmetrical,invertedTwaves
• HorizontalordownslopingSTsegmentswithorwithoutT
waveinversion
ST-TchangesoI
myocardial
ischemia
• Elevatedtake-oIIoItheSTsegmentattheJjunction
• ConcaveupwardSTelevationendingwithasymmetrical
uprightTwave,whichisoItenoIlargeamplitude
• DistinctnotchorslurondownstrokeoIRwave
• MostcommonlyinvolvesleadsV
2
-V
5
Normalvariant,
early
repolarization
• PersistentlynegativeTwaves,whichareusuallynot
symmetricalordeep,inleadsV
1
-V
3
innormaladults
• UprightTwavesinleadsI,II,V
5
,V
6
• MostIrequentlyseeninyounghealthyIemales
Normalvariant,
juvenileTwaves
• AcuteSTsegmentelevationwithupwardconvexityinthe
leadsrepresentingtheareaoIinIarction
• TwavesinvertbeIoreSTsegmentsreturntobaseline
ST-TchangesoI
myocardial
injury
—452—
ECG76. 65-year-oldmalewithchestpain:
—453—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—454—
ECG76wasobtainedIroma65-year-oldmalewithchestpain.TheECGshowssinusrhythmatarateoI87beats/minute.The8
th
beat(arrow)
isanatrialprematurecomplex;theshortPRinterval(0.12seconds)indicatestheAPCoriginatedrelativelyclosetotheAVnode.Thereisslight
irregularityoItherhythm,butsinusarrhythmiashouldnotbecodedsincethePPintervalsvaryby·0.16seconds.ThereareabnormalQwaves
andSTsegmentelevationleadsIandaVL(asterisks),consistentwithrecentoracutelateralmyocardialinIarction.ThelossoIRwaveamplitude
intheleItlateralleadsisduetotheinIarct.ThereissubtleSTelevationinV
2
-V
3
(arrowheads)which,giventheclinicalcontext,likelyrepresents
anteriormyocardialinjury.ProlongedQTinterval(QTc÷0.47seconds)ismostevidentinleadsIIandIII.
Codes: 07 Sinusrhythm
13 Atrialprematurecomplexes
55 LateralQwaveMI(agerecentoracute)
65 STand/orTwaveabnormalitiessuggestingmyocardialinjury
68 ProlongedQTinterval
*
*
Questions: ECG 76
1. Clinical conditions associated with abnormal Q waves include:
a. Primary and metastatic tumors of the heart
b. Scleroderma of the heart
c. Muscular dystrophy
d. Amyloid heart
e. Hypertrophic obstructive cardiomyopathy
f. Myocardial contusion
g. Mitral valve prolapse
Answers: ECG 76
1. Patients with hypertrophic cardiomyopathy often demon-
strate abnormal (Ͼ 0.04 seconds in duration) Q waves in
leads I, aVL, and V
4
- V
6
, reflecting exaggerated septal Q
waves from marked septal hypertrophy. Abnormal Q waves
are also seen in conditions where electrically active tissue
is replaced by fibrous tissue or electrically inert substances,
as in muscular dystrophy, scleroderma, amyloid, or primary/
metastatic tumors of the heart. Abnormal Q waves can also
be seen in areas of intramyocardial hemorrhage and edema
following myocardial contusion (inconjunction with nonspe-
cific ST and T wave changes and various degrees of heart
block if the conduction system is involved). Mitral valve
prolapse has rarely been associated with abnormal Q waves
in leads III and aVF. Other causes of abnormal Q waves in-
clude left bundle branch block, left anterior fascicular block,
left and right ventricular hypertrophy, and dilated cardio-
myopathy. The “Q” waves in WPW syndrome are actually
negative delta waves. (Answer: all)
—(«:·/k:.::«I(—
Lateral or high lateral MI (age recent or
probably acute)
· Abnormal Q waves and ST elevation in leads I and
_____
· An isolated Q wave in aVL (does/does not) qualify as
a lateral MI
ST and/or T wave changes suggesting
myocardial injury
· Acute ST segment (elevation/depression) with
upward (convexity/concavity) in the leads
representing the area of infarction
· T waves invert (before/after) ST segments return to
baseline
· Associated ST (elevation/depression) in the
noninfarct leads is common
· Acute ______ wall injury often has horizontal or
downsloping ST segment depression with upright T
waves in V
1
-V
3
, with or without a prominent R
wave in these same leads
Prolonged QT interval
· Corrected QT interval (QTc) Ն ______ seconds,
where QTc ϭ QT interval divided by the square
root of the preceding ______ interval
· QT interval varies (directly/inversely) with heart
rate
· The normal QT interval should be (less than/greater
than) 50% of the RR interval when the ventricular rate
is between 65–90.
aVL
does not
elevation
convexity
before
depression
posterior
0.44
RR
inversely
less than
— 455 —
—456—
—POPOU¡Z—
PatternRecognItIon:A-VInteractIons
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. Fusioncomplex
b. Canbeseenwithventricular
tachycardia
c. ResultsIromsimultaneousactivation
oIventricleIrom2diIIerentsitesoI
origin
d. Echobeat
e. FormoInonsustainedreentry
I. Capturecomplex
g. SuggestdiagnosisoISVTinsetting
oIwideQRStachycardia
h. Occurswhenatrialimpulse
stimulatestheventricleduringVT
i. Atrialandventricularrhythmsoccur
independantoIeachother
j. AVdissociation
k. Ventriculophasicsinusarrhythmia
Reciprocal (echo) complexisaIormoI
nonsustainedreentrythatoccurswhenanelectrical
impulseactivatesachamber(atriaorventricle),
andthenreturnstothesiteoIorigintoreactivate
thesamechamberagain.InthepresentECG,an
ectopicatrialimpulse(invertedPwave;
arrowhead)triggersaQRScomplex(arrow),and
thenreturnsinaretrogradeIashiontoreactivate
theatria(negativePwaveimmediatelyIollowing
theQRScomplex).(Answer:d,e)
Ventricular capture complexoccurswhenanatrial
impulsestimulatestheventricleduringventricular
tachycardia.The“captured”ventricleresultsina
QRScomplexsimilartothatduringsinusrhythm
(narrowQRSinthisECG).ThepresenceoIa
ventricularcapturecomplexinthesettingoIa
wideQRStachycardiastronglysuggeststhe
diagnosisoIventriculartachycardia.(Answer:b,
I,h)
Fusion complexresultIromsimultaneous
activationoItheventricleIrom2sitesoIorigin,
resultinginaQRScomplexintermediatein
morphologybetweentheQRScomplexesoIeach
source.Canbeseenwithventricularpremature
complexes,ventriculartachycardia,ventricular
parasystole,acceleratedidioventricularrhythm,
WolII-Parkinson-WhiteSyndrome,andpaced
rhythms.(Answer:a,b,c,i,j)
—457—
CommonDilemmas
inECG¡nterpretation
Problem
With so many diIIerent criteria Ior the diagnosis oI LVH,
whichshouldbeusedasthe“gold-standard?”
Recommendation
TheCornell criteria(RwaveinaVL¹SwaveinV
3
~28
mminmalesand~20mminIemales)isprobablythemost
accurateoIthevoltagecriteria.However,manyECGsmeet
voltage criteria in one area oI the tracing but not in the
others.ThereIore,thebestpolicyisknowmostoralloIthe
variouscriteriausedtodiagnoseLVH.Remembertocode
item 67 (ST and/or T wave abnormalities secondary to
hypertrophy) in addition to item 40 (leIt ventricular
hypertrophy) when a “strain” pattern is associated with
LVH.
—458—
ECG77. 72-year-olddiabeticmalewithhypertension:
—459—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8 RHYTHM8 RHYTHM8 RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—460—
ECG77wasobtainedina72-year-oldmalewithhypertensionanddiabetes.TheECGshowssinusrhythmatapproximately75beats/minute
with"groupedbeating."TherecurringsequencethroughoutthetracingconsistsoItwonormallyconductedPwaves(whichallhavethesame
morphology;arrowheadsmarkthePwaves)Iollowedbyapause(asterisks)thatissomewhatlessthantwotimestheusualPPinterval.These
IindingsareconsistentwiththediagnosisoI3:2sinoatrialexitblock(amaniIestationoIsicksinussyndrome).Sinusarrhythmiashouldalso
becoded.
Codes: 07 Sinusrhythm
08 Sinusarrhythmia
12 Sinoatrialexitblock
89 Sicksinussyndrome
*
*
* *
*
—461—
Ouestions:ECG77
1. ECGIeaturesoIMobitzTypeIsinoatrialexitblockinclude:
a. ConstantPRinterval
b. Groupbeating
c. ShorteningoIthePPinterval
d. PPpauselessthantwotimesthenormalPPinterval
2. MobitzTypeIISAexitblockresultsinaPPpausethatis¸¸¸
timestheusualPPinterval:
a. 2
b. 3
c. 4
d. AnyoItheabove
Answers:ECG77
1. MobitzTypeIsinoatrialexitblockresultsinintermittentIailure
oI the sinus impulse to capture the atria, resulting in a pause
without a P wave. Additional ECG maniIestations include
shortening oI the PP interval leading up to the pause, group
beating,aPPpauselessthantwotimesthenormalPPinterval,
andaconstantPRinterval.(Answer:all)
2. MobitzTypeIIsinoatrialexitblockresultsinaPPpausethatis
amultipleoItheusualPPinterval.PPpausesthatare2,3,or4
times the basic PP interval are oIten due to Mobitz Type II
sinoatrialexitblock.(Answer:d)
—(«:·/k:.::«II— —(«:·/k:.::«II— —(«:·/k:.::«II— —(«:·/k:.::«II—
8inusarrhythmia
• (Sinus/nonsinus)Pwave
• LongestandshortestPPintervalsvaryby~
secondsor10°
• SinusarrhythmiadiIIersIrom“ventriculophasic”
sinusarrhythmia,thelatteroIwhichoccursinthe
settingoI
Sinus
0.16
heartblock
8inoatrial{8A}exitblock
Firot-Jegree:ConductionoIsinusimpulsestothe
atriumis(normal/delayed),but:1responseis
maintained
• First-degreeSAexitblock(is/isnot)detectableon
thesurIaceECG
SeconJ-Jegree:SomesinusimpulsesIailto
theatria
• TypeI(MobitzI):
SinusPwave(true/Ialse)
“beating”with:
(1)(Shortening/lengthening)oIthePPinterval
priortoabsentPwave
(2)(Constant/variable)PRinterval
(3)PPpause·normalPPinterval
• TypeII(MobitzII):ConstantPPintervalIollowed
byapausethat(is/isnot)amultiple(2x,3x,etc.)
oIthenormalPPinterval
ThirJ-Jegree:
• CompleteIailureoIconduction
• CannotbediIIerentiatedIrom
delayed,1
isnot
capture
true
Group
Shortening
Constant
2
is
sinoatrial
completesinus
arrest
—462—
—POPOU¡Z—
MakeTheDIagnosIs
Instructions:Determinetheclinicaldisorderthatbestcorrespondstothe
ECGIeatureslistedbelow(seeitems70-89onanswersheetIoroptions).
ECG Features Diagnosis
• RSR’complexinleadV
1
• LeItaxisdeviation
• First-degreeAVblockin15-40°
• Advancedcaseshavebiventricularhypertrophy
Atrialseptal
deIect,primum
• TypicalRSRorrSRcomplexinleadV
1
withaQRS
duration·0.11seconds
• IncompleteRBBB
• Rightaxisdeviation+rightventricularhypertrophy
• Rightatrialabnormalityin30°
• First-degreeAVblockin·20°
Atrialseptal
deIect,
secundum
• P-QRS-TinleadsIandaVLareinvertedor“upsidedown”
• DecreasingRwaveamplitudeIromleadsV
1
-V
6
Dextrocardia
• Rightventricularhypertrophy
• Rightaxisdeviation
• Rightatrialabnormality
• ShiItoItransitionalzonecounterclockwise
• LowvoltageQRS
• PseudoinIarctpatternintheanteroseptalleads
• S
1
S
2
S
3
pattern
• Mayalsoseesinustachycardia,junctionalrhythm,various
degreesoIAVblock,IVCD,andbundlebranchblock
Chroniclung
disease
— 463 —
DifferentialDiagnosis
PP PAU8E GREATER THAN 1.6-2.0 8ECOND8
• Sinuspause/arrest:DuetotransientIailureoIimpulse
IormationattheSAnode;sinusrhythmresumesata
PPintervalthatisnotamultipleoIthebasicsinusPP
interval
• Sinusarrhythmia:PhasicchangeinPPintervalin
responsetobreathcycle
• Second-degreesinoatrialexitblock,MobitzI
(Wenckebach):ProgressiveshorteningoIPPinterval
untilaPwaveIailstoappear
• Second-degreesinoatrialexitblock,MobitzII:
ResumptionoIsinusrhythmataPPintervalthatisa
multiple(e.g.,2x,3x,etc.)oIthebasicsinusrhythm
• Third-degreesinoatrialexitblock:CompleteIailureoI
sinoatrialconduction;cannotbediIIerentiatedIrom
completesinusarrestonsurIaceECG
• Abruptchangeinautonomictone(e.g.,vagalreaction)
• “Pseudo”sinuspauseduetononconductedAPCs:P
waveappearstobeabsentbutisactuallyburiedinthe
Twave—lookIorsubtledeIormityoItheTwavejust
precedingthepausetodetectnonconductedAPC
—464—
ECG78. 31-year-oldmalewithpalpitations:
—465—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—466—
ECG78wasobtainedina31-year-oldmalewithpalpitations.ThetracingshowssinusrhythmwithashortPRinterval,deltawaves(arrows),
andaprolongedQRS(~0.10seconds),consistentwithWolII-Parkinson-Whitepattern.
Codes: 07 Sinusrhythm
34 WolII-Parkinson-Whitepattern
—467—
Ouestions:ECG78
1. Fusioncomplexescanbeseenwith:
a. WolII-Parkinson-Whitesyndrome
b. Atrialprematurecomplexes
c. Pacedbeats
d. Ventriculartachycardia
2. ConditionsassociatedwithashortPRintervalinclude:
a. AVjunctionalrhythm
b. WolII-Parkinson-Whitesyndrome
c. Lown-Ganong-Levinesyndrome
d. Normalvariant
e. Pericarditis
3. SupraventriculartachycardiaisneededtomakethediagnosisoI
WolII-Parkinson-Whitepattern:
a. True
b. False
4. Which oI the Iollowing statements about WolII-Parkinson-
WhitesyndromeareIalse:
a. WPWmayinterIerewithECGrecognitionoIleItandright
ventricularhypertrophy
b. WPWmayinterIerewithECGrecognitionoIbundlebranch
block
c. WPW may interIere with ECG recognition oI acute
myocardialinIarction
d. The polarity oI the delta waves can be used to accurately
predictthelocationoIthebypasstract
e. AshortQTintervaliscommoninWPW
Answers:ECG78
1. Fusion complexes result Irom simultaneous activation oI the
ventricle Irom two sources, resulting in a QRS complex
intermediateinmorphologybetweentheQRScomplexoIeach
source.FusioncomplexescanbeseenwithWolII-Parkinson-
White,pacedbeats,ventriculartachycardia,orisolated VPCs.
AtrialprematurecomplexesdonotresultinIusioncomplexes.
(Answer:a,c,d)
2. The PR interval represents the time Irom the onset oI atrial
depolarization to the onset oI ventricular depolarization (i.e.,
conductionIromtheatriaAVnodebundleoIHisPurkinje
Iibersventricle).AVjunctionalrhythmscanresultinashort
PRintervalwhenretrogradeatrialactivationoccursbeIorethe
—468—
antegrade impulse reaches the ventricles. In the WPW
syndrome,thepresenceoIanaccessoryAVpathway(bundleoI
Kent), which connects the atria directly to the ventricles and
bypasses the normal conduction delay in the AV node,
prematurelyactivatestheventriclestoresultinashortPR.In
the Lown-Ganong-Levine (LGL) syndrome, many experts
believethattheshortPRintervalisdueto“enhancedAVnode
conduction” Irom an immature AV node — not, as was once
thought,IromconductiondowndistinctatrioHisianIibers.In
LGL syndrome, the QRS is normal in duration and
conIiguration,unliketheWPWsyndrome,inwhichmorethan
2/3oIcasesshowinitialslurringoItheQRS(deltawave)with
aQRSduration~0.11seconds.AshortPRintervalmayalso
occurasanormalvariant,althoughitismuchmorecommonin
thepediatricpopulation(asopposedtoadults)andatIaster(as
comparedtoslower)heartrates.Pericarditisisassociatedwith
PR segment depression, but a short PR interval is not a
characteristicIinding.(Answer:allexcepte)
3. WolII-Parkinson-White pattern diIIers Irom WolII-Parkinson-
Whitesyndrome:theIormerrequiresdeltawavesandashort
PR interval; the latter requires delta waves, a short PR, and a
history oI supraventricular tachycardia or atrial Iibrillation.
(Answer:b)
4. WolII-Parkinson-White syndrome (WPW) is characterized by
the presence oI an abnormal muscular network oI specialized
conductiontissuethatconnectstheatriumtotheventricleand
bypassesconductionthroughtheAVnode.ItisIoundin0.2-
0.4°oItheoverallpopulationandismorecommoninmales
and younger patients. Most patients with WPW do not have
structural heart disease, although there is an increased
prevalence oI this disorder among patients with Epstein’s
anomaly(downwarddisplacementoIthetricuspidvalveintothe
right ventricle due to anomalous attachment oI the tricuspid
leaIlets), hypertrophic cardiomyopathy, mitral valve prolapse,
and dilated cardiomyopathy. ECG maniIestations include a
shortPRinterval(·0.12seconds)andawidenedQRScomplex
(~0.10seconds)withslurringoItheinitial30-50milliseconds
(deltawave).TwotypesoIaccessorypathways(AP)exist:In
maniIest AP, antegrade conduction occurs over the AP and
results in preexcitation on baseline ECG (which may be
intermittent).InconcealedAP,antegradeconductionoccursvia
theAVnodeandretrogradeconductionoccursovertheAP,so
preexcitation is not evident on the baseline ECG.
Approximately 50° oI patients with WPW maniIest
tachyarrhythmias,oIwhich80°isAVreentrytachycardia,15°
is atrial Iibrillation, and 5° is atrial Ilutter. Asymptomatic
individuals have an excellent prognosis. For patients with
recurrenttachycardias,theoverallprognosisisgoodbutsudden
deathmayoccur.ThepresenceoIdeltawavesandsecondary
repolarizationabnormalitiescanleadtoaIalsepositiveorIalse
negative diagnosis oI ventricular hypertrophy, bundle branch
block,oracutemyocardialinIarction.ThepolarityoIthedelta
waves can be used to predict the location oI the bypass tract.
(Answer:e)
—469—
—(«:·/k:.::«I2— —(«:·/k:.::«I2— —(«:·/k:.::«I2— —(«:·/k:.::«I2—
Fusioncomplexes
• DuetosimultaneousactivationoItheventricle
Iromsources,resultinginaQRScomplex
thatisinmorphologybetweeneachsource
2
intermediate
Wolff-Parkinson-Whitepattern
• (Sinus/nonsinus)Pwave
• PRinterval·seconds
• InitialslurringoIQRS(wave)resultingin
QRSduration~seconds
• SecondaryST-Twavechangesoccur(true/Ialse)
• PJinterval(beginningoIPwavetoendoIQRS)(is
constant/varies)
sinus
0.12
delta
0.10
true
isconstant
—470—
—POPOU¡Z—
DIIIerentIaIDIagnosIs:PRIntervaIJSegment
Instructions:Foreachdiagnosisbelow,selectallPRinterval/segmentchangesthatapply:
a. ProlongedPRinterval
b. ShortPRInterval
c. PRsegmentdepression
d. PRsegmentelevation
Diagnosis Answer
Lowectopicatrialrhythm ShortPRinterval.InvertedPwavesinII,III,andaVFmaybepresent,especiallywhenthe
ectopicIocusisintheloweratrium(neartheAVnode).ProlongedPRintervalisunusual,
andwouldrequiremarkedconductiondelayintheAVnode.PRsegmentdeviationdoes
notoccur.(Answer:b)
3°AVblock IndependenceoIatrialandventricularrhythmsresultsinvaryingPRintervals,whichmay
beprolonged,normaland/orshort.PRsegmentdeviationdoesnotoccur.(Answer:a,b)
Atrialprematurecontractions(APCs) PRintervalmaybeprolonged,normal,orshort,dependingonthedegreeoIprematurityand
originoItheAPC.Ingeneral,themoreprematuretheAPC,thelongerthePRinterval.
APCsoriginatingneartheAVnodetendtohaveshorterPRintervals(andinvertedP
waves).PRsegmentdeviationdoesnotoccur.(Answer:a,b)
WolII-Parkinson-White(WPW)syndrome ShortPRinterval,duetoconductionoveraccessoryAVpathway(bundleoIKent),which
bypassestheAVnode(andAVnodalconductiondelay).SlurringoItheQRScomplexis
duetoIusionoIelectricalwaveIrontsIromconductiondowntheaccessorypathway(delta
wave)andAVnode.(Answer:b)
Junctionalrhythmwithretrogradeatrial
activation
Retrogradeatrialactivity(maniIestasinvertedPwaves)mayimmediatelyprecedetheQRS
(shortPRinterval),beburiedintheQRS(noPwave),orimmediatelyIollowtheQRS(long
PRinterval).PRsegmentdeviationdoesnotoccur.(Answer:a,b)
Pericarditis DiIIusePRsegmentdepression.PRintervalisnormal.(Answer:c)
AtrialinIarction PRelevationinareaoIinIarction;PRdepressioninreciprocalleads.PRintervalisnormal.
(Answer:c,d)
—471—
DifferentialDiagnosis
FU8¡ONCOMPLEXE8
SimultaneousactivationoItheventricleIromtwosources,
resulting in a QRS complex intermediate in morphology
betweentheQRScomplexesoIeachsource
• Ventricularprematurecomplexes
• Ventriculartachycardia
• Ventricularparasystole
• Acceleratedidioventricularrhythm
• WolII-Parkinson-Whitesyndrome
• Pacedrhythm
—472—
ECG79. 80-year-oldmalewithpalpitations:
—473—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8 RHYTHM8 RHYTHM8 RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—474—
ECG79wasobtainedIroman80-year-oldmalewithpalpitations.TheECGshowsanirregularrhythmwithnativeandventricularpacedbeats.
TheV-VintervaloIthepacemaker,evidentIromtheseparationbetweenthe1
st
and2
nd
ventricularpacingspikes(asterisk),representsthekey
timing interval oI the pacemaker. The relatively long pause between the Iirst and second beats (double asterisk) exceeds the V-V interval,
indicatingoversensingoIelectricalactivitywithinappropriatesuppressionoIpacemakerIiring.Inaddition,thepacemakerIailstosensethe
2
nd
nativeQRScomplex(arrow),resultinginprematureIiringoIthepacemakerrelativetotheV-Vinterval(arrowhead).The6
th
and8
th
beats
areappropriatelysensed,sothesensingIailureisintermittent.Thenativerhythmismarkedsinusbradycardia.ThereisanabnormalQwave
inleadIII,butinIeriorMIshouldnotbecodedsincethereisasmallRwaveinaVF.ThenativebeatsinleadsV
1
-V
3
showdownslopingST
segmentdepressionwithTwaveinversions,suggestingmyocardialischemia.ThispatientwasIoundtohaveacrushedpacemakerlead.
Codes: 09 Sinusbradycardia
64 STand/orTwaveabnormalitiessuggestingmyocardialischemia
94 PacemakermalIunction,notconstantlysensing(atriumorventricle)
** *
—475—
Ouestions:ECG79
1. CausesoIpacemakermalIunctionwithIailuretosenseinclude:
a. TypeIIIantiarrhythmicdrugs
b. Electrolytedisorders
c. Leaddisplacement
d. MyocardialinIarction
e. Myopotentialinhibition
2. CausesoIpacemakeroversensinginclude:
a. LeadIracture
b. Myopotentialinhibition
c. Twaveoversensing
Answers:ECG79
1. PacemakermalIunctionwithIailuretosensecanariseIromany
partoIthepacing“circuit,”includingthepacemakergenerator,
thepacinglead,orleadcontactwiththeventricle.Nonviable
myocardium,electrolyteabnormalities,anddrugssuchasType
III antiarrhythmics can also alter conductivity and result in
sensingmalIunction.(Answer:all)
2. Twavesandmusclepotentialsmaybesensedasatrial(Pwaves)
orventricularactivity(QRScomplexes),resultingininhibition
oIpacemakeroutput.OversensingoITwavesandmyopotential
inhibitioncanbecorrectedbydecreasingthesensitivityoIthe
pacemaker. Lead Iracture can cause erratic patterns oI
oversensing,undersensing,andIailuretopaceorcapture;lead
replacementisrequired.(Answer:all)
—476—
—(«:·/k:.::«I7— —(«:·/k:.::«I7— —(«:·/k:.::«I7— —(«:·/k:.::«I7—
8Tand/orTwaveabnormalities
suggestingmyocardialischemia
• Abnormallytall,symmetrical,(upright/inverted)T
waves
• HorizontalorSTsegmentswithorwithoutT
waveinversion
• AssociatedECGIindings:
QTintervalisusually(normal/prolonged)
Reciprocalwavechangesmaybeevident
ProminentUwavesareoItenpresentandmay
beuprightorinverted(true/Ialse)
inverted
downsloping
prolonged
T
true
Pacemakermalfunction,notconstantly
sensing{atriumorventricle}
• Pacemakersintheinhibitedmode:PacemakerIails
tobe byanappropriateintrinsic
depolarization
• Pacemakersinthetriggeredmode:PacemakerIails
tobe byanappropriateintrinsic
depolarization
• PrematuredepolarizationsmaynotbesensediI
theyIallwithintheprogrammedperiodoIthe
pacemaker,orhaveinsuIIicientatthesensing
electrodesite
inhibited
triggered
reIractory
amplitude
—477—
—POPOU¡Z—
MakeTheDIagnosIs
Instructions: Determine the ECG diagnosis that best corresponds to the
ECGIeatureslistedbelow(seeanswersheetIoroptions).
ECG Features Diagnosis
• Sensedatrialactivityinhibitsatrialoutput.IIno
ventricularactivityissensedbytheendoItheAVinterval,
ventricularpacingoccurs
DDDpacing
• PacemakerstimulusIollowedbyanatrialdepolarization Atrialpacing
• PacemakerstimulusIollowedbyaQRScomplexthathas
diIIerentmorphologycomparedtotheintrinsicQRS
• MustdemonstrateinhibitionoIpacemakeroutputin
responsetointrinsicQRS
Ventricular
demandpacing
• Ventricularpacingwithoutdemonstrableoutputinhibition
byintrinsicQRScomplexes
Ventricular
pacing,Iixed
rate,
asynchronous
• Increaseinstimulusintervalsovertheprogrammed
intervals
• UsuallyanindicatoroIbatteryendoIliIe
• OItennotedIirstduringmagnetapplication
Pacemaker
malIunction,
slowing
—478—
ECG80. Healthy32-year-oldmalebeingscreenedfor
aninsurancephysicalexam:
—479—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—480—
ECG80wasobtainedIromahealthy32-year-oldmalebeingscreenedIoraninsurancephysicalexam.TheECGshowssinusbradycardia
atarateoI47beats/minute.SubtlenotchingoI the J point (most apparentinleadsII,III,aVF,V
2
-V
6
)withconcaveupwardSTsegment
elevation(arrows)andtalluprightTwaves(asterisks)isconsistentwithnormalvariantearlyrepolarizationabnormality.AlltheIindingsinthis
tracingareconsistentwithnormalvariantECG.
Codes: 02 BorderlinenormalECGornormalvariant
09 Sinusbradycardia(·60)
61 Normalvariant,earlyrepolarization
*
*
—481—
Ouestions:ECG80
1. CausesoIdiIIuseSTelevationinclude:
a. AcuteMI
b. Pericarditis
c. LeItventricularhypertrophy
d. Hyperkalemia
e. LVaneurysm
I. Variant(Printzmetal’s)angina
g. Earlyrepolarization
2. WhichoItheIollowingstatementsaboutSTelevationaretrue?
Jentricularaneurysm:
a. Q wave or QS is usually present in the same leads as ST
segmentelevation
b. STandTwavechangesremainstableovertime
Pericarditis:
a. ReciprocalSTdepressioniscommon
b. QwavesareoItenevident
c. STandTwavechangesremainstableovertime
d. TwavesusuallybecomeinvertedaIterSTsegmentsreturn
tobaseline
3. “Normal variant” ECG Iindings include all oI the Iollowing
except:
a. SmallnegativeTwavesinV
1
-V
3
b. SwavesinleadsI-III
c. AmplitudeoIRwaveequaltodepthoISwaveinV
1
d. AmplitudeoIRwaveequaltodepthoISwaveinV
2
e. STelevationoI1-2mminV
2
andV
3
I. Qwaveduration~0.03seconds
g. STdepressioninprecordialleads
h. Uwaveamplitude~1.5mm
i. RSr’orrSR’inV
1
withaQRSduration·0.10secondsin
V
1
Answers:ECG80
1. Causes oI diIIuse ST elevation include pericarditis, severe
hyperkalemia (“dialyzable current oI injury”), and early
repolarization(usuallymostapparentinleadsII,III,aVF,and
V
2
-V
5
). Focal ST elevation occurs in acute myocardial
inIarction, LV aneurysm, and variant angina, and is usually
conIinedtothedistributionoItheculpritvessel.STelevation
withLVHisusuallyconIinedtoleadsV
1
-V
4
.(Answer:b,d,g)
2. The ST elevation oI ventricular aneurysm diIIers Irom
pericarditis in several ways: In ventricular aneurysm, ST
elevationislocalized,Qwavesareusuallypresentinthesame
—482—
leadsasSTelevation,andSTandTwavechangesremainstable
overtime.Inpericarditis,STelevationisdiIIuse,Qwavesare
notevident(unlesspericarditisIollowsacuteMI),andSTandT
wave changes evolve and are transient. The ST elevation oI
pericarditis diIIers Irom acute MI in that reciprocal ST
depressiondoesnotoccur,andTwavesusuallybecomeinverted
after the ST segment has returned to baseline. (Answers:
ventricularaneurysm÷a,b;pericarditis÷d)
3. ThetransitionzoneisdeIinedastheleadinwhichtheamplitude
oIthepositiveandnegativeQRSdeIlectionsareequal(R/S÷1).
ThenormaltransitionzoneoccursinleadV
2
,V
3
,orV
4
.Atall
RwaveinV
1
(R~S)isabnormalinadults,andmayoccurin
posteriorMI,rightventricularhypertrophy,WPWsyndrome,or
chronic lung disease. Q wave duration ~ 0.03 seconds is
abnormalIormostleads,andoccursinmyocardialinIarction,
cardiomyopathy, pulmonary embolism, inIiltrative myocardial
disorders (e.g., amyloid, sarcoid, muscular dystrophy), CNS
disorders,amongothers.STdepressionorelevationoI1mmin
the limb leads, and ST elevation oI 1-2 mm in the precordial
leads (especially V
2
, V
3
) can be seen in normals, but ST
depressionintheprecordialleadsisabnormal.ShallowTwave
inversioninleadsV
1
-V
3
isacommonnormalvariant,especially
inchildrenandwomen.AnincompleteRBBBpatterninleadV
1
canbeseenin2°oInormals.(Answer:c,I,g)
—(«:·/k:.::«20— —(«:·/k:.::«20— —(«:·/k:.::«20— —(«:·/k:.::«20—
Normalvariant,earlyrepolarization
• ElevatedoItheSTsegmentattheJjunction
• (Concave/convex)upwardSTelevationendingwith
asymmetricaluprightTwave,whichisoItenoI
largeamplitude
• DistinctnotchorslurondownstrokeoIwave
• Mostcommonlyinvolvesleads
• ReciprocalSTsegmentdepressionispresent
(true/Ialse)
• SomedegreeoISTelevationispresentinthe
majorityoIyounghealthyindividuals,especiallyin
theprecordialleads(true/Ialse)
take-oII
concave
R
V
2
-V
5
Ialse
true
—483—
DifferentialDiagnosis
ELECTR¡CALALTERNAN8
(Alternationintheamplitudeand/or
directionoIP,QRS,and/orTwaves)
• Pericardial eIIusion. Only 12° oI patients with
pericardialeIIusionhaveelectricalalternans.IIelectrical
alternansinvolvestheP,QRS,andT(“totalalternans”),
eIIusionwithtamponadeisoItenpresent.
• SevereleItventricularIailure
• Hypertension
• Coronaryarterydisease
• Rheumaticheartdisease
• Supraventricularorventriculartachycardia
• Deeprespirations
—484—
ECG81. 64-year-oldmalefoundunconscious:
—485—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—486—
ECG81wasobtainedina64-year-oldmaleIoundunconscious.TheECGshowsatrialIibrillationwithaveryslowventricularresponse,
prominentJ(“Osborne”)waves(arrows),andnonspeciIicQRSwidening.ArtiIactduetoshivering(asterisks)issuperimposedontheatrial
Iibrillation.TheseIindingsareconsistentwithhypothermia.
Codes: 04 ArtiIact
19 AtrialIibrillation
49 NonspeciIicintraventricularconductiondisturbance
88 Hypothermia
* *
—487—
Ouestions:ECG81
1. ECGIindingsconsistentwithhypothermiainclude:
a. Osbornewave
b. Junctionalrhythm
c. AtrialIibrillationwithslowventricularresponse
d. ProlongedPR,QRS,andQTintervals
e. Sinusbradycardia
I. Twaveinversions
2. The oscillations in the baseline seen in the present tracing
(asterisks)aremostlikelydueto:
a. Fibrillationwaves
b. Parkinson’sdisease
c. LooseECGelectrode
d. Muscletremor
Answers:ECG81
1. ProIound hypothermia (core temperature · 32
o
C) causes
peripheral vasoconstriction, impaired enzymatic activity,
decreased cardiac output, and reduced respirations.
Complicationsincludeaspirationpneumonia,adultrespiratory
distress syndrome, pulmonary edema, rhabdomyolysis, acute
tubular necrosis, gastric dilitation, upper GI bleed,
hyperviscosity syndrome, and disseminated intravascular
coagulation. The classic ECG Iinding oI hypothermia is the
Osborne wave (or “J” wave), which is an extra positive
deIlectionbetweentheterminalportionoItheQRScomplexand
the beginning oI ST segment. The Osborne wave is usually
positiveintheleItprecordialleads,andhasanamplitudethatis
inverselyproportionaltobodytemperature.OtherECGchanges
caused by hypothermia include prolongation oI the PR, QRS,
and QT intervals; T wave inversion; and bradyarrhythmias
consisting oI sinus bradycardia, junctional rhythm, or atrial
Iibrillationwithaslowventricularresponse.(Answer:all)
2. SignalsunrelatedtocardiacconductionareseenIrequentlyon
theECG.Muscletremor(e.g.,shiveringorParkinsondisease)
can be continuous or intermittent, and in some instances,
crescendo-decrescendo in character (e.g., scratching).
PhysiologictremoroccursatarateoI7-9cyclespersecond(~
500perminute);thetremoroIParkinson’sdiseaseoccursata
rate oI 4-6 cycles per second (~ 300 per minute) and can
simulate atrial Ilutter. AC electrical interIerence, particularly
60-cycle oscillations, can be severe in intensive care units,
operatingrooms,andcardiaccatheterizationlaboratories.The
extremely rapid, intermittent oscillations in this severely
hypothermicpatientwereduetoshivering.(Answer:d)
—488—
—(«:·/k:.::«21— —(«:·/k:.::«21— —(«:·/k:.::«21— —(«:·/k:.::«21—
Atrialfibrillation
• wavesareabsent
• Atrialactivityistotallyandrepresentedby
Iibrillatory(I)wavesoIvaryingamplitudes,
durationandmorphology
• Atrialactivityisbestseenintheand
leads
• Ventricularrhythmis(regularly/irregularly)
irregular
• toxicitymayresultinregularizationoIthe
RRintervalduetocompleteheartblockwith
junctionaltachycardia
• Ventricularrateisusuallyperminuteinthe
absenceoIdrugs
ThinkiItheventricularrateis~200per
minuteandtheQRSis~0.12seconds
P
irregular
rightprecordial,
inIerior
irregularly
Digitalis
100-180
WolII-Parkinson-
White
Hypothermia
• Sinus(tachycardia/bradycardia)
• PR,QRS,andQTprolonged(true/Ialse)
• Osborne(“J”)wave:lateuprightterminal
deIlectionoIQRScomplex;amplitude
(increases/decreases)astemperaturedeclines
• Atrialin50-60°
• OtherarrhythmiasincludeAVjunctionalrhythm,
ventriculartachycardia,ventricularIibrillation
(true/Ialse)
bradycardia
true
increases
Iibrillation
true
—489—
Don’tGetConfusedl
WanderingAtrialPacemaker
Pwaveswith~3morphologies,atrialrate·100perminute,
andvaryingPR,RR,andRPintervals
MaybeconIusedwIth:
Sinus rhythm with multifocal APCs
Sinus rhythm with multiIocal APCs demonstrates one
dominant atrial pacemaker (i.e., the sinus node); in
wanderingatrialpacemaker,nodominantatrialpacemaker
(i.e.,nodominantPwavemorphology)ispresent
Atrial fibrillation/flutter
In atrial Iibrillation/Ilutter, there is lack oI an isoelectric
baseline;inwanderingatrialpacemaker,adistinctisoelectric
baselineispresent
—490—
ECG82. 58-year-old withchestpain2daysago: female
—491—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—492—
ECG82wasobtainedIroma58-year-oldIemalewithchestpaintwodaysago.TheECGshowssinusrhythmatarateoI91beats/minutewith
Iirst-degree AV block (PR interval ÷ 0.21 seconds). Leads I and aVL show abnormal Q waves (arrows), consistent with old lateral wall
myocardialinIarction,whichaccountsIortherightaxisdeviation.ThereispoorRwaveprogression(transitionzonebetweenV
5
andV
6
),but
intheabsenceoIabnormalQwaves,anteriorinIarctshouldnotbecoded.AlsopresentareleItandrightatrialenlargement(asterisk),LVHby
Cornellcriteria(RinaVL¹SinV
3
~20mminIemales),andprolongedQTinterval(QTc÷0.49seconds).TheSTsegmentelevationinV
2
-V
4
ismostlikelyduetoLVH.
Codes: 05 Rightatrialabnormality/enlargement
06 LeItatrialabnormality/enlargement
07 Sinusrhythm
29 AVblock,1°
37 Rightaxisdeviation(~¹100
o
)
40 LeItventricularhypertrophy
56 LateralMI(ageindeterminateorold)
68 ProlongedQTinterval
*
—493—
Ouestions:ECG82
1. CriteriaIorbi-atrialenlargementinclude:
a. Pwaveamplitude~2.5mmandduration~0.12secondsin
leadsII,III,oraVF
b. P wave amplitude ~ 1.5 mm in leads V
1
-V
3
withwide,
notchedPwavesinleadsII,IIIoraVF
c. BiphasicPwaveinleadV
1
withaninitialpositiveamplitude
~1.5mmandaterminalnegativeamplitude~1mm
2. CausesoIrightaxisdeviationinclude:
a. LateralmyocardialinIarction
b. Rightbundlebranchblock
c. Rightventricularhypertrophy
d. OstiumsecundumASD
e. Dextrocardia
I. Chroniclungdisease(e.g.,emphysema)
Answers:ECG82
1. ThediagnosisoIbi-atrialenlargementisbasedoncriteriaused
Iorindividualatrialenlargement.Allthreechoicesarecorrect
(Answer:all)
2. Rightaxisdeviationcanbeseenasanormalvariant,butismore
oIten associated with COPD, cor pulmonale, right ventricular
hypertrophy,lateralMI,leItposteriorIascicularblock(LPFB),
dextrocardia,leadreversal(apparentRAD),ostiumsecundum
ASD,andWolII-Parkinson-Whitesyndrome.ThemeanQRS
axisinrightbundlebranchblockisnormal.Rightaxisdeviation
(QRS axis 90° to 180°) must be distinguished Irom right
superior axis (-90° to -180°), which can be caused by leIt
anterior Iascicular block with right ventricular hypertrophy or
lateral MI, right ventricular hypertrophy alone, or COPD.
(Answer:allexceptb)
—494—
—(«:·/k:.::«2z— —(«:·/k:.::«2z— —(«:·/k:.::«2z— —(«:·/k:.::«2z—
Rightatrialabnormality
• UprightPwave~mminleadsII,IIIandaVF
or~ mminleadsV
1
orV
2
• Pwaveaxis~ degrees
2.5
1.5
70
Leftatrialabnormality
• NotchedPwavewithaduration~ secondsin
leadsII,IIIoraVF,or
• TerminalnegativeportionoIthePwaveinleadV
1
~1mmdeepand~ secondsinduration
0.12
0.04
Rightaxisdeviation
• MeanQRSaxisbetweenanddegrees 101,270
ProlongedOTinterval
• CorrectedQTinterval(QTc)~ seconds,
whereQTc÷QTintervaldividedbythesquare
rootoItheprecedinginterval
• QTintervalvaries(directly/inversely)withheart
rate
• ThenormalQTintervalshouldbe(less
than/greaterthan)50°oItheRRinterval
0.44
RR
inversely
lessthan
—495—
—POPOU¡Z—
RhythmRecognItIon:HR<100;NarrowQRS;IrreguIarRRIntervaI
Instructions:DeterminethecardiacrhythmIoreachoItheIollowingECGs.
ECG Diagnosis
Answer:Wanderingatrialpacemaker.Description:Irregularatrial(nonsinus)
rhythmwithatleastthreediIIerentPwavemorphologies(originatingIrom
separateatrialIoci)atanatrialrate·100perminutewithvaryingPPandPR
intervals.(RhythmmayberelativelyconstantiIatrialIociareinclose
proximitytoeachother.)Pwavesmaybeblocked(notIollowedbyaQRS
complex),ormayconductwithanarroworaberrant(wide)QRScomplex.
SometimesconIusedwithatrialIibrillation/Ilutterorsinusrhythmwith
multiIocalAPCs.Seeninnormals,athletes,andorganicheartdisease.
Answer:Sinusarrhythmia.Description:Sinusrhythmwithagradual
(sometimesabrupt)phasicchangeinPPinterval,usuallyinresponsetothe
breathcycle.LongestandshortestPPintervalsvaryby~0.16secondsor
10°.Commoninyoungadultsandathletes.AmarkerIorintactvagal
activity.
Answer:2
"
degreeAVblock,MobitzTypeI(Wenkebach).Description:
Regularsinusoratrialrhythmwithintermittentnonconducted(blocked)P
waves.ClassicWenkebachperiodicitymaniIestsasprogressivelengthening
oIthePRintervalandshorteningoItheRRintervaluntilaPwaveisblocked;
theRRintervalcontainingthenonconductedPwaveislessthantwoPP
intervals.BlockusuallyoccursattheleveloItheAVnode,resultingina
narrowQRScomplex.Causesincludedrugs(e.g.,digitalis,beta-blockers),
myocardialinIarction(especiallyinIerior),acuterheumaticIever,and
myocarditis;sometimesseeninnormalsandathletes.Note:Classical
WenckebachperiodicitymaynotbeevidentinthepresenceoIsinus
arrhythmiaoranabruptchangeinautonomictone(e.g.,vagalreaction).
—496—
ECG83. 46-year-oldmalewithahistoryofrheumatic
fevernowwithdyspneaonexertion:
—497—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—498—
ECG83wasobtainedIroma46-year-oldmalewithdyspneaonexertionandahistoryoIrheumaticIever.TheECGshowssinusrhythmwith
RBBB (arrows mark wide rSR’ complex in V
1
, and wide, slurred S waves in I, V
5
, V
6
) and secondary ST-T abnormalities. Right atrial
abnormality(asterisk),leItatrialabnormality(arrowhead),andleItaxisdeviationareevident.Theaxisis–35°,whichdoesnotmeetcriteria
IorleItanteriorIascicularblock(i.e.,axis~–45°).TheseIindingsarecompatiblewithmitralvalvedisease.
Codes: 05 Rightatrialabnormality/enlargement
06 LeItatrialabnormality/enlargement
07 Sinusrhythm
43 RBBB,complete
*
—499—
Ouestions:ECG83
1. WhichoItheIollowingstatementsaboutthePwavearetrue:
a. The right atrium is responsible Ior the electrical potential
inscriptioninthelateportionoIthePwave
b. ThePwaveisnormallyuprightinleadsI,IIandaVF,and
invertedinaVR
c. AnatomicalleItatrialenlargementcanexistwithnormalP
waveamplitude,duration,andcontour
d. LeItatrialenlargementcancauseaP-pulmonalepattern
2. P-pulmonalecanbeseenin:
a. TetralogyoIFallot
b. COPDwithoutcorpulmonale
c. Pulmonaryembolism
d. Normalvariant
3. NotchingandwideningoIthePwave(P-mitrale)maybecaused
by:
a. Intra-atrialconductiondelay
b. Atrialdilatation
c. Atrialhypertrophy
4. Which oI the Iollowing statements about the PR
interval/segmentaretrue:
a. The PR interval correlates with the period oI atrial
repolarization
b. Leads with tall P waves are more likely to have PR
depressionthanleadswithsmallerPwaves
c. PRelevationcanbeanormalIinding
d. PRdepressioncanbeanormalIinding
Answers:ECG83
1. TherightandleItatriaareresponsibleIortheelectricalpotential
inscription in the early and late portions oI the P wave,
respectively.ThePwaveamplitude,duration,andcontourlack
sensitivity and speciIicity Ior leIt atrial enlargement (i.e., leIt
atrialenlargementcanexistwithanormalPwave,andP-mitrale
mayoccurwithoutleItatrialenlargement).SincetheleItatrium
isresponsibleIortheelectricalpotentialinscriptioninthelate
portion oI the P wave, leIt atrial enlargement can result in a
pseudo-P-pulmonale pattern in the absence oI right atrial
enlargement.(Answer:b,c,d)
2. P-pulmonale,deIinedasatallandpeakedPwave(amplitude~
2.5mminleadsII,III,aVF)oInormalduration,maybeseenin
pulmonaryembolism(usuallytransient),COPDwithorwithout
cor pulmonale, or as a normal variant in patients with a thin
bodyhabitusorverticleheart.P-pulmonalecanalsobeseenin
—500—
tetralogyoIFallotandotherIormsoIcongenitalheartdisease,
including Eisenmenger’s physiology, tricuspid atresia,
pulmonaryhypertension,andpulmonicstenosis.(Answer:all)
3. P-mitraleisdeIinedbythepresenceoIanotchedandwidened
(~ 0.12 seconds) P wave. While minor notching is common,
pronouncednotching(peak-to-peakinterval~0.04seconds)is
unusual. Mechanisms responsible Ior P-mitrale include leIt
atrial hypertrophy or dilatation, intra-atrial conduction delay,
increased leIt atrial volume, or an acute rise in leIt atrial
pressure.(Answer:all)
4. The PR segment represents the time Irom the onset oI atrial
depolarization to the onset oI ventricular depolarization. It is
usuallyorientedinpolarityoppositetothatoIthePwave,and
ismostpronouncedinleadswithtallerPwaves.PRdepression
·0.8mmispresentonmanynormalECGs,butPRdepression
~0.8mmisoItenabnormal.PRelevationinanyleadotherthan
aVRisabnormal.(Answer:b,d)
—(«:·/k:.::«2;— —(«:·/k:.::«2;— —(«:·/k:.::«2;— —(«:·/k:.::«2;—
Mitralvalvedisease
• Mitralstenosis:CombinationoI(right/leIt)
ventricularhypertrophyand(right/leIt)atrial
abnormalityissuggestive
• Mitralvalveprolapse:
FlattenedorinvertedwavesinleadsII,III
andaVF(andsometimesinrightprecordial
leads)+STsegmentdepressionintheleIt
precordialleads
Prominentwaves
Prolongedinterval
right
leIt
T
U
QT
—501—
—POPOU¡Z—
PatternRecognItIon:IntraventrIcuIarConductIonDIsturbances
Instructions:MatchtheIollowingECGswithalldescriptionsthatapply.
ECG Choose All That Apply Answer
a. Rightbundlebranchblock
b.QRSaxisisusuallynormal
c. DoesnotinterIerewithECGdiagnosisoI
ventricularhypertrophy
d.LeItanteriorIascicularblock
e. CanresultinIalse-positivediagnosisoI
LVHbasedonvoltagecriteriausingleadsI
oraVL
I. CanmaskthepresenceoIlateralwallMI
g. LeItposteriorIascicularblock
h. CanmaskthepresenceoIinIeriorwallMI
i. Leastprevelantconductionabnormality
j. LeItbundlebranchblock
k. CommonlyassociatedwithsecondaryST
&Tchangesinoppositedirectiontomain
QRScomplex
Left anterior fascicular block(LAFB)resultsinleItaxis
deviation(meanQRSaxisbetween-45°and-90°);qR
complexes(oranRwave)inleadsIandaVL;rS
complexesinleadIII;andnormalorslightlyprolonged
QRSduration(0.08-0.10seconds).Thediagnosisrequires
thatnoothercauseoIleItaxisdeviationispresent(LVH,
inIeriorwallMI,chroniclungdisease,leItbundlebranch
block,ostiumpremumatrialseptaldeIect,severe
hyperkalemia).LAFBreducesthespeciIicityoILVH
basedonvoltagecriteriausingonlyleadsIoraVL,andcan
maskthepresenceoIinIeriorwallMIonECG.LAFBis
seeninorganicheartdisease,congenitalheartdisease,and
rarelyinnormals.(Answer:d,e,h)
Left posterior fascicular block(LPFB)resultsinrightaxis
deviation(meanQRSaxisbetween¹101°and¹180°);an
S
1
Q
3
pattern(deepSwaveinleadIandQwaveinlead
III);andnormalorslightlyprolongedQRSduration(0.08-
0.10seconds).Thediagnosisrequiresthatnoothercause
oIrightaxisdeviationispresent(RVH,verticalheart,
chroniclungdisease,pulmonaryembolism,lateralwallMI,
dextrocardia,leadreversal,ostiumsecundumASD,WolII-
Parkinson-Whitesyndrome).LPFBcanmaskthepresence
oIlateralwallMIonECG.IsolatedLPFBismuchless
prevalentthanleItbundlebranchblock,rightbundle
branchblock,orleItanteriorIascicularblock.LPFBis
seenmostcommonlywithcoronaryarterydisease,andis
rareinnormals.(Answer:c,I,g,i)
—502—
ECG84. 69-year-oldsmokerwithdyspnea:
—503—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—504—
ECG84wasobtainedIroma69-year-oldsmokerwithdyspnea.TheECGshowssinustachycardiaatarateoI144beats/minute.Thereisa
rightwardaxis(whichdoesnotquitemeetcriteriaIorrightaxisdeviation)andprominentSwavesintheleItprecordialleads(R/S·1inV
5
-V
6
)
(arrows),consistentwithrightventricularhypertrophy.PoorRwaveprogressionintheprecordialleadsandlowvoltageinthelimbleadsare
alsopresent.ThisconstellationoIIindingsisconsistentwithchroniclungdisease.AlsonotedareinsigniIicantQwavesinII,IIIandaVF,and
anRSR’patterninV
1
,whichIailtomeetcriteriaIorQ-waveMIorincompleteRBBB.
Codes: 10 Sinustachycardia(~100)
41 Rightventricularhypertrophy
81 Chroniclungdisease
—505—
Ouestions:ECG84
1. Chroniclungdiseaseissuggestedby:
a. PoorRwaveprogressionintheprecordialleads
b. EarlyRwaveprogressionintheprecordialleads
c. Rightaxisdeviation
d. Rightatrialenlargement
e. LowvoltageQRS
2. Causes oI right axis deviation include all oI the Iollowing
except:
a. LeItposteriorIascicularblock
b. LateralmyocardialinIarction
c. OstiumprimumatrialseptaldeIect
d. Limbleadmisplacement
Answers:ECG84
1. Chronic lung disease is characterized by poor R wave
progressionacrosstheanteriorprecordialleads,whichmaybe
mistaken Ior prior anterior myocardial inIarction. Other
commonIindingsincludesinustachycardia,rightaxisdeviation,
right atrial enlargement, right bundle branch block, and low
voltage. Many oI these Iindings can also be seen in acute cor
pulmonale, including pulmonary embolism. Early R wave
progressionisnotassociatedwithchroniclungdisease,unless
it is complicated by pulmonary hypertension with right
ventricularhypertrophy.(Answer:allexceptb)
2. Right axis deviation (QRS axis ~ ¹100°) is seen in many
conditions,includingleItposteriorIascicularblock,lateralwall
MI, right ventricular hypertrophy, chronic lung disease,
pulmonaryembolism,anddextrocardia.TranspositionoIECG
electrodes I and aVL can cause inversion oI the P-QRS-T
complex in these leads and apparent right axis deviation.
Ostium secundum atrial septal deIect (ASD) causes right axis
deviation;primumASDresultsinleItaxisdeviation.Rightaxis
deviationcanalsobeanormalIinding,especiallyinthin,young
individuals.(Answer:c)
—506—
—(«:·/k:.::«2;— —(«:·/k:.::«2;— —(«:·/k:.::«2;— —(«:·/k:.::«2;—
Rightventricularhypertrophy
• MeanQRSaxis~ degrees
• DominantwaveinV
1
:
R/SratioinV
1
orV
3R
(·,÷,~)1,or R/Sratio
inV
5
orV
6
(,~)1
RwaveinV
1
~ mm
RwaveinV
1
¹SwaveinV
5
orV
6
~ mm
rSRinV
1
withR~ mm
• SecondarydownslopingSTdepression&T-wave
inversioninthe(right/leIt)precordialleads
• (Right/leIt)atrialabnormality
100
R
~

7
10.5
10
right
right
Chroniclungdisease
• (Right/leIt)ventricularhypertrophy
• (Right/leIt)axisdeviation
• (Right/leIt)atrialabnormality
• ShiItoItransitionalzone
(clockwise/counterclockwise)
• (High/low)voltageQRS
• PseudoinIarctpatternintheleads
• Swavesinleads(S
1
S
2
S
3
pattern)
• Mayalsoseesinustachycardia,junctionalrhythm,
variousdegreesoIAVblock,IVCD,andbundle
branchblock(true/Ialse)
Right
Right
Right
clockwise
low
anteroseptal
I,II,andIII
true
—507—
DifferentialDiagnosis
R RR R¡GHTAX¡8DEV¡AT¡ONANDADOM¡NANTR WAVE¡NV
1
M¡M¡CK¡NGR¡GHTVENTR¡CULARHYPERTROPHY
• PosteriororinIeroposterolateralwallMI
• Rightbundlebranchblock
• WolII-Parkinson-Whitesyndrome
• Dextrocardia
• LeItposteriorIascicularblock
• Normalvariant(especiallyinchildren)
—508—
ECG85. 40-year-oldmaleathletewithpalpitations:
—509—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconductiondisturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonaryembolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—510—
ECG85wasobtainedIroma40-year-oldmaleathletewithpalpitations.TheECGshowsnormalsinusrhythmatarateoI77bpm.LVHwith
secondaryrepolarizationabnormalityispresent(SwaveinaVR~15mm;RwaveinaVF~21mm).TheaxisisshiItedrightwardbutis·100
o
(sorightaxisdeviationshouldnotbecoded).Likewise,thePwaveinleadII,QwavesinleadsII,III,andaVF,andUwavesinleadsV
2
and
V
3
do not meet criteria Ior right atrial abnormality, Q-wave MI, or prominent U waves. The rightward axis, large P wave in lead II, and
prominentinIeriorvoltageareconsistentwithaverticalheart,thinbodyhabitus,and“physiologichypertrophy,”notuncommoninwell-trained
athletes.
Codes: 07 Sinusrhythm
40 LeItventricularhypertrophy
67 STand/orTwaveabnormalitiessecondarytohypertrophy
—511—
Ouestions:ECG85
1. CausesoIrightaxisdeviationinclude:
a. ReversaloIrightandleItarmleads
b. COPD
c. Horizontalheart
d. LeItposteriorIascicularblock(LPFB)
e. Dextrocardia
I. OstiumprimumatrialseptaldeIect(ASD)
g. Rightventricularhypertrophy(RVH)
2. FactorsthatreducethespeciIicity(i.e.,increasetherateoIIalse-
positives)IorthediagnosisoILVHbyvoltagecriteriainclude:
a. SevereCOPD
b. Thinbodyhabitus
c. Obesity
d. PericardialorpleuraleIIusion
e. Coronaryarterydisease
I. Pneumothorax
g. SarcoidosisoramyloidosisoItheheart
h. LeItanteriorIascicularblock(LAFB)
i. SevereRVH
Answers:ECG85
1. Causes oI right axis deviation include RVH, vertical heart,
COPD, pulmonary embolus, leIt posterior Iascicular block,
lateralwallMI,dextrocardia,reversaloIrightandleItarmleads,
and ostium secundum ASD. Horizontal hearts and ostium
primumASDsareassociatedwithaleItwardshiItoIthemean
QRSaxis.(Answer:a,b,d,e,g)
2. ConditionsthatincreaseQRSamplitudereducethespecificity
IorLVHbyvoltagecriteria,includingthinbodyhabitusandleIt
anterior Iascicular block (LAFB increases QRS amplitude in
leads I and aVL). Conditions that decrease QRS amplitude
reducethe sensitivity(i.e.,increasetherateoIIalse-negatives)
IorLVHbyvoltagecriteria,andincludeconditionsthatincrease
theamountoIbodytissue(obesity),air(COPD,pneumothorax),
Iluid(pericardialorpluraleIIusion),orIibroustissue(coronary
artery disease, sarcoid or amyloid oI the heart) between the
myocardium and ECG electrodes. Severe RVH can also
underestimateLVHbycancellingprominentQRSIorcesIrom
thethickenedLV.(Answer:b,h)
—(«:·/k:.::«2,— —(«:·/k:.::«2,— —(«:·/k:.::«2,— —(«:·/k:.::«2,—
Rightaxisdeviation
• MeanQRSaxisbetweenanddegrees 101,270
—512—
ECG86. 49-year-oldmalewithchestpain:
ECGA ECGB
—513—
GENERALFEATURE8
G 01. NormalECG
G 02. BorderlinenormalECGornormalvariant
G 03. Incorrectelectrodeplacement
G 04. ArtiIact
PWAVEABNORMAL¡T¡E8
G 05. Rightatrialabnormality/enlargement
G 06. LeItatrialabnormality/enlargement
8UPRAVENTR¡CULARRHYTHM8
G 07. Sinusrhythm
G 08. Sinusarrhythmia
G 09. Sinusbradycardia(·60)
G 10. Sinustachycardia(~100)
G 11. Sinuspauseorarrest
G 12. Sinoatrialexitblock
G 13. Atrialprematurecomplexes
G 14. Atrialparasystole
G 15. Atrialtachycardia
G 16. Atrialtachycardia,multiIocal
G 17. Supraventriculartachycardia,paroxysmal
G 18. AtrialIlutter
G 19. AtrialIibrillation
JUNCT¡ONALRHYTHM8
G 20. AVjunctionalprematurecomplexes
G 21. AVjunctionalescapecomplexes
G 22. AVjunctionalrhythm/tachycardia
VENTR¡CULAR RHYTHM8
G 23. Ventricularprematurecomplexes
G 24. Ventricularparasystole
G 25. Ventriculartachycardia(≥ 3consecutive
complexes)
G 26. Acceleratedidioventricularrhythm
G 27. Ventricularescapecomplexesorrhythm
G 28. VentricularIibrillation
AVCONDUCT¡ONABNORMAL¡T¡E8
G 29. AVblock,1°
G 30. AVblock,2°-MobitztypeI(Wenckebach)
G 31. AVblock,2°-MobitztypeII
G 32. AVblock,2:1
G 33. AVblock,3°
G 34. WolII-Parkinson-Whitepattern
G 35. AVdissociation
ABNORMAL¡T¡E8OFOR8AX¡8
G 36. LeItaxisdeviation(~–30°)
G 37. Rightaxisdeviation(~¹100°)
G 38. Electricalalternans
OR8VOLTAGEABNORMAL¡T¡E8
G 39. Lowvoltage
G 40. LeItventricularhypertrophy
G 41. Rightventricularhypertrophy
G 42. Combinedventricularhypertrophy
¡NTRAVENTR¡CULARCONDUCT¡ON
ABNORMAL¡T¡E8
G 43. RBBB,complete
G 44. RBBB,incomplete
G 45. LeItanteriorIascicularblock
G 46. LeItposteriorIascicularblock
G 47. LBBB,complete
G 48. LBBB,incomplete
G 49. NonspeciIicintraventricularconduction
disturbance
G 50. Functional(rate-related)aberrantintraventricular
conduction
O-WAVEMYOCARD¡AL¡NFARCT¡ON8
G 51. Anterolateral(agerecentoracute)
G 52. Anterolateral(ageindeterminateorold)
G 53. Anteriororanteroseptal(agerecentoracute)
G 54. Anteriororanteroseptal(ageindeterminateorold)
G 55. Lateral(agerecentoracute)
G 56. Lateral(ageindeterminateorold)
G 57. InIerior(agerecentoracute)
G 58. InIerior(ageindeterminateorold)
G 59. Posterior(agerecentoracute)
G 60. Posterior(ageindeterminateorold)
REPOLAR¡ZAT¡ONABNORMAL¡T¡E8
G 61. Normalvariant,earlyrepolarization
G 62. Normalvariant,juvenileTwaves
G 63. NonspeciIicSTand/orTwaveabnormalities
G 64. STand/orTwaveabnormalitiessuggesting
myocardialischemia
G 65. STand/orTwaveabnormalitiessuggesting
myocardialinjury
G 66. STand/orTwaveabnormalitiessuggesting
electrolytedisturbances
G 67. STand/orTwaveabnormalitiessecondaryto
hypertrophy
G 68. ProlongedQTinterval
G 69. ProminentUwaves
8UGGE8TEDCL¡N¡CALD¡8ORDER8
G 70. DigitaliseIIect
G 71. Digitalistoxicity
G 72. AntiarrhythmicdrugeIIect
G 73. Antiarrhythmicdrugtoxicity
G 74. Hyperkalemia
G 75. Hypokalemia
G 76. Hypercalcemia
G 77. Hypocalcemia
G 78. AtrialseptaldeIect,secundum
G 79. AtrialseptaldeIect,primum
G 80. Dextrocardia,mirrorimage
G 81. Chroniclungdisease
G 82. Acutecorpulmonaleincludingpulmonary
embolus
G 83. PericardialeIIusion
G 84. Acutepericarditis
G 85. Hypertrophiccardiomyopathy
G 86. Centralnervoussystemdisorder
G 87. Myxedema
G 88. Hypothermia
G 89. Sicksinussyndrome
PACEDRHYTHM8
G 90. Atrialorcoronarysinuspacing
G 91. Ventriculardemandpacemaker(VVI),normally
Iunctioning
G 92. Dual-chamberpacemaker(DDD)
G 93. PacemakermalIunction,notconstantlycapturing
(atriumorventricle)
G 94. PacemakermalIunction,notconstantlysensing
(atriumorventricle)
—514—
ECGs86Aand86Bwereobtainedina49-year-oldmalewithchestpain.ECG86AshowsacuteinIeriorinjurywithSTelevationinleads
II,III,andaVFplusdiagnosticQwavesinleadsIIIandaVF.ThereisalsoSTdepressioninleadsI,aVLandV
1
-V
4
,whichmayrepresent
ischemia,reciprocalchangesassociatedwithacuteinIeriorinjurypattern,orposteriorinjury.TohelpidentiIyposteriorwallinjury/inIarction,
posteriorchestleadsarerecorded(ECG86B).TorecordposteriorchestleadsV
7
-V
9
,leadsV
4
,V
5
andV
6
areplacedinthe5
th
intercostalspace
(similartotheoriginalV
4
-V
6
leads)attheleItposterioraxillaryline(V
7
),leItmidscapularline(V
8
),andjustleItoIthespine(V
9
).ECG86B
demonstratesSTelevationplusasmallQwaveinleadsV
7
-V
9
,consistentwithacuteposteriorinIarction. Posteriorchestleadsshouldbe
consideredinpatientswithacuteinIeriorinIarctionwhodemonstrateSTdepressionanduprightTwavesinleadsV
1
-V
2
.
Codes: 07 Sinusrhythm
29 AVblock,1o
57 InIerior(agerecentoracute)
59 Posterior(agerecentoracute)
ECGA ECGB
—515—
Ouestions:ECG86
1. ST depression in leads V
1
and V
2
in a patient with an acute
inIeriormyocardialinIarctionrepresentsposteriorinjurywhen
thereis:
a. AninvertedTwaveinleadV
2
b. Aninjurypatterninright-sidedchestleads
c. AnuprightTwaveinleadV
2
d. AssociatedSTsegmentdepressioninleadsIandaVL
2. Which coronary artery is most oIten involved in isolated
posteriorMI:
a. LeItanteriordescending
b. LeItcircumIlexartery
c. Rightcoronaryartery
Answers:ECG86
1. STdepressioninleadsV
1
andV
2
iscommoninthesettingoI
acuteinIeriormyocardialinIarction.ThemechanismoItheST
depression can be anterior ischemia, reciprocal changes, or
posterior injury. In this setting, posterior injury is the most
commoncauseoIatallRwave(R~S)andanuprightTwave
in V
1
. However, since none oI the 12 ECG leads Iace the
posteriorwall,posteriorinjuryisoItenoverlooked/undetected.
(SinceV
1
recordselectricalactivityIromtheoppositesideIrom
theposteriorwall,thelargeRwave,STdepression,andupright
TwaveseeninposteriorinIarctionaremirrorimagereIlections
oItheQwave,STelevation,andinvertedTwaveusuallyseen
in acute MI). ST elevation in posterior chest leads V
7
-V
9
identiIiespatientswithlargerinIeriorMI’sduetoconcomitant
posteriorwallinvolvement.(Answer:c)
2. Patientswithischemic-typechestpainandnoevidenceoIST
elevationonstandard12-leadECGbeneIitIromposteriorchest
lead (V
7
-V
9
) placement. ST elevations in these leads are
associatedwithcardiacenzymeelevationsandposteriorwall
motionabnormalitiesonechocardiographyinthevastmajority
oI cases; mitral regurgitation is oIten present as well. On
coronary angiography, the culprit vessel is usually the leIt
circumIlexartery.(Answer:b)
—(«:·/k:.::«2(— —(«:·/k:.::«2(— —(«:·/k:.::«2(— —(«:·/k:.::«2(—
AVblock,1°
• PRinterval seconds 0.20
PosteriorM¡,recentorprobablyacute
• InitialRwave secondsinleads and
with:
Rwaveamplitude(greaterthan/lessthan)S
waveamplitudeandSTsegment
(elevation/depression)with
(upright/inverted)Twaves
0.04,V
1
V
2
greaterthan
depression
upright
• PosteriorMIisusuallyseeninthesettingoI
acuteinIeriorMI(true/Ialse)
• RVH,WPWandRBBB(do/donot)interIere
withtheECGdiagnosisoIposteriorMI
true
do
—516—
—POPOU¡Z—
PatternRecognItIon:DrugEIIectsandRhythmDIsturbances
Instructions:ChoosealldrugscommonlyassociatedwitheachoItheIollowingrhythmabnormalities.
ECG Choose All That Apply Answer
a. Amiodarone
b. Atropine
c. Aminophylline
d. Digitalis
e. Atorvastatin
I. Ramipril
g. Nitroglycerin
h. Metoprolol
i. Verapamil
Multifocal atrial tachycardia(MAT)resultsinanirregular
atrialrate~100perminutewithatleastthreediIIerentPwave
morphologies(originatingIromseparateatrialIoci)andvarying
PPandPRintervals.MATisusuallyassociatedwithsome
IormoIlungdisease(COPD,corpulmonade,hypoxia),andcan
beprecipitatedbyaminophylline.(Answer:c)
Paroxysmal atrial tachycardia (PAT) with block resultsin
nonsinusPwavesataregularatrialrate(usually150-240per
minute),isoelectricintervalsbetweenPwaves,andsome
nonconductedPwavesdueto2°AVblock.Digoxintoxicityis
responsibleIor75°oIcasesandorganicheartdiseaseIor25°
oIcases.AtropinemayworsenTypeII2°AVblock,butrarely
causesthisarrhythmia.Note:2:1AVblockinthisECGmaybe
eitherMobitzTypeIorTypeII.(Answer:d)
Sinus bradycardiaresultsinaregularsinus(uprightPwavesin
leadII)rhythmatarate·60perminute.Commoncauses
includebeta-blockers,amiodarone,verapamil,diltiazem,
digitalis,TypeIantiarrhythmics,clonidine,-methyldopa,
reserpine,guanethidine,cimetidine,andlithium.Low-dose
atropinemayalsocauseaparadoxicalslowingoIheartrate.
(Answer:a,b|lowdose|,d,h,i)
—517—
—POPOU¡Z—
DIIIerentIaIDIagnosIs:U-wave
Instructions:DeterminewhetherthediagnosesbelowareassociatedwithprominentuprightUwaves,inverted
Uwaves,orboth.
Diagnosis Answer
Hypokalemia ProminentuprightUwaves.STdepressionandIlattenedTwavesare
common.
LeItventricularhypertrophy(LVH) ProminentuprightorinvertedUwaves.
Coronaryarterydisease ProminentuprightorinvertedUwaves.
Bradycardia ProminentuprightUwaves.
Hypothermia ProminentuprightUwaves.Osborne(J)wavesandprolongationoIPR,QRS,
andQTarecommon.
Digoxin ProminentuprightUwaves.SaggingSTdepressionwithupwardconcavity
andTwavechanges(Ilat,inverted,orbiphasic)arecommon.QTshortening
andPRprolongationmayoccur.
Antiarrhythmicdrugs ProminentuprightUwaves(oneoIearliestIindings).ProlongedQTinterval
andnonspeciIicSTandTwavechangesarecommon.
—518—
ECG87{advanced}.29-year-oldfemalewith
intermittentpalpitationsandaheartmurmur:
ECGA ECGB
—519—
ECGs87Aand87Bwereobtainedina29-year-oldIemalewithintermittentpalpitationsandaheartmurmurand areassociatedwitha
uniqueclinicalpresentation.ThispatienthasEbstein’sanomalywithventricularpre-excitation(WolII-Parkinson-Whitepattern).InECG87A,
pre-excitationispresentwithanaccessorypathwayconnectingtherightatriumandrightventricle.ThisgivesrisetoaleItbundlebranchblock
(LBBB)patternsincebothventriclesareactivatedovertheright-sidedaccessorypathway.ThePRintervalisshort,adeltawaveispresent,and
theQRScomplexisprolonged,consistentwithWPWpattern.InECG87B,pre-excitationisnolongerpresent,andthemoretypicalrightbundle
branchblock(RBBB)patternoIconductiondelayassociatedwithEbstein’sanomalyisnowapparent.Theventricleisactivatedbytheelectrical
impulsetravelingthroughtheAVnodeandtheHis-Purkinjepathways,andEbstein’sanomalyhasresultedinabnormalconductionthrough
therightventricle,consistentwithaRBBBconductionpattern.First-degreeAVblockandST-TchangessuggestiveoIinIeriorwallischemia
arealsoevident.Ventricularpre-excitationduetoaright-sidedaccessoryAVpathwayshouldbesuspectedwheneverapatientwithEbstein’s
anomalyhasanECGshowingabsenceoItheexpectedRBBBpatternandinsteadshowsnormalorshortenedAVconductionwithaLBBB
conductionpattern.
Codes:
ECG87A. 06 LeItatrialabnormality/enlargement
07 Sinusrhythm
34 WolII-Parkinson-Whitepattern
ECG87B. 10 Sinustachycardia(~100)
29 AVblock,1°
43 RBBB,complete
64 STand/orTwaveabnormalitiessuggestingmyocardialischemia
—520—
ECG88{advanced}.30-year-oldmalewith
palpitationsandsyncope:
—521—
ECG88wasobtainedina30-year-oldmalewithpalpitationsandsyncope.TheECGshowsthecharacteristicpatternIortheuniqueclinical
presentationoIarrhythmogenicrightventriculardysplasia/cardiomyopathy(ARVD/C).ECGIindingsconsistentwithARVD/Cincludethe
epsilonwaveinleadV
1
(arrow),asharpdeIlectionattheendoItheQRScomplex,andtheinvertedTwavesinleadsV
1
-V
3
.Patientswith
ARVD/CdevelopacardiomyopathyoItherightventriclethatattimescaninvolvetheleItventricle.Theventricularmyocardiumisreplaced
withIibrousandIattytissue.ThesepatientscandevelopheartIailureandventriculartachycardiaduetoreentrycircuitsoccurringinthescarred
rightventricle.ThetachycardiasaremostcommonlymonomorphicventriculartachycardiawithaleItbundlebranchblockmorphology(since
theyoriginateintherightventricle).TachycardiasarisingneartherightventricularoutIlowtractwillhavealeItbundlebranchblock,rightaxis
(inIerioraxis)morphology;tachycardiasoriginatingIromthemid-partoItherightventriclewillhavealeItbundlebranchblock,normalaxis
morphology; and tachycardias originating Irom the right ventricular apex will have a leIt bundle branch block, leIt axis (superior axis)
morphology.OtherECGIindingsincludeproIoundsinusbradycardiaat45beats/minuteandleItaxisdeviation.
Codes: 09 Sinusbradycardia(·60)
37 Rightaxisdeviation(~¹100o)
64 ST-Tand/orTwaveabnormalitiessuggestingmyocardialischemia
—522—
ECG89{advanced}.41-year-oldmaleonroutineECG
priortoelectivesurgery:
I
aVR V1 V4
II
II
aVL V2 V5
III
aVF V3 V6
—523—
ECG89wasobtainedina41-year-oldmaleonroutineECGpriortoelectivesurgery.TheECGisassociatedwithadistinctiveQRScomplex
inleadsV
1
andV
2
consistentwiththe Brugada pattern of conduction.PatientsareconsideredtohavetheuniqueclinicalpresentationoIthe
Brugada SyndromewhenthisECGpatternisassociatedwithventriculartachycardia,whichcanresultinsyncopeorsuddencardiacdeath.The
Brugada patterninvolvesadepolarizationabnormalitycharacterizedbyanR’andSTelevationinleadV
1
andoIteninleadV
2
.ThisECG
pattern is associated with a genetic deIect oI the SCN5A gene, which aIIects the sodium channel and is associated with liIe-threatening
ventriculararrhythmiasandsuddendeathinotherwisehealthyindividuals.
I aVR V1 V4
II
II
aVL V2 V5
III aVF V3 V6
—525—
Section 4
ECG CRITERIA
(diagnoses are listed in order of
appearance on answer sheet)
General Features
01. Normal ECG(no abnormalities of rate, rhythm, axis
or P-QRS-T):
P Wave
Duration: 0.08-0.11seconds
Axis: 0-75
0
Morphology: UprightinI,II;uprightorinvertedinaVF;
invertedorbiphasicinIII,aVL,V
1
,V
2
;small
notchingmaybepresent
Amplitude: Limbleads·2.5mm;V
1
:positivedeIlection
·1.5mmandnegativedeIlection·1mm
PR Interval
Duration: 0.12-0.20seconds
PR segment: Usually isoelectric; may be displaced ina
directionoppositetothePwave;elevationis
usually·0.5mm;depressionistypically·
0.8mm
QRS Complex
Duration: 0.06-0.10seconds
Axis: –30
0
to¹105
0
Transition zone (precordial leads with equal positive and
negative deflection):V
2
-V
4
Q wave: SmallQwaves(duration·0.04secondsand
amplitude · 2 mm) are common in most
leadsexceptaVR,V
1
andV
2
Onset of intrinsicoid deflection (beginning of QRS to peak of
R wave): Rightprecordialleads·0.035seconds;leIt
precordialleads·0.045seconds
ST Segment
Usually isoelectric. In limb leads, may vary Irom 0.5 mm
belowto1mmabovebaseline;inV
2
-V
3
(sometimesV
4
)up
to3mmconcaveupwardelevationinprecordialleadsmaybe
seen in young adults (early repolarization, item 61), but is
usually · 2 mm iI over age 40; in V
5
-V
6
concave upward
elevationmorethan1mmisuncommon
T Wave
Morphology: UprightinI,II,V
3
-V
6
;invertedinaVR,V
1
;
maybeupright,IlatorbiphasicinIII,aVL,
aVF, V
1
, V
2
; T wave inversion may be
present in V
1
-V
3
in healthy young adults
(juvenileTwaves,item62)
Amplitude: Usually·6mminlimbleadsand·10mm
inprecordialleads
QT Interval
CorrectedQT(QTintervaldividedbythesquarerootoIthe
RR interval) ÷ 0.30 - 0.44 seconds; varies inversely with
heartrate
U Wave
Morphology: UprightinallleadsexceptaVR
Amplitude: 5-25° the height oI the T wave (usually·
1.5mm)
02. Borderline normal ECG or normal variant
• Earlyrepolarization(item61)
• JuvenileTwaves(item62)
• SwaveinleadsI,II,andIII(S
1
S
2
S
3
pattern)
Note:Presentinupto20°oIhealthyyoungadults.
• RSR or rSr’ in lead V
1
with QRS duration · 0.10
seconds, r wave amplitude · 7 mm, and r' amplitude
smallerthanrorSwaves
Note:Seenin2°oInormals,butcanalsobeseenin:
RVH(item41)
PosteriorMI(items59,60)
SkeletaldeIormities(pectusexcavatum,straightback
syndrome)
The Complete Guide to ECGs
—526—
High electrode placement oI V
1
(in 3rd intercostal
spaceinsteadoI4th)
• TallPwaves
• NotchedPwavesoInormalduration
Note: Hyperventilation may cause prolonged PR, sinus
tachycardia,andSTdepression+Twaveinversion(usually
seenininIeriorleads).
Note:LargeIoodintakemaycauseSTdepressionand/orT
waveinversion,especiallyaIterahighcarbohydratemeal.
03. Incorrect electrode placement
Limbleadreversal:
• ReversaloIrightandleItarmleads
ResultantECGmimicsdextrocardiainlimbleadswith
inversionoItheP-QRS-TinleadsIandaVL
LeadsIIandIIItransposed
LeadsaVRandaVLtransposed
Note:Todistinguishbetweentheseconditions,lookat
precordial leads: dextrocardia shows reverse R wave
progression(withgraduallossoIRwavevoltageIromV
1
-V
6
); limb lead reversal shows normal R wave
progression.
• ReversaloIleItarmandleItlegleads
LeadsIandIItransposed
LeadsaVFandaVLtransposed
LeadIIIinverted
• ReversaloIrightarmandleItlegleads
LeadsI,II,andIIIinverted
LeadsaVRandaVFtransposed
Precordial lead reversal: Typically maniIests as an
unexplaineddecreaseinRwavevoltageintwoconsecutive
leads (e.g., V
1
, V
2
) with a return to normal R wave
progressionontheIollowingleads
04. Artifact
• AC electrical interference(60cyclesperseconds):Due
to an unstable or dry electrode, poor grounding oI the
ECG machine, or excessive current leak Irom an ECG
machinetooclosetootherelectronicequipment.Rapid
sine-wavechangesmakeassessmentoIPwavesandST
segmentshiItsunreliable.
• Wandering baseline:Duetoanunstableelectrode,deep
respirations, or uncooperative patient. Evaluation oI P
waves,QRSvoltage,andSTsegmentshiItsareunreliable.
• Skeletal muscle fasciculations (e.g.,shivering,anxiety
withmuscletension)
• Commonlyduetotremor(mostprominentinlimbleads)
ParkinsonstremorsimulatesatrialIlutterwitharate
oI~300perminute(4-6cyclespersecond)
Physiologic tremor rate is 500 per minute (7-9 per
second)
• Poor standardization: 1 mV signal is not recorded,
underdamped, or overdamped; ECG recorded at halI-
standardordouble-standard.Voltagesmaybeinaccurate.
• ECG recorded at double-speed or half-speed
• Rapid arm motion or lead movement (e.g., brushing
teeth or hair): Can simulate VPCs or ventricular
tachycardia;oItenmistakenIorventriculartachycardiaon
telemetryorHoltermonitoring.
• Cautery: PronouncedbaselineinterIerence
• IV infusion pump: May give appearance oI rapid P
waves
ECG Criteria
—527—
P Wave Abnormalities
05. Right atrial abnormality/enlargement
• TalluprightPwave:
~2.5mminleadsII,III,andaVF(P-pulmonale),or
~1.5mminleadsV
1
orV
2
• PwaveaxisshiItedrightward(i.e.,axis70°)
Note: In up to 30° oI cases, P pulmonale may actually
represent leIt atrial enlargement. Suspect this possibility
whenleItatrialabnormality/enlargement(item05)ispresent
inleadV
1
.
Note:Prominentatrialrepolarizationwaves(Ta)canmimic
Q waves and ST depression by deIorming the PR and ST
segments,respectively.
Note:Ppulmonalecanbeseenin
COPDwithorwithoutcorpulmonale(item81)
Pulmonaryhypertension
Congenital heart disease (such as pulmonic stenosis,
Tetralogy oI Fallot, tricuspid atresia, Eisemenger’s
physiology)
Pulmonaryembolism(usuallytransient)(item82)
Normalvariantinpatientswithathinbodyhabitusand/or
verticalheart
06. Left atrial abnormality/enlargement
• TerminalnegativeportionoIthePwaveinleadV
1
1
mmdeepand0.04secondsinduration(i.e.,onesmall
boxdeepandonesmallboxwide), or
• NotchedPwavewithaduration0.12secondsinleads
II,IIIoraVF(P-mitrale)
Note:LeItatrialenlargementbyechocardiographycanexist
withanormalPwave,andPmitralemaybepresentinthe
absenceoIleItatrialenlargement.
Note:Prominentatrialrepolarizationwaves(Ta)canmimic
Q waves and ST depression by deIorming the PR and ST
segments,respectively.
Note: Mechanisms responsible Ior P mitrale include leIt
atrial hypertrophy or dilation, intraatrial conduction delay,
increased leIt atrial volume, and an acute rise in leIt atrial
pressure.
Note:Canbeseenin:
Mitralvalvedisease
Organicheartdisease
Aorticvalvedisease
HeartIailure
MyocardialinIarction
Hypertension/LVH
Supraventricular Rhythms
07. Sinus rhythm
• NormalPwaveaxisandmorphology
• Atrialrateis60-100perminuteandregular(PPinterval
variesby·0.16secondsor·10°)
08. Sinus arrhythmia
• NormalPwavemorphologyandaxis
• PhasicchangeinPPinterval(onsetmaysometimes
occurabruptly),usuallyinresponsetothebreathcycle
• LongestandshortestPPintervalsvaryby~0.16
secondsor10°
Note:SinusarrhythmiaisamajorIactorinbeat-to-beat
heartratevariability(HRV).ThepresenceoImaintained
HRVisamaniIestationoIactive,healthy,vagaltone,and
animportantmarkerIorgoodcardiovascularprognosis.
The Complete Guide to ECGs
—528—
09. Sinus bradycardia (< 60)
• NormalPwaveaxisandmorphology
• Rate·60perminute
Note: IItheatrialrateis·40perminute,thinkoI2:1
sinoatrialexitblock(item12)
Note:Causesinclude:
Highvagaltone(normals,especiallyduringsleep;
trainedathletes;Bezold-JarischreIlex;inIeriorMI,
pulmonaryembolism)
MyocardialinIarction(usuallyinIerior)
Drugs(beta-blockers,verapamil,diltiazem,digitalis,
TypeIA,IB,ICantiarrhythmics,amiodarone,sotalol,
clonidine,-methyldopa,reserpine,guanethidine,
lithium)
Hypothyroidism(item87)
Hypothermia(item88)
Obstructivejaundice
Hyperkalemia(item74)
Increasedintracranialpressure(item86)
Sicksinussyndrome(item89)
10. Sinus tachycardia (> 100)
• NormalPwaveaxisandmorphology
• Rate~100perminute
Note: PwaveamplitudeoItenincreasesandPRinterval
oItenshortenswithincreasingheartrate(e.g.,during
exercise)
Note: Causesinclude:
Physiologicresponsetostress(exercise,anxiety,pain,
Iever,hypovolemia,hypotension,anemia)
Thyrotoxicosis
Myocardialischemia/inIarction
HeartIailure
Myocarditis
Pulmonaryembolism(item82)
Pheochromocytoma
AVIistula
Drugs(caIIeine,alcohol,nicotine,cocaine,
amphetamines,albuterolandotherbeta-agonists,
endogenouscatecholamines,hydralazine,exogenous
thyroid,atropine,aminophylline)
11. Sinus pause or arrest
• PPinterval(pause)greaterthan1.6-2.0seconds
• SinuspauseisnotamultipleoIthebasicsinusPPinterval
Note: II sinus pause is a multiple oI the basic PP
interval,considersinoatrialexitblock(item12).
Note:SinuspausesmustbediIIerentiatedIrom:
Sinusarrhythmia(item08):Phasic,gradualchangeinPP
interval
Second-degreesinoatrialblock,MobitzI(Wenckebach)
(item12):ProgressiveshorteningoIPPintervaluntilaP
waveIailstoappear
Second-degreesinoatrialblock,MobitzII(item12):Sinus
pauseisamultiple(e.g.,2x,3x,etc.)oIthebasicsinus
rhythm(PPinterval)
Abruptchangeinautonomictone(e.g.,vagalreaction)
“Pseudo” sinus pause due to nonconducted atrial
prematurecomplexes(APC;item13):Pwaveappearsto
beabsentbutisactuallyburiedintheTwave—lookIor
subtle deIormity oI the T wave at the beginning oI the
pausetodetectnonconductedAPCs
Note:CompleteIailureoIsinoatrialconduction(third-degree
sinoatrial block; item 12) cannot be diIIerentiated Irom
completesinusarrestonsurIaceECG
Note:Sinuspause/arrestisduetotransientIailureoIimpulse
IormationattheSAnode.Etiologyisthesameassinoatrial
exitblock(item12).
12. Sinoatrial exit block
• SECOND-DEGREE: SomesinusimpulsesIailtocapture
theatria,resultingintheintermittentabsenceoIaPwave.
OItenacomponentoItheSickSinusSyndrome(item89)
ECG Criteria
—529—
TypeI(MobitzI)sinoatrialexitblock:
• P wave morphology and axis consistent with a
sinusnodeorigin
• “Groupbeating”with:
(1)ShorteningoIPPintervaluptopause
(2)ConstantPRinterval
(3)PPpause·2xthenormalPPinterval
TypeII(MobitzII)sinoatrialexitblock
• ConstantPPintervalIollowedbyapausethatisa
multiple (e.g., 2x, 3x, etc.) oI the normal PP
interval
• The pause may be slightly less than twice the
normalPPinterval(usuallywithin0.10seconds).
Note:Causesinclude:
Drugs (digitalis, quinidine, Ilecainide,
propaIenone,procainamide)
Hyperkalemia(item74)
SinusnodedysIunction
Organicheartdisease
MyocardialinIarction
Vagalstimulation
Note:First-degreesinoatrialexitblock(conductionoIsinus
impulses to the atrium is delayed, but 1:1 response is
maintained) is not detectable on surIace ECG, and third-
degree sinoatrial exit block (complete Iailure oI sinoatrial
conduction) cannot be diIIerentiated Irom complete sinus
arrest(item11)
13. Atrial premature complexes
• PwavethatisabnormalinconIigurationandpremature
relativetothenormalPPinterval
• QRS complex is usually similar in morphology to the
QRS complex present during sinus rhythm. Exceptions
include:
AberrantlyconductedAPCs:QRSmaybewideand
bizarre; more likely to occur with very premature
APCs.QRSmorphologyismostoItenRBBBpattern
(duetothelongerreIractoryperiodoItherightbundle
comparedtotheleItbundle),butcanbeLBBBpattern
orvariable.
BlockedAPCs:VeryprematurePwavenotIollowed
byaQRScomplex.PwavesareoItenhiddeninthe
preceding T wave — look Ior a deIormed T wave
immediately aIter the Iirst QRS oI the RR pause to
identiIy the presence oI a nonconducted atrial
prematurecomplex.
• ThePRintervalmaybenormal,increased,ordecreased.
• Thepost-extrasystolicpauseisusuallynoncompensatory
(i.e.,theintervalIromtheprecedingnormalPwavetothe
normalPwaveIollowingtheAPCislessthantwonormal
PP intervals). However, an interpolated APC or a
compensatorypausemaybeevidentwhensinoatrial(SA)
“entranceblock”ispresentandtheSAnodeisnotreset.
Note:Canbeseeninnormals,Iatigue,stress,smoking,drugs
(includingcaIIeineandalcohol),organicheartdisease,cor
pulmonale
14. Atrial parasystole
• Frequent atrial premature complexes oI similar
morphologythat“marchthrough”thetracingindependent
oItheunderlyingsinusrhythm.
• Interectopicintervalsareamultiple(2x,3x,etc.)oIthe
shortestinterectopicinterval(sincetheparasystolicIocus
IiresataregularrateandinscribesaPwavewheneverthe
atriaarenotreIractory)
• Resultantectopicatrialcomplexvariesinrelationshipto
theprecedingsinusbeats(i.e.,nonIixedcoupling)
Note:ExitblockIromaparasystolicIocusmayoccurand
result in absence oI an atrial ectopic beat when it would
otherwisebeexpectedtooccur.
Note:AtrialparasystoleisduetothepresenceoIanectopic
atrialIocusthatactivatestheatriaindependentoIthebasic
sinus rhythm, and is protected Irom depolarization by an
entranceblock.TheatrialIocusIiresataregularcyclelength
and results in an ectopic atrial beat that bears no constant
relationship(nonIixedcoupling)totheprevioussinusbeat.
The Complete Guide to ECGs
—530—
Note: Think oI atrial parasystole in the presence oI atrial
prematurecomplexesoIsimilarmorphologywithnonIixed
coupling.
15. Atrial tachycardia
• Threeormoreconsecutiveectopicatrialbeats(nonsinus
Pwaves)atanatrialrateoI100-240perminute
• P wave may precede, be buried in (sometimes not
visualized),orimmediatelyIollowtheQRScomplex
• QRS complex Iollows each P wave unless second- or
third-degreeAVblockispresent.Atrialtachycardiawith
block may be conIused with atrial Ilutter. Atrial
tachycardiawithblockhasadistinctisoelectricbaseline
between P waves, atrial Ilutter does not (except
occasionallyinleadV
1
).Atrialtachycardiawithblockis
secondary to digitalis toxicity (item 71) in 75° and
organicheartdiseasein25°
• QRSmorphologyisusuallynarrowandresemblesQRS
morphology during sinus rhythm, but can be wide (iI
underlyingbundlebranchblockoraberrancy)
Note: Automatic atrial tachycardia and intraatrial
reentranttachycardiaaccountIor10°oISVTs.Carotid
sinusmassageproducesAVblockbutdoesnotterminate
the tachycardia. Nonsustained Iorm is common in
normals;thesustainedIormismorecommoninorganic
heartdisease.
16. Atrial tachycardia, multifocal
• Atrialrate~100perminute
• Pwaveswith3morphologies(eachoriginatingIroma
separateatrialIocus)
• VaryingPPandPRintervals
& P waves may be blocked (i.e., not Iollowed by a QRS
complex),ormaybeconductedwithanarroworwide(iI
underlying bundle branch block or aberrancy) QRS
complex.
Note:MultiIocalatrialtachycardiamaybeconIusedwith:
Sinus tachycardia with multiIocal APCs, which
demonstrates one dominant atrial pacemaker (i.e., the
sinusnode).Incontrast,inmultiIocalatrialtachycardia,
nodominantatrialpacemaker(i.e.,nodominantPwave
morphology)ispresent.
Atrial Iibrillation/Ilutter, in which there is lack oI an
isoelectric baseline. In contrast, multiIocal atrial
tachycardia demonstrates a distinct isoelectric baseline
andPwaves.
Note:Usuallyassociated withsomeIormoIlungdisease.
Etiologiesinclude:
COPD/pneumonia
Corpulmonale
Aminophyllinetherapy
Hypoxia
Organicheartdisease
HeartIailure
Post-op
Sepsis
Pulmonaryedema
17. Supraventricular tachycardia, paroxysmal
Withoutaberrancy Withaberrancy
• Regularrhythm
• Rate~100perminute
• PwavesnoteasilyidentiIied
• QRScomplexisusuallynarrow(butoccasionallywideiI
underlyingbundlebranchblockoraberrancy)
• OnsetandterminationoISVTissudden,andSVTdoes
notpersistthroughouttheentiretracing
• Retrogradeatrialactivitymaybepresent
Note:IIrateisapproximately150perminute,atrialIlutter
with2:1blockmaybepresent.LookIortypical“sawtooth”
IlutterwavesininIeriorleads(II,III,aVF)orV
1
;everyother
Ilutter wave may be buried in the QRS complex or ST
segment.
Note:ThereareseveraldiIIerenttypesoIsupraventricular
tachycardia,themajorityoIwhichcannotbediIIerentiatedby
surIace ECG alone and may require an EP study to
diIIerentiate:
ECG Criteria
—531—
AVnodalreentranttachycardiaaccountsIor60-70°oI
SVTs,andisusuallyinitiatedbyanAPC.Reentryoccurs
intheAVnode,withantegradeconductiondowntheslow
()AVnodalpathwayandretrogradeconductionupthe
Iast()AVnodalpathway.Carotidsinusmassageslows
andIrequentlyterminatestachycardia.Occurscommonly
innormals.
AtypicalAVnodalreentranttachycardiaaccountsIor5-
10° oI AV node reentry and 2-5° oI SVTs. Reentry
circuitinAVnodewithantegradeconductiondownthe
rapid()AVnodepathwayandretrogradeconductionup
the slow () pathway. May require an EP study to
diagnose. Carotid sinus massage may terminate the
tachycardia.
AVreentranttachycardia(orthrodromicSVT)occurswith
WolII-Parkinson-Whitesyndromeandconcealedbypass
tracts.Theheartsareusuallynormalintheseconditions,
but WPW can be associated with Ebstein’s anomaly,
cardiomyopathy,ormitralvalveprolapse.Usuallyashort
RPSVT,butcanhavealongRPintervalandbeincessant
iI there is slow retrograde (VA) conduction. OIten
initiatedbyAPCs,andusuallyterminatessuddenlywith
carotidsinusmassage.
IncontrasttotheotherIormsoIatrialtachycardia,sinus
nodereentranttachycardiamaniIestssinusPwavesandis
indistinguishable Irom sinus tachycardia. It involves
reentryinoraroundthesinusnode,andaccountsIor·5°
oISVTs.CarotidsinusmassageproducesAVblock,but
doesnotterminatethetachycardia.Occasionallyseenin
normals,butmorecommoninorganicheartdisease.
18. Atrial flutter
• Rapid regular atrial undulations (Ilutter or “F” waves)
usuallyatarateoI240-340perminute
Note: Flutter rate may be Iaster (~ 340 per minute) in
children and slower (200-240perminute) in the presence
oI antiarrhythmic drugs (Type IA, IC, III) and/or
massivelydilatedatria.
Note: ECG artiIact due to Parkinsonian tremor ( 4-6
cycles second) can simulate Ilutter waves. Look Ior
evidence oI distinct superimposed P waves preceding
eachQRScomplex,especiallyinleadsI,II,orV
1
.
• TypicalatrialIlutter morphology is usually present:
Leads II, III, AVF: Inverted F waves without an
isoelectric baseline (“picket-Ience” or “sawtooth”
appearance)
Lead V
1
: Small positive deIlections usually with a
distinctisoelectricbaseline
• Atypical atrial Ilutter can exhibit upright F waves in
inIeriorleads
• QRS complex may be normal or wide (iI underlying
bundle branch block oraberrancy)
• RateandregularityoIQRScomplexesdependontheAV
conductionsequence
AV conduction ratio (ratio oI Ilutter waves to QRS
complexes)isusuallyIixedandanevennumber(e.g.,
2:1,4:1),butmayvary.
Note: Odd-numbered conduction ratios oI 1:1 and
3:1 are uncommon. Atrial Ilutter with 1:1 AV
conduction oIten conducts aberrantly, resulting in a
wideQRStachycardiathatmaybeconIusedwithVT.
In untreated patients, 4:1 block suggests the
coexistenceoIAVconductiondisease.
Note: Carotid sinus massage typically causes a
transient increase in AV block and slowing oI the
ventricular response, without a change in the atrial
Ilutterrate.Attimes,noeIIectisseen.Whenatrial
Ilutterwith2:1AVblockissuspected,carotidsinus
massagemayunmaskIlutterwavesandhelpconIirm
thediagnosis.UpondiscontinuationoIcarotidsinus
massage, the usual response is return to the original
ventricularrate.
Completeheartblockwithajunctionalorventricular
escaperhythmmaybepresent.
Note:ConsiderdigitalistoxicityinthesettingoIatrialIlutter
withcompleteheartblockandjunctionaltachycardia.
Note:FlutterwavescandeIormQRS,STand/orTtomimic
intraventricularconductiondelayand/ormyocardialischemia.
Note:EtiologyisthesameasIoratrialIibrillation(item19).
19. Atrial fibrillation
• Pwavesabsent
• Atrial activity is totally irregular and represented by
Iibrillatory(I)wavesoIvaryingamplitude,durationand
morphology,causingrandomoscillationoIthebaseline
The Complete Guide to ECGs
—532—
Note:AtrialactivityisbestseeninleadsV
1
,V
2
,II,III,
aVF.
• Ventricularrhythmistypicallyirregularlyirregular
Note: II the RR interval is regular, second- or third-
degreeAVblockmaybepresent.
Note:DigitalistoxicitymayresultinregularizationoIthe
QRS due to complete heart block with junctional
tachycardia.
• Ventricular rate is usually 100-180 per minute in the
absenceoIdrugs
Note:IItheratewithoutAVblockingdrugsislessthan
100beatsperminute, AVconductionsystemdiseaseis
likelytobepresent.
Note: Consider Wolff-Parkinson-White syndrome
(item34)iItheventricularrateis~200perminuteand
the QRS is ~ 0.12 seconds. The 12-lead ECG during
sinusrhythmshouldshowashortPRintervalandawide
QRScomplexwithinitialslurring(deltawave):
Note:ConditionsmimickingatrialIibrillationinclude:
MultiIocalatrialtachycardia(item16)
AtrialIlutter(item18)
Note:Etiologiesinclude:
Mitralvalvedisease(especiallyiIsevere)
Organicheartdisease
Hypertension
Post-CABG(30°oIpatients)
MyocardialinIarction
Thyrotoxicosis
Pulmonaryembolism(item82)
Post-operativestate
Hypoxia
Chroniclungdisease(e.g.,emphysema)(item81)
AtrialseptaldeIect(items78,79)
WolII-Parkinson-Whitesyndrome(item34)
Sicksinussyndrome(tachy-bradysyndrome)(item89)
Alcohol(“Holidayheart”syndrome)
Normals(loneatrialIibrillation)
Junctional Rhythms
20. AV junctional premature complexes
• Premature QRS complex (relative to the basic RR
interval), which may be narrow or wide (iI underlying
bundlebranchblockoraberrancy)
• The P wave may precede the QRS by 0.11 seconds
(retrogradeatrialactivation,),maybeburiedintheQRS
(andnotvisualized),ormayIollowtheQRScomplex
• InvertedPwavesinleadsII,III,aVFanduprightPwaves
inleadsIandaVLarecommonlyseenduetothespread
oI atrial activation Irom near the AV node and in a
superior and leItward direction (i.e., away Irom the
inIeriorleadsandtowardtheleItlateralleads).
Note:Theatriummayoccasionallybeactivatedbythe
sinus node, resulting in a normal sinus P wave. This
occurs when retrograde block exists between the AV
junctional Iocus and the atrium, or the sinus node
activatestheatriumbeIoretheAVjunctionalimpulse.
Note:Aconstantcouplingintervalandnoncompensatory
pauseareusuallypresent.
Note:Seen innormalsandorganicheartdisease.
21. AV junctional escape complexes
• Typically narrow QRS complex beat(s) that Iollow the
previous conducted beat at a coupling interval
correspondingtoarateoI40-60perminute.QRSmaybe
wideiIunderlyingbundlebranchblock
• Pwavemayprecede(PR·0.11seconds),beburiedin,or
Iollow the QRS complex (similar to AV junctional
prematurecomplexes;item23)
• QRS morphology is similar to the sinus or
supraventricularimpulse
Note:QRScomplexoccursasasecondaryphenomenonin
responsetodecreasedsinusimpulseIormationorconduction,
ECG Criteria
—533—
high-degree AV block, or aIter a pause Iollowing
termination oI atrial tachycardia, atrial Ilutter, or atrial
Iibrillation.
22. AV junctional rhythm/tachycardia
• RRintervalisusuallyregular
• Heartrateisbetween40-60perminuteIorAVjunctional
rhythm,and~60perminuteIorjunctionaltachycardia
• P wave may proceed, be buried in, or Iollow the QRS
complex
• QRS is usually narrow, but may be wide iI underlying
bundlebranchblockoraberrancy
• Relationship between atrial and ventricular rates may
vary:
IIretrograde(VA)blockispresent,theatriaremainin
sinus rhythm and AV dissociation (item 35) will be
present
IIretrogradeatrialactivation(invertedPwavesinII,
III,aVF)occurs,aconstantQRS-Pintervalisusually
present
Note: Considerdigitalistoxicity(item71)iIatrialIibrillation
orIlutterwitharegularRRisseen—thisoItenrepresents
completeheartblockwithjunctionaltachycardia
Note:Junctionaltachycardiacanbeseeninacutemyocardial
inIarction (usually inIerior), myocarditis, digitalis toxicity,
andIollowingopenheartsurgery.
Ventricular Rhythms
23. Ventricular premature complexes
RequiresalloItheIollowing:
• Awide,notchedorslurredQRScomplexthatis:
PrematurerelativetothenormalRRinterval,and
NotprecededbyaPwave(exceptwhenlatecoupled
VPCs Iollow a sinus P wave; in this case, the PR
intervalisusually0.11seconds)
Note:QRSisalmostalways~0.12seconds,butVPCs
originatinghighintheinterventricularseptummayhave
arelativelynormalQRSduration.
Note:WhenaVPCoccursjustdistaltothesiteoIbundle
branch block and near the interventricular septum, the
QRSoItheVPCmaybenarrowerthan theQRSoIthe
bundlebranchblock.
Note:InitialdirectionoItheQRSisoItendiIIerentIrom
theQRSduringsinusrhythm.
• SecondaryST&Twavechangesinadirectionopposite
tothemajordeIlectionoItheQRS(i.e.,STdepression&
TwaveinversioninleadswithadominantRwave;ST
elevationanduprightTwaveinleadswithadominantS
waveorQScomplex)
• Coupling interval (relation oI VPCs to the preceding
QRS)maybeconstantorvariable
Note:Non-IixedcouplingshouldraisethesuspicionoI
ventricularparasystole(item24)
• MorphologyoIVPCsinanygivenleadmaybethesame
(uniIorm)ordiIIerent(multiIorm)
Note:AlthoughmultiIormVPCsareusuallymultiIocal
in origin (i.e., originate Irom more than one ventricular
Iocus), a single ventricular Iocus can produce VPCs oI
varyingmorphology.
Note:RetrogradecaptureoIatriamayoccur
Note:AIullcompensatorypause(PPintervalcontainingthe
VPCistwicethenormalPPinterval)isusuallyevident,but
this relationship may be altered iI sinus arrhythmia is also
present. A partial compensatory pause may Iollow a VPC
when ventriculoatrial conduction penetrates and resets the
sinus node. Less commonly, interpolated VPCs occur,
maniIesting as VPCs that are interposed between two
consecutive sinus beats without disrupting the basic sinus
rhythm;interpolatedVPCsresultinneitherapartialnoraIull
compensatorypause.
Note: Clues on the electrocardiogram suggestive oI a
ventricular (rather than atrial) origin oI an ectopic beat
includeaninitialQRSvectordiIIerentIromthesinusbeats,
QRSduration~0.12seconds,retrogradePwaves(causedby
retrograde conduction through the AV node), and the
presenceoIaIullcompensatorypause.
Note: Seen in normals and all causes oI ventricular
tachycardia(item25).
The Complete Guide to ECGs
—534—
24. Ventricular parasystole
• Frequentventricularprematurecomplexes(VPCs)usually
at a rate oI 30-50 per minute with the interectopic
intervals a multiple (2x, 3x, etc.) oI the shortest
interectopicintervalpresent(sincetheparasystolicIocus
Iires at a regular rate and inscribes a QRS complex
whenevertheventriclesarenotreIractory)
• ResultantVPCsvaryinrelationshiptotheprecedingsinus
orsupraventricularbeats(i.e.,nonIixedcoupling)
• VPCs typically maniIest uniIorm morphology (which
resemblesaVPC,item23)unlessIusionoccurs
Note: Fusion complexes, resulting Irom simultaneous
activation oI the ventricles by atrial and parasystolic
impulses,arecommonlyseenbutarenotrequiredIorthe
diagnosis.
Note:ExitblockIromaparasystolicIocusmayoccurand
result in absence oI a ventricular ectopic beat when it
wouldbeexpectedtooccur.
Note:VentricularparasystoleisduetothepresenceoIan
ectopic ventricular Iocus that activates the ventricles
independentoIthebasicsinusorsupraventricularrhythm,
andisprotectedIromdepolarizationbyanentranceblock.
TheventricularIocusIiresataregularcyclelengthand
results in a VPC that bears no constant relationship
(nonIixedcoupling)totheprevioussinusbeat.Incontrast
to ventricular parasystole, uniIorm VPC’s due to local
reentryinitiatedbypriorsinusactivationoItheventricle
showIixedcoupling.
Note: Think oI parasystole when you see ventricular
prematurecomplexeswithnonIixedcouplingandIusion
beats.
25. Ventricular tachycardia
• RapidsuccessionoIthreeormoreventricularpremature
complexes(item23)atarate~100perminute
• RRintervalisusuallyregularbutmaybeirregular
• AbruptonsetandterminationoIarrhythmiaisevident
• AVdissociation(item35)iscommon
• On occasion, retrograde atrial activation, Iusion
complexes,andventricularcapturecomplexesoccur
Note:Ventriculoatrial(VA)conductionmayoccurat1:1or
may maniIest variable, Iixed, or complete block;
ventriculoatrialWenckebachmayalsooccur.
Note: In the setting oI a wide QRS tachycardia, certain
Iindings may help distinguish ventricular tachycardia Irom
supraventriculartachycardiawithaberrancy(Table).
Note:Rarely,VTcanpresentasanarrowQRStachycardia.
Note: Bidirectional VT is a rare type oI VT in which the
QRScomplexesinanygivenleadalternateinpolarity.Itis
mostoItencausedbydigitalistoxicity.
Note:Seenin:
Organicheartdisease
Hypokalemia/hyperkalemia(items74,75)
Hypoxia/acidosis
Drugs(digitalistoxicity,antiarrhythmics,phenothiazines,
tricyclics,caIIeine,alcohol,nicotine)
Mitralvalveprolapse
Occasionallyinnormals
Table. Origin of Wide QRS Tachycardia
Favors VT Favors SVT with
Aberrancy
QRSmorphology SimilartoVPCs Similartosinusrhythm
orAPCswithaberrancy
InitiationoI
tachycardia
VPCs APCs
AVdissociation
present
Yes No
CaptureorIusion
complexespresent
Yes No
QRSdurationwhen
QRSisnarrow
duringsinus
rhythm
RBBBmorphology(~
0.14seconds);LBBB
morphology(~0.16
seconds)
QRSdurationgenerally
·0.14seconds
QRSdeIlectionin
precordialleads
Concordant(all
positiveornegative)
Discordant(some
positive;somenegative)
QRSaxis LeItornorthwest —
RSR’inleadV
1
RwavetallerthanR’ R’tallerthanRwave
ECG Criteria
—535—
26. Accelerated idioventricular rhythm
• Regularorslightlyirregularventricular(widecomplex)
rhythm
• RateoI60-110perminute
• QRSmorphologysimilartoVPCs(item23)
• AVdissociation(item35),ventricularcapturecomplexes,
andIusionbeatsarecommonbecauseoIthecompetition
betweenthenormalsinusandectopicventricularrhythms.
Note: Unlike ventricular tachycardia, AIVR is not
associatedwithanadverseprognosis.
Note:Seenin:
Myocardialischemia
FollowingcoronaryreperIusion
Digitalistoxicity(item71)
Occasionallyinnormals
27. Ventricular escape complexes or rhythm
• Single beat or regular or slightly irregular ventricular
rhythm
• RateoI30-40perminute(canbe20-50permin)
• QRSmorphologysimilartoVPCs(item23)
Note:QRSescapecomplex/rhythmoccursasasecondary
phenomenon in response to decreased sinus impulse
Iormationorconduction(e.g.,highvagaltone),high-degree
AVblock,oraIterthepauseIollowingterminationoIatrial
tachycardia,atrialIlutter,oratrialIibrillation.
28. Ventricular fibrillation
• An extremely rapid and irregular ventricular rhythm
demonstrating:
ChaoticandirregulardeIlectionsoIvaryingamplitude
andcontour
AbsenceoIdistinctPwaves,QRScomplexes,andT
waves
Note: A lethal arrhythmia that can nearly always be
converted into a stable rhythm when deIibrillation occurs
within the Iirst minute. SuccessIul cardioversion occurs in
only25°whendelayedaslittleas4-5minutes.
AV Conduction Abnormalities
29. AV block, 1°
• PRinterval0.20seconds(usually0.21-0.40secondsbut
maybeaslongas0.80seconds)
• EachPwaveisIollowedbyaQRScomplex
Note:ThePRintervalrepresentsthetimeIromtheonsetoI
atrialdepolarizationtotheonsetoIventricularrepolarization
(i.e., conduction time Irom the atrium AV node His
bundle Purkinjesystemventricles).ItdoesnotreIlect
conduction Irom the sinus node to the atrial tissue.
ThereIore, a prolonged PR interval with a narrow QRS
complexidentiIiesthesiteoIblockintheAVnode.IIthe
QRSiswide,conductiondelayorblocktypicallyoccursin
theHis-Purkinjesystem(althoughblockintheAVnodecan
maniIestasaprolongedPRandwideQRSiIbundlebranch
blockorrate-dependantaberrancyispresent).
Note:Etiologiesinclude:
Normals
Athletes
Highvagaltone
Drugs (digitalis, quinidine, procainamide, Ilecainide,
propaIenone,amiodarone,sotalol,popranolol,verapamil)
AcuterheumaticIever
Myocarditis
Congenital heart disease (atrial septal deIect, patent
ductusarteriosus)
The Complete Guide to ECGs
—536—
30. AV block, 2° - Mobitz Type I (Wenckebach)
• Progressive prolongation oI the PR interval and
progressiveshorteningoItheRRintervaluntilaPwave
isblocked
Note: The progressive shortening oI the RR interval is
due to a decrease in the beat-to-beat increment oI PR
prolongation.
• RRintervalcontainingthenonconductedPwaveisless
thantwoPPintervals
Note:ClassicalWenckebachperiodicitymaynotalwaysbe
evident, especially when sinus arrhythmia is present or an
abruptchangeinautonomictoneoccurs.
Note: In Type I block with high conduction ratios (i.e.,
inIrequentpauses),thePRintervaloIthebeatsimmediately
precedingtheblockedPwave may beequaltoeachother,
suggesting Type II block. In these situations, it is best to
compare the PR intervals immediately beIore and aIter the
blockedPwave;diIIerencesinthePRintervalssuggestType
I block, whereas a constant PR interval suggests Type II
block.
Note:MobitzTypeIresultsin“group”or“patternbeating”
duetothepresenceoInonconductedPwaves.Othercauses
oIgroupbeatinginclude:
BlockedAPCs
TypeIIsecond-degreeAVblock(item31)
Concealed His-bundle depolarizations: Premature His
depolarizations render the AV node reIractory to
subsequentsinusbeats,resultinginblockedPwavesand
pseudo-AVblock.
Note: Type I block usually occurs at the level oI the AV
node, resulting in a narrow QRS complex. In contrast,
Mobitz Type II block usually occurs within or below the
bundleoIHis,andisassociatedwithawideQRScomplexin
80°oIcases.
Note:Etiologiesinclude:
Normals
Athletes
Drugs(digitalis,-blocker,calciumblockers,clonidine,
-methyldopa,Ilecainide,sotalol,amiodaroneencainide,
propaIenone,lithium)
MyocardialinIarction(especiallyinIerior)
AcuterheumaticIever
Myocarditis
31. AV block, 2° - Mobitz Type II
• Regular sinus or atrial rhythm with intermittent
nonconducted P waves and no evidence Ior atrial
prematurity
• PRintervalintheconductedbeatsisconstant
• RRintervalcontainingthenonconductedPwaveisequal
totwoPPintervals
Note:TypeIIsecond-degreeAVblockusuallyoccurswithin
orbelowthebundleoIHis;theQRSiswidein80°oIcases.
Note:2:1AVblockcanbeMobitzTypeIorII(Table).
Note:InTypeIblockwithhighconductionrates(e.g.,10:9
conduction), the PR interval oI the beats immediately
precedingtheblockedPwavemaybeequal,suggestingType
II block. In these situations, it is best to compare the PR
interval immediately beIore and aIter the blocked P wave;
diIIerencesinthePRintervalsuggestTypeIblock,whereas
aconstantPRintervalisevidenceIorTypeIIblock,whichis
almostalwaysduetoorganicheartdisease.
Table. Features Suggesting the Mechanism of 2:1 AV Block
Mechanism
Feature Mobitz Type I Mobitz Type II
QRSduration Narrow Wide
Responsetomaneuvers
thatincreaseheartrate&
AVconduction(e.g.,
atropine,exercise)
Blockimproves Blockworsens
Responsetomaneuvers
thatreduceheartrate&
AVconduction(e.g.,
carotidsinusmassage)
Blockworsens Blockimproves
DevelopsduringacuteMI InIeriorMI AnteriorMI
Other MobitzIon
anotherpartoI
ECG
HistoryoI
syncope
ECG Criteria
—537—
32. AV block, 2:1
• RegularsinusoratrialrhythmwithtwoPwavesIoreach
QRScomplex(i.e.,everyotherPwaveisnonconducted)
Note:CanbeMobitzTypeIorIIsecond-degreeAVblock
(seeTableonpreviouspage).
33. AV block, 3°
• Atrial impulses consistently Iail to reach the ventricles,
resulting in atrial and ventricular rhythms that are
independentoIeachother
• PRintervalvaries
• PPandRRintervalsareconstant
• AtrialrateisusuallyIasterthanventricularrate
• Ventricular rhythm is maintained by a junctional or
idioventricularescaperhythmoraventricularpacemaker
Note:ThePwavemayprecede,beburiedwithin(andnot
visualized),orIollowtheQRStodeIormtheSTsegmentor
Twave.
Note: Ventriculophasic sinus arrhythmia—PP interval
containing a QRS complex is shorter than the PP interval
withoutaQRScomplex—ispresentin30-50°
Note:Completeheartblockispresentwhentheatrialrate
is Iaster than the ventricular escape rate (identiIied by the
presenceoInonconductedPwaveswhentheAVnodeand
ventriclearenotreIractory).Incontrast,AVdissociationis
usuallypresentiItheatrialrateisslowerthantheventricular
rate.
Note:CausesoIcompleteheartblockinclude:
MYOCARDIAL INFARCTION:5-15°oIacutemyocardial
inIarctionsarecomplicatedbycompleteheartblock:In
inIeriorMI,completeheartblockisusuallyprecededby
Iirst-degreeAVblockorTypeIsecond-degreeAVblock,
usually occurs at the level oI the AV node, is typically
transient (· 1 week), and is usually associated with a
stablejunctionalescaperhythm(narrowQRS;rate40
perminute).InanteriorMI,completeheartblockoccurs
as a result oI extensive damage to the leIt ventricle, is
typicallyprecededbyTypeIIsecond-degreeAVblockor
biIascicularblock,andisassociatedwithmortalityrates
as high as 70° (due to pump Iailure rather than heart
blockperse)
DEGENERATIVE DISEASES oI the conduction system
(Lev’sdisease,Lenegre’sdisease)
INFILTRATIVE DISEASES oI the myocardium (e.g.,
amyloid,sarcoid)
DIGITALIS TOXICITY:OneoIthemostcommoncausesoI
reversiblecompleteAVblock;usuallyassociatedwitha
junctionalescaperhythm(narrowQRS),whichis oIten
accelerated
ENDOCARDITIS: InIlammationandedemaoItheseptum
andperi-AVnodaltissuesmaycauseconductionIailure
and complete heart block; PR prolongation usually
precedesthisevent
ADVANCED HYPERKALEMIA (death is usually Irom
ventriculartachyarrhythmias)
LYME DISEASE: Caused by a tick-borne spirochete
(Borrelia burgdorIeri), this disorder begins with a
characteristic skin rash (erythema chronicum migrans),
andmaybeIollowedinsubsequentweekstomonthsby
joint, cardiac and neurological involvement. Cardiac
involvementincludesAVblockthatpartialorcomplete,
usuallyoccursattheleveloItheAVnode,andmaybe
accompaniedbysyncope
OTHERS: Myocardial contusion, acute rheumatic Iever,
aorticvalvedisease
34. Wolff-Parkinson-White pattern
Sinus rhythmmmmmmmmmmmAtrial fibrillation
• NormalPwaveaxisandmorphology
• PRinterval·0.12seconds(rarely~0.12seconds)
Note: AV conduction over the accessory pathway
(BundleoIKent)bypassestheAVnode(andAVnodal
conduction delay), resulting in pre-excitation oI the
ventriclesandashortPRinterval
• Initial slurring oI the QRS (delta wave), resulting in an
abnormallywideQRS(~0.12seconds)
Note:TheQRSdurationis0.10secondsin30°.In
thesecases,theventriclesaredepolarizedalmostentirely
The Complete Guide to ECGs
—538—
by the normal AV conduction system, with minimal
contribution Irom antegrade conduction along the
accessorypathway.
Note: The widened QRS complexes represent Iusion
between electrical waveIronts conducted down the
accessory pathway (delta wave) and the AV node.
DiIIering degrees oI pre-excitation (Iusion) may be
present,resultinginvariabilityinthedeltawaveandQRS
duration.
• SecondaryST-Twavechanges(oppositeindirectionto
maindeIlectionoIQRS)
Note:ThePJinterval(beginningoIPwavetotheJpoint
(i.e.,endoIQRScomplex)isconstantand0.26seconds.
ThisisduetoaninverserelationshipbetweenthePRinterval
and QRS duration — iI the PR interval shortens, the QRS
widens;iIthePRintervallengthens,theQRSnarrows.
Note: Think WPW when atrial Iibrillation or Ilutter is
associatedwithaQRSthatvariesinwidth(generallywide)
andhasarate~200perminute
Note: Atrial Iibrillation can conduct extremelyrapidly,
resulting in aberrant conduction and an irregular wide
complex tachycardia, which resembles VT and can
degenerateintoVF.
OVERVIEW: WolII-Parkinson-White syndrome (WPW) is
characterized by the presence oI an abnormal muscular
network oI specialized conduction tissue that connects the
atriumtotheventricleandbypassesconductionthroughthe
AVnode.ItisIoundin0.2-0.4°oItheoverallpopulation
andismorecommoninmalesandyoungerpatients.Most
patients with WPW do not have structural heart disease,
although there is an increased prevalence oI this disorder
among patients with Epstein’s anomaly (downward
displacementoIthetricuspidvalveintotherightventricledue
to anomalous attachment oI the tricuspid leaIlets),
hypertrophic cardiomyopathy, mitral valve prolapse, and
dilatedcardiomyopathy.TwotypesoIaccessorypathways
(AP)exist:InmanifestAP,antegradeconductionoccursover
theAPandresultsinpre-excitationonbaselineECG(which
may be intermittent). In concealed AP, antegrade
conduction occurs via the AV node and retrograde
conduction occurs over the AP, so pre-excitation is not
evidentonthebaselineECG.Approximately50°oIpatients
withWPWmaniIesttachyarrhythmias,oIwhich80°isAV
reentrytachycardia,15°isatrialIibrillation,and5°isatrial
Ilutter. Asymptomatic individuals have an excellent
prognosis. For patients with recurrent tachycardias, the
overallprognosisisgood,butinrareinstancessuddendeath
may occur. The presence oI delta waves and secondary
repolarization abnormalities can lead to a Ialse positive or
IalsenegativediagnosesoIventricularhypertrophy,bundle
branchblock,oracutemyocardialinIarction.ThepolarityoI
the delta waves can be used to predict the location oI the
bypasstract.
35. AV dissociation
• Atrial and ventricular rhythms are independent oI each
other
• Ventricularrateisusuallyatrialrate
Note:AVdissociationisasecondaryphenomenonresulting
IromsomeotherdisturbanceoIcardiacrhythm.
• AVdissociationmayinvolve:
AventricularratethatisIasterthanthenormalatrial
ratebecauseoIaccelerationoIasubsidiarypacemaker
(e.g.,junctionalorventriculartachycardia,myocardial
ischemia,digitalistoxicity,post-operativestate)
AventricularratethatisIasterthanthenormalatrial
rate because oI slowing oI the atrial rate (sinus
bradycardia, sinus arrest, sinoatrial exit block, high
vagaltone,post-cardioversion,-blockers)belowthe
intrinsic rate oI a subsidiary AV junctional or
ventricularpacemaker
A ventricular rate that is slower than the atrial rate
becauseoIAVblock
Abnormalities of QRS Axis
36. Left axis deviation
• MeanQRSaxisbetween-30°and-90°
Note:Causesinclude:
LeItanteriorIascicularblock(iIaxis~–45°,item45)
InIeriorwallMI(items57,58)
LBBB(item47)
LVH(items40)
OstiumprimumASD(item79)
Chroniclungdisease(item81)
ECG Criteria
—539—
Hyperkalemia(item74)
37. Right axis deviation
• MeanQRSaxisbetween100°and270°
Note:Causesinclude:
RVH(item41)
Verticalheart
Chroniclungdisease(item81)
Pulmonaryembolus(item82)
LeItposteriorIascicularblock(item46)
LateralwallmyocardialinIarction(items55,56)
Dextrocardia(item80)
Leadreversal(item03)
OstiumsecundumASD(item78)
38. Electrical alternans
• Alternationintheamplitudeand/ordirectionoIP,QRS,
and/orTwaves
Note:Causesinclude:
PericardialeIIusion(item83)
Note:ElectricalalternansisduetoswingingoItheheart
in the pericardial Iluid during the cardiac cycle. Only
one-third oI patients with QRS alternans have a
pericardial eIIusion, and only 12° oI patients with
pericardial eIIusions have QRS alternans. II electrical
alternansinvolvestheentireP-QRS-T(“totalalternans”),
eIIusionwithtamponadeisoItenpresent(whichisalmost
alwaysassociatedwithsinustachycardia).
SevereheartIailure
Hypertension
Coronaryarterydisease
Rheumaticheartdisease
Supraventricularorventriculartachycardia
Deeprespirations
QRS Voltage Abnormalities
39. Low voltage
• AmplitudeoItheentireQRScomplex(R¹S)·10mmin
allprecordialleadsand·5mminalllimbleads
Note:Causesinclude:
Chroniclungdisease(item81)
PericardialeIIusion(item83)
Obesity
RestrictiveorinIiltrativecardiomyopathies
Coronary disease with extensive inIarction oI the leIt
ventricle
Myxedema(item87)
PleuraleIIusion
40. Left ventricular hypertrophy
VOLTAGE CRITERIA FOR LVH(sufficient for diagnosis
without repolarization abnormalities)
• Cornell Criteria (mostaccurate):
R wave in aVL + S wave in V
3
:
~28mminmales
~20mminIemales
• Other commonly used voltage-based criteria
PRECORDIAL LEADS(oneormore)
• RwaveinV
5
orV
6
¹SwaveinV
1
~35mmiIage~40years
~40mmiIage30-40years
~60mmiIage16-30years
• MaximumRwave¹Swaveinprecordialleads~
45mm
• RwaveinV
5
~26mm
• RwaveinV
6
~20mm
LIMB LEADS(oneormore)
• RwaveinleadI¹SwaveinleadII26mm
The Complete Guide to ECGs
—540—
• RwaveinleadI14mm
• SwaveinaVR15mm
• RwaveinaVL12mm(ahighlyspeciIicIinding,
exceptwhenassociatedwithleItanteriorIascicular
block)
• RwaveinaVF21mm
Note:TheamplitudeoItheQRS(andsensitivityIorthe
diagnosisoILVHbyvoltagecriteria)isoItendecreased
by conditions that increase the amount oI body tissue
(obesity),air(COPD,pneumothorax),Iluid(pericardialor
pluraleIIusion),orIibroustissue(coronaryarterydisease,
sarcoidoramyloidoItheheart)betweenthemyocardium
andECGelectrodes.SevereRVHcanalsounderestimate
theECGdiagnosisoILVHbycancelingprominentQRS
IorcesIromthethickenedLV.LeItbundlebranchblock
mayalsoreduceQRSamplitudeaswell.Incontrast,thin
body habitus, leIt mastectomy, LBBB, WPW, and leIt
anteriorIascicularblockmayincreaseQRSamplitudein
the absence oI LVH, decreasing the speciIicity oI the
voltagecriteria.
• NON-VOLTAGE RELATED CHANGES(oItenpresentbutnot
requiredIorthediagnosisoILVH)
LeItatrialabnormality/enlargement(item06)
LeItaxisdeviation(item36)
NonspeciIic intraventricular conduction disturbance
(item49)
DelayedonsetoIintrinsicoiddeIlection(beginningoI
QRStopeakoIRwave~0.05seconds)
SmallorabsentRwavesinV
1
-V
3
(lowanteriorIorces)
AbsentQwavesinleadsI,V
5
,V
6
Abnormal Q waves in leads II, III, aVF (due to leIt
axisdeviation)
ProminentUwaves(item69)
R wave in V
6
~ V
5
, provided there are dominant R
wavesintheseleads
• REPOLARIZATION (ST AND/OR T WAVE)
ABNORMALITIES SUGGESTING LVH(seeitem67)
41. Right ventricular hypertrophy
• RightaxisdeviationwithmeanQRSaxis¹100°
• DominantRwave
R/SratioinV
1
orV
3R
~1,or R/SratioinV
5
orV
6

1
RwaveinV
1
7mm
RwaveinV
1
¹SwaveinV
5
orV
6
~10.5mm
rSRinV
1
withR~10mm
qRcomplexinV
1
• SecondaryST-Tchanges(downslopingSTdepression,T-
wave inversion) in right precordial leads (iI present, be
suretocodeitem67)
• Rightatrialabnormality/enlargement(item06)iscommon
• Onset oI intrinsicoid deIlection (beginning oI QRS to
peakoIRwave)inV
1
·0.05seconds
Note: For ECG Ieatures oI RVH in the setting oI chronic
lungdisease,seeitem81.
Note: Severe RVH can also underestimate the ECG
diagnosisoILVHbycancelingprominentQRSIorcesIrom
thethickenedLV.
Note:Conditionsthatcanpresentwithrightaxisdeviation
and/oradominantRwaveandpossiblymimicRVHinclude:
PosteriororinIeroposterolateralwallMI(items59,60).
When a tall R wave is present in lead V
1
, other ECG
Iindingscanhelpdistinguishrightventricularhypertrophy
(RVH)IromposteriorMI:TwaveinversionsinV
1
V
2
and
rightaxisdeviationIavorsthediagnosisoIRVH,while
inIerior Q waves suggestive oI inIerior MI Iavors the
diagnosisoIposteriorMI.
Rightbundlebranchblock(items43,44)
WolII-Parkinson-Whitesyndrome(typeA)(item34)
Dextrocardia(item80)
LeItposteriorIascicularblock(item46)
Normalvariant(especiallyinchildren)
42. Combined ventricular hypertrophy
SuggestedbyanyoItheIollowing:
• ECGmeetsoneormorediagnosticcriteriaIorLVH(item
40)andRVH(item41)
• PrecordialleadsshowLVHbutQRSaxisis~90°
• LVHplus:
Rwave~QwaveinaVR,and
Swave~RwaveinV
5,
and
TwaveinversioninV
1
• Largeamplitude,equiphasic®÷S)complexesinV
3
and
V
4
(Kutz-Wachtelphenomenon)
• Rightatrialabnormality/enlargement(item05)withLVH
pattern(item40)inprecordialleads
ECG Criteria
—541—
Intraventricular Conduction Abnormalities
43. RBBB, complete
• ProlongedQRSduration(0.12seconds)
• SecondaryRwave(R)inleadsV
1
andV
2
(rsR’orrSR’)
withRusuallytallerthantheinitialRwave
• DelayedonsetoIintrinsicoiddeIlection(beginning
oI QRS to peak oI R wave ~ 0.05 seconds) in V
1
andV
2
• Secondary ST & T-wave changes (T wave inversion;
downslopingSTsegmentmayormaynotbepresent)in
leadsV
1
andV
2
• WideslurredSwaveinleadsI,V
5
,andV
6
Note:InRBBB,meanQRSaxisisdeterminedbytheinitial
unblocked0.06-0.08secondsoIQRS,andshouldbenormal
unlessleItanteriorIascicularblock(item45)orleItposterior
Iascicularblock(item46)ispresent.
Note:RBBBdoesnotinterIerewiththeECGdiagnosisoI
ventricularhypertrophyorQ-waveMI.
Note:Canbeseenin:
Occasionally in normal adults (incidence 2/1000)
without underlying structural heart disease (unlike
LBBB). These patients have essentially the same
prognosis as the general population. However, among
patientswithcoronaryarterydisease,RBBBisassociated
witha2-Ioldincreaseinmorality(comparedtopatients
withcoronarydiseasebutwithoutbundlebranchblock).
Hypertensiveheartdisease
Myocarditis
Cardiomyopathy
Rheumaticheartdisease
Corpulmonale(acuteorchronic)
DegenerativediseaseoItheconductionsystem(Lenegre’s
disease) or sclerosis oI the cardiac skeleton (Lev’s
disease)
Ebstein’sanomaly
44. RBBB, incomplete
• RBBB morphology (rSR in V
1
; item 43) with a QRS
durationbetween0.09and0.12seconds
Note:OthercausesoIRSR’pattern·0.12secondsinlead
V
1
include:
Normalvariant(presentin2°oIhealthyadults)(item
02)
Rightventricularhypertrophy(item41)
PosteriorwallMI(items59,60)
Incorrectleadplacement(electrodeIorleadV
1
placedin
3
rd
insteadoI4
th
intercostalspace)(item03)
SkeletaldeIormities(e.g.,pectusexcavatum)
AtrialseptaldeIect(items78,79)
45. Left anterior fascicular block
• LeItaxisdeviationwithmeanQRSaxisbetween–45°and
–90°(item36)
• qRcomplex(oranRwave)inleadsIandaVL
• rScomplexinleadIII
• Normal or slightly prolonged QRS duration (0.08-0.10
seconds)
• NootherIactorsresponsibleIorleItaxisdeviation:
LVH(items40)
InIeriorwallMI(items57,58)
Emphysema(chroniclungdisease)(item81)
LeItbundlebranchblock(item47)
OstiumprimumatrialseptaldeIect(item79)
Severehyperkalemia(item74)
Note:LAFBmayresultinaIalse-positivediagnosisoILVH
basedonvoltagecriteriainleadsIoraVL.
Note:PoorRwaveprogressioniscommon.
Note:LeItanteriorIascicularblockcanmaskthepresence
oIinIeriorwallMI.
Note:WhenQScomplexesarepresentintheinIeriorleads,
inIeriorMIandLAFBmaybothbepresent,butinIeriorMI
aloneshouldbecoded.
Note: The anterior Iascicle oI the leIt bundle branch
suppliesthePurkinjeIiberstotheanteriorandlateralwallsoI
theleItventricle.
Note:Seeninorganicheartdisease,congenitalheartdisease,
andrarelyinnormals.
The Complete Guide to ECGs
—542—
46. Left posterior fascicular block
• RightaxisdeviationwithmeanQRSaxisbetween¹100°
and¹180°(item37)
• Normal or slightly prolonged QRS duration (0.08-0.10
seconds)
• NootherIactorsresponsibleIorrightaxisdeviation:
RVH(item41)
Verticalheart
Emphysema(chroniclungdisease)(item81)
Pulmonaryembolism(item82)
LateralwallMI(items55,56)
Dextrocardia(item80)
Leadreversal(item03)
WolII-Parkinson-White(item34)
Note:LeItposteriorIascicularblockcanmaskthepresence
oIlateralwallMI.
Note: Compared to the leIt anterior Iascicle, the leIt
posterior Iascicle is shorter, thicker, and receives blood
supplyIrombothleItandrightcoronaryarteries.IsolatedleIt
posteriorIascicularblock(LPFB)ismuchlessprevalentthan
leItbundlebranchblock,rightbundlebranchblock,orleIt
anteriorIascicularblock.
Note:CoronaryarterydiseaseisthemostcommoncauseoI
LPFB; when it develops during acute MI, multivessel
coronarydiseaseandextensiveinIarctionareusuallypresent,
andtheprognosisispoor.LPFBisrarelyseeninnormals.
47. LBBB, complete
• ProlongedQRSduration(0.12seconds)
• DelayedonsetoIintrinsicoiddeIlection(i.e.,beginningoI
QRStopeakoIRwave~0.05seconds)inleadsI,V
5
,V
6
• Broad monophasic R waves in leads I, V
5
, V
6
that are
usuallynotchedorslurred
• SecondaryST&Twavechangesoppositeindirectionto
themajorQRSdeIlection(i.e.,STdepression&Twave
inversion in leads I, V
5
, V
6
; ST elevation & upright T
waveinleadsV
1
andV
2
)
• rSorQScomplexinrightprecordialleads
Note:LeItaxisdeviationmaybepresent(item36).
Note:LBBBinterIereswithdeterminationoIQRSaxisand
identiIication oI ventricular hypertrophy and acute MI.
AlthoughtheIormaldiagnosisoILVHshouldnotbemadein
thesettingLBBB,echocardiographicandpathologicalstudies
show that ~ 80° oI patients with LBBB have abnormally
increasedLVmass
Note:Seenin:
LVH(item40)
MyocardialinIarction
Organicheartdisease
Congenitalheartdisease
Degenerativeconductionsystemdisease
Rarelyinnormals
48. LBBB, incomplete
• LBBBmorphology(item47)withaQRSduration0.09
secondsand·0.12seconds
49. Nonspecific intraventricular conduction disturbance
• QRS0.11secondsindurationbutmorphologydoesnot
meetcriteriaIorLBBB(item47)orRBBB(item43),or
• Abnormal notching oI the QRS complex without
prolongation
Note:NonspeciIicIVCDmaybeseenwith:
Antiarrhythmicdrugtoxicity(especiallyTypeIAandIC
agents)(item73)
Hyperkalemia(item74)
LVH(item40)
WolII-Parkinson-White(item34)
Hypothermia(item88)
Severemetabolicdisturbances
50. Functional (rate-related) aberrant intraventricular
conduction
ECG Criteria
—543—
• Wide (~ 0.12 seconds) QRS complex rhythm due to
underlying supraventricular arrhythmia, such as atrial
Iibrillation,atrialIlutter,otherSVTs.
Note: Since the right bundle has a longer reIractory
periodthantheleItbundle,aberrantconductionusually
occursdowntheleItbundle,resultinginQRSmorphology
withRBBBpattern.
Note: May resemble VT (see item 25 Ior criteria to
distinguishbetweenSVTwithaberrancyvs.VT).
Note:Returntonormalintraventricularconductionmay
beaccompaniedbyTwaveabnormalities.
Q Wave Myocardial Infarctions
MYOCARDIAL ISCHEMIA VS. INJURY VS. INFARCTION
Ischemia:STsegmentdepression:Twavesusuallyinverted;
Qwavesabsent
Injury:STsegmentelevation;Qwavesabsent
InIarction: Abnormal Q waves; ST segment elevation or
depression; T waves inverted, normal, or upright &
symmetricallypeaked
Note: Prior MI may be present without Q waves in: (1)
AnteriorMI:MayonlyseelowanteriorRwaveIorceswith
decreasing R wave progression in leads V
2
-V
5
; and (2)
PosteriorMI:DominantRwaveinV
1
and/orV
2
,usuallyin
the setting oI inIerior MI. ST depression is oIten present
duringacuteinIarctioninleadsV
1
-V
3
SIGNIFICANT ST ELEVATION
New ST segment elevation at the J point (where QRS
complexmeetstheSTsegment)in2contiguousleads
STelevation2mminleadsV
1
,V
2
,orV
3
STelevation1mminotherleads
Usually with upwardly convex (“out-pouching”)
conIiguration
Canpersist48hoursto4weeksaIterMI
Note:PersistentSTelevationbeyond4weekssuggests
thepresenceoIaventricularaneurysm
T WAVE INVERSIONtypicallybeginswhiletheSTsegmentsare
still elevated (in contrast to pericarditis) and may persist
indeIinitely
Note: Acute inIarction can occur without signiIicant ST
segmentelevationordepression:upto40°oIpatientswith
acuteocclusionoItheleItcircumIlexcoronaryarteryand10-
15°oIpatientswithRCAorLADocclusionsmaynothave
signiIicantECGchanges.
ABNORMAL Q WAVES
AnyQwaveinleadsV
1
-V
3
Qwave0.03secondsinleadsI,II,aVL,aVF,V
4
,V
5
,or
V
6
Qwavechangesmustbepresentinatleast2contiguous
leads,andmustbe1mmindepth
Note:ThepresenceoIaQwavecannotbeusedtoreliably
distinguishtransmuralIromsubendocardialMI.
Note:AbnormalQwavesregressordisappearovermonths
toyearsinupto20°oIpatientswithQ-waveMI.
AGE OF INFARCT CAN BE APPROXIMATED FROM THE ECG:
Age Recent or Acute: The repolarization abnormalities
associated with acute myocardial inIarction typically
evolve in a relatively predictable Iashion. Usually, the
earliest Iinding is marked peaking oI the T waves
(“hyperacuteTwaves”)intheregionoItheinIarct;these
are oIten missed since they occur very early (· 15
minutes)inthecourseoItheacuteeventandaretransient.
II transmural ischemia persists Ior more than a Iew
minutes, the peaked T waves evolve into ST segment
elevation, which should be 1 mm in height to be
considered signiIicant. The ST segment elevation oI
myocardial inIarction is usually upwardly convex (in
contrast to acute pericarditis or normal variant early
repolarization, in which the ST elevation is usually
upwardlyconcave).AstheacuteinIarctioncontinuesto
evolve, the ST segment elevation decreases and the T
waves begin to invert. The T waves usually become
progressively deeper as the ST segment elevation
subsides.AbnormalQwavesdevelopwithintheIirstIew
hourstodaysaIteraninIarction.
• Acute MI: Abnormal Q waves, ST elevation
(associated ST depression is sometimes present in
noninIarctleads).Hyperacute(tall,peaked)Twaves
areseenveryearly(transient)
• Recent MI: Abnormal Q waves, isoelectric ST
segments,ischemic(usuallyinverted)Twaves
Age Indeterminate or Old: Abnormal Q waves,
isoelectricSTsegments,nonspeciIicornormalTwaves
Note:Exception:MImaybepresentwithoutQwavesin:
(1) Anterior MI: May only see low anterior R wave
IorceswithdecreasingRwaveprogressioninleadsV
2
-V
5
;
and (2) Posterior MI: Dominant R wave and ST
depressioninleadsV
1
-V
3
PSEUDOINFARCTION PATTERN: See pages 17-18 Ior conditions
causing “pseudoinIarcts” (ECG pattern mimicking myocardial
inIarction).
DIAGNOSIS OF Q WAVE MI IN THE PRESENCE OF BUNDLE BRANCH
BLOCK
RBBB:DoesnotinterIerewiththediagnosisoIQwave
MI;QwavecriteriaapplyIorallinIarctions
The Complete Guide to ECGs
—544—
LBBB:DiIIiculttodiagnoseanyinIarctinthepresence
oILBBB.However,acuteinjuryissometimesapparent
51. Anterolateral MI (age recent or acute)
• AbnormalQwaveswithsigniIicantSTsegmentelevation
inleadsV
4
-V
6
52. Anterolateral MI (age indeterminate or old)
• AbnormalQwavesinleadsV
4
-V
6
withoutsigniIicantST
segmentelevation
53. Anterior anteroseptal MI (age recent or acute)
• AbnormalQwaveswithsigniIicantSTsegmentelevation
inatleast2consecutiveleadsbetweenV
1
-V
4
Note: The presence oI a Q wave in V
1
distinguishes
anteroseptalIromanteriorinIarction,althoughthedistinction
betweenthetwoinnotnecessaryIortestingpurposes.
Note:ManyECGtextsconsiderdecreasingRwavevoltage
IromV
2
-V
5
consistentwithageindeterminateanteriorMI,
evenintheabsenceoIabnormalQwaves.However,because
the board score sheet lists the various MIs under the
subheadingoI“Q-waveinIarction,”lossoIRwavevoltagein
the precordial leads in the absence oI abnormal Q waves
shouldnotbecodedasanMI.
54. Anterior or anteroseptal MI (age indeterminate or
old)
• AbnormalQwavesinatleast2consecutiveleadsbetween
V
1
-V
4
withoutsigniIicantSTsegmentelevation
55. Lateral MI (age recent or acute)
• AbnormalQwaveswithsigniIicantSTsegmentelevation
inleadsIandaVL
Note: An isolated Q wave in aVL does not qualiIy as a
lateralMI.
56. Lateral MI (age indeterminate or old)
• AbnormalQwavesinleadsIandaVLwithoutsigniIicant
STsegmentelevation
57. Inferior MI (age recent or acute)
• AbnormalQwaveswithsigniIicantSTsegmentelevation
inatleasttwooIleadsII,III,aVF
Note:AssociatedSTdepressionisusuallyevidentinleads
I,aVL,V
1
-V
3
.
58. Inferior infarct (age indeterminate or old)
• Abnormal Q waves in at least two oI leads II, III, aVF
withoutsigniIicantSTsegmentelevation
59. Posterior MI (age recent or acute)
• InitialRwave0.04 secondsinV
1
orV
2
withRwave
amplitudeSwaveamplitude(R/S~1)andsigniIicant
(usually2mm)STsegmentdepression
UprightTwavesareusuallyevidentinsameleadsas
dominantRwave
Note:TheposteriorwalloItheleItventriculardiIIersIrom
the anterior, inIerior, and lateral walls by not having ECG
leads directly overlying it. Instead oI Q waves and ST
elevation, acute posterior MI presents with mirror-image
changes in the anterior precordial leads (V
1
-V
3
), including
dominantRwaves(themirror-imageoIabnormalQwaves),
andhorizontalSTsegmentdepression(themirror-imageoI
STelevation).AcuteposteriorinIarctionisoItenassociated
with ECG changes oI acute inIerior or inIerolateral
myocardialinIarction,butmayoccurinisolation.
Note:RVH(item41),WPW(item34),andRBBB(item43)
mayinterIerewiththeECGdiagnosisoIposteriorMI.
60. Posterior MI (age indeterminate or old)
• Dominant R wave (R/S ~ 1) in leads V
1
or V
2
without
signiIicantSTsegmentdepression
Note:MustbedistinguishedIromother causesoIatallR
wave in leads V
1
or V
2
, including RVH, WolII-Parkinson-
White,RBBB,andincorrectelectrodeplacement.
Note: Evidence oI inIerior wall ischemia or inIarction is
oItenpresent
Repolarization Abnormalities
61. Normal variant, early repolarization
ECG Criteria
—545—
• Elevatedtake-oIIoISTsegmentatthejunctionbetween
theQRSandSTsegment(Jjunction)
• ConcaveupwardSTelevationendingwithasymmetrical
uprightTwave(oItenoIlargeamplitude)
Note:STelevationshouldbelessthan25°oItheheight
oItheTwaveinleadV
6
• DistinctnotchorslurondownstrokeoIRwave
• MostcommonlyinvolvesV
2
-V
5
;sometimesII,III,aVF
• NoreciprocalSTsegmentdepression
Note:SomedegreeoISTelevationispresentinthemajority
oI young healthy individuals, especially in the precordial
leads.
62. Normal variant, juvenile T waves
• PersistentlynegativeTwaves(usuallynotsymmetricalor
deep)inleadsV
1
-V
3
innormaladults
• TwavesstilluprightI,II,V
5
,V
6
Note: Juvenile T waves is a normal variant ECG Iinding
commonly seen in children, occasionally seen as a normal
variantinadultwomen,butonlyrarelyseeninadultmen.
63. Nonspecific ST and/or T wave abnormalities
• Slight(·1mm)STdepressionorelevation,and/or
• TwaveIlatorslightlyinverted
Note:NormalTwavesusually10°theheightoIRwave
Note:Canbeseenin:
Organicheartdisease
Drugs(e.g.,quinidine)
Electrolytedisorders(e.g.,hyperkalemia,hypokalemia)
Hyperventilation
Myxedema(item87)
Recentlargemeal
Stress
Pancreatitis
Pericarditis(item84)
CNSdisorders(item86)
LVH(item40)
RVH(item41)
Bundlebranchblock(items43,47)
Healthyadults(normalvariant)(item02)
Persistentjuvenilepattern:TwaveinversioninV
1
-V
3
in
youngadults
64. ST and/or T wave abnormalities suggesting
myocardial ischemia
• IschemicSTsegmentchanges:
Horizontal or downsloping ST segments with or
withoutTwaveinversion
Note:Flutterwavesorprominentatrialrepolarization
waves (as can be seen in leIt/right atrial enlargement,
pericarditis,atrialinIarction)candeIormtheSTsegment
andresultin“pseudodepression.”
• IschemicTwavechanges:
BiphasicTwaveswithorwithoutSTdepression
SymmetricalordeeplyinvertedTwaves;QTinterval
isoItenprolonged
Note:ReciprocalTwavechangesmaybeevident(e.g.,tall
upright T waves in inIerior leads with deeply inverted T
wavesinanteriorleads).
Note:Twavesmaybecomelessinvertedoruprightduring
acuteischemia(“pseudonormalization).
Note:ProminentUwaves(uprightorinverted)(item69)are
oItenpresent.
Note:TalluprightTwavesmayalsobeseenin:
Normalhealthyadults(item02)
Hyperkalemia(item74)
EarlymyocardialinIarction
LVH(item40)
CNSdisorders(item86)
Anemia
The Complete Guide to ECGs
—546—
65. ST and/or T wave abnormalities suggesting
myocardial injury
• Acute ST segment elevation 1 mm with upward
convexity (may be concave early) in the leads
representing the area oI jeopardized myocardium/acute
inIarction
• STandTwavechangesevolve:TwavesinvertbeIoreST
segmentsreturntobaseline
• Associated ST depression in the noninIarct leads is
common
• Acute posterior wall injury oIten has horizontal or
downslopingSTsegmentdepressionwithuprightTwaves
in V
1
and/or V
2
with prominent R wave in these same
leads
Note:Itisimportanttoconsidertheclinicalcontext,sinceST
segmentelevationsuggestingmyocardialinjurycanalsobe
seenin:
Acutepericarditis(item84)
Ventricularaneurysm
Earlyrepolarization(item61)
LVH(item40)
• Hyperkalemia(item74)
Bundlebranchblock(items43,47)
Myocarditis
Apicalhypertrophiccardiomyopathy(item85)
Centralnervoussystemdisease(item86)
Normals(STelevationupto3mmmaybeseeninleads
V
1
-V
3
)
66. ST and/or T wave abnormalities suggesting
electrolyte disturbances
• Anyabnormalitiessuggestinghyperkalemia,hypokalemia,
hypercalcemia,orhypocalcemia(seeitems74-77)
Note: Hypomagnesemia causes changes similar to
hypocalcemia(QTprolongation)
Note:RenalIailureoItenresultsinmultipleelectrolyte
derangements with a wide variety oI associated ECG
abnormalities
67. ST and/or T wave abnormalities secondary to
hypertrophy
• LVH:STsegmentandTwavedisplacementoppositeto
themajorQRSdeIlection:
ST depression (upwardly concave) and T wave
inversion when the QRS is mainly positive (leads I,
V
5
,V
6
)
Subtle (· 1 mm) ST elevation and upright Twaves
whentheQRSismainlynegative(leadsV
1
,V
2
);with
moreextremevoltage,STelevationupto2-3mmcan
beseeninleadsV
1
-V
2
• RVH:STsegmentdepressionandTwaveinversionin
leadsV
1
-V
3
andsometimesinleadsII,III,aVF
68. Prolonged QT interval
• CorrectedQTinterval(QTc)0.44seconds,whereQTc
= QT when the heart rate is 60 BPM = QT interval
divided by the square root of the preceding RR interval
Note: BesuretomeasuretheQTintervalinaleadwitha
largeTwaveanddistincttermination.AlsolookIorthe
leadwiththelongestQT.
• EasiermethodtodetermineQTinterval:
Use0.40secondsasthenormalQTintervalIoraheart
rate oI 70. For every 10 BPM change in heart rate
above(orbelow)70,subtract(oradd)0.02seconds.
(Measuredvalueshouldbewithin+0.04secondsoI
thecalculatednormal.)Example:ForaheartrateoI
100BPM,thecalculatednormalQTinterval÷0.40
seconds–(3x0.02seconds)÷0.34+0.04seconds.
ForaheartrateoI50BPM,thecalculatednormalQT
interval÷0.40seconds¹(2x0.02seconds)÷0.44+
0.04seconds.
Ingeneral,thenormalQTintervalshouldbelessthan
50°oItheRRinterval
ECG Criteria
—547—
Note:TheQTintervalrepresentstheperiodoIventricular
electrical systole (i.e., the time required Ior ventricular
depolarizationandrepolarizationtooccur),variesinversely
withheartrate,andislongerwhileasleepthanwhileawake
(presumablyduetovagalhypertonia).
Note:ConditionsassociatedwithaprolongedQTinterval
include:
Drugs (quinidine, procainamide, disopyramide,
amiodarone,sotalol,doIetilide,azimilide,phenothiazines,
tricyclics,lithium)
Hypomagnesemia
Hypocalcemia(item77)
Markedbradyarrhythmias
Intracranialhemorrhage(item86)
Myocarditis
Mitralvalveprolapse
Myxedema(item87)
Hypothermia(item88)
Veryhighproteindiets
Romano-Wardsyndrome(congenital;normalhearing)
Jervell and Lange-Nielson syndrome (congenital;
deaIness)
69. Prominent U waves
• Amplitude1.5mm
Note:TheUwaveisnormally5-25°theheightoItheT
wave,andislargestinleadsV
2
andV
3
Note:Causesinclude:
Hypokalemia(item75)
Bradyarrhythmias
Hypothermia(item88)
LVH(item40)
Coronaryarterydisease
Drugs(digitalis,quinidine,amiodarone,isoproterenol)
Suggested Clinical Disorders
70. Digitalis effect
• SaggingSTsegmentdepressionwithupwardconcavity
• TwaveIlat,inverted,orbiphasic
• QTintervalshortened
• Uwaveamplitudeincreased
• PRintervallengthened
Note:STchangesarediIIiculttointerpretinthesettingoI
LVH,RVH,orbundlebranchblock.However,iItypical
saggingSTsegmentsarepresentandtheQTintervalis
shortened,considerdigitaliseIIect.
71. Digitalis toxicity
• DigitalistoxicitycancausealmostanytypeoIcardiac
dysrhythmiaorconductiondisturbanceexceptbundle
branchblock.Typicalabnormalitiesinclude:
Paroxysmalatrialtachycardiawithblock
AtrialIibrillationwithcompleteheartblock(regular
RRintervals)
Secondorthird-degreeAVblock
Completeheartblock(item33)withaccelerated
junctionalrhythm(item22)oraccelerated
idioventricularrhythm(items26)
Supraventriculartachycardiawithalternatingbundle
branchblock
Note:Digitalistoxicitymaybeexacerbatedbyhypokalemia,
hypomagnesemia,andhypercalcemia.
Note: Electrical cardioversion oI atrial Iibrillation is
contraindicated in the setting oI digitalis toxicity since
protracted asystole or ventricular Iibrillation can occur.
(Digitalislevelsshouldalwaysbecheckedpriortoelective
electricalcardioversion).
72. Antiarrhythmic drug effect
SuggestedbytheIollowing:
• MildprolongationoIQTinterval(item68)
• ProminentUwaves(oneoItheearliestIindings)(item69)
• NonspeciIicSTand/orTwaveabnormalities(item63)
• DecreaseinatrialIlutterrate
The Complete Guide to ECGs
—548—
73. Antiarrhythmic drug toxicity
SuggestedbytheIollowing:
• MarkedprolongationoIQTinterval(item68)
• Ventriculararrhythmiasincluding“TorsadedePointes”
(paroxysmsoIirregularventriculartachyarrhythmiaata
rateoI200-280BPMwithsinusoidalcyclesoIchanging
QRSamplitudeandpolarityinthesettingoIaprolonged
QTinterval)
• WideQRScomplex
• VariousdegreesoIAVblock
• Marked sinus bradycardia (item 09), sinus arrest (item
11),orsinoatrialexitblock(item12)
74. Hyperkalemia
ECGchangesdependonserumK
¹
levelandrapidityoIrise:
• K
¹
÷5.5-6.5mEq/L
Tall,peaked,narrowbasedTwaves
Note: Generally deIined as ~ 10 mm in precordial
leadsand~6mminlimbleads).Mayalsobeseenas
normalvariantorinacuteMI,LVH,orLBBB
QTintervalshortening
ReversibleleItanteriorIascicularblock(item45)or
leItposteriorIascicularblock(item46)
• K
¹
÷6.5-7.5mEq/L
First-degreeAVblock(item29)
FlatteningandwideningoIthePwave
QRSwidening
• K
¹
~7.5mEq/L
DisappearanceoIPwaves,whichmaybecausedby:
• Sinusarrest(item11),or
• “Sinoventricular conduction” (sinus impulses
conducted to the ventricles via specialized atrial
Iibers withoutatrialdepolarization)
LBBB (items 47, 48), RBBB (items 43, 44), or
markedly widened and diIIuse intraventricular
conductiondisturbance (item49)resemblingasine-
wavepattern
STsegmentelevation
Arrhythmias and conduction disturbances including
ventricular tachycardia (item 25), ventricular
Iibrillation(item28),idioventricularrhythm(item26,
27),asystole
75. Hypokalemia
SuggestedbytheIollowing:
• ProminentUwaves(item69)
• STsegmentdepressionandIlattenedTwaves
Note:TheST-TandUwavechangesoIhypokalemiaare
seen in approximately 80° oI patients with potassium
levels · 2.7 mEq/L, compared to 35° oI patients with
levelsoI2.7-3.0mEq/L,and10°oIpatientswithlevels
~3.0mEq/L.
• IncreasedamplitudeanddurationoIthePwave
• ProlongedQTsometimesseen
Note: II potassium replacement does not normalize the
QTinterval,suspecthypomagnesemia.
• Arrhythmias and conduction disturbances, including
paroxysmalatrialtachycardiawithblock,Iirst-degreeAV
block (item 29), Type I second-degree AV block (item
30), AV dissociation (item 35), VPCs (item 23),
ventricular tachycardia (item 25), and ventricular
Iibrillation(item28).
76. Hypercalcemia
• QTc shortening (usually due to shortening oI the ST
segment)
• MayseePRprolongation
Note:LittleiIanyeIIectonP,QRS,orTwave.
77. Hypocalcemia
ECG Criteria
—549—
• Prolonged QTc (item 68) (earliest and most common
Iinding)duetoSTsegmentprolongationwithoutchanging
thedurationoItheTwave(seenonlywithhypocalcemia
orhypothermia)
• OccasionalIlattening,peaking,orinversionoITwaves
78. Atrial septal defect, secundum
SuggestedbytheIollowing:
• TypicalRSRorrSRcomplexinV
1
withaQRSduration
·0.11seconds(incompleteRBBB,item44)
• Right axis deviation (item 37) + right ventricular
hypertrophy(item41)
• Rightatrialabnormality/enlargement(item05)in30°
• First-degreeAVblock(item29)in·20°
Note: Ostium secundum ASDs represent 70-80° oI all
ASDs, and are due to deIicient tissue in the region oI the
Iossaovalis.
79. Atrial septal defect, primum
SuggestedbytheIollowing:
• RSR’complexinV
1
• IncompleteRBBB(item44)
• LeIt axis deviation (item 36) (in contrast to right axis
deviationinostiumsecundumASD)
• First-degreeAVblock(item29)in15-40°
• Advancedcaseshavecombinedventricularhypertrophy
(item42)
Note:OstiumprimumASDsrepresent15-20°oIallASDs,
and are due to deIicient tissue in the lower portion oI the
septum. These ASDs are usually large and may be
accompanied by anomalous pulmonary venous drainage.
PrimumASDsareoItenassociatedwithacleItanteriormitral
valveleaIlet,mitralregurgitation,andDown’ssyndrome.
80. Dextrocardia, mirror image
SuggestedbytheIollowing:
• P-QRS-T in leads I and aVL are inverted or “upside
down”
Note:Dextrocardiaandleadreversal(item03)canboth
produceanupsidedownP-QRS-Tin leadsIandaVL.
To distinguish between these conditions, look at the R
wavepatterninV
1
-V
6
:
ReverseRwaveprogression(i.e.,decreasingRwave
amplitudeIormleadsV
1
-V
6
)suggestsdextrocardia
NormalRwaveprogressionsuggestsleadreversal
Note: In mirror-image dextrocardia, the most common
IormoIdextrocardia,theabdominalandthoracicviscera(in
additiontotheheart)aretransposedtothesideoppositetheir
usual locations (dextrocardia with “situs inversus”). This
IormoIdextrocardiaisgenerallynotassociatedwithsevere
congenitalcardiacabnormalities(otherthanthemalposition,
which does not aIIect cardiac Iunction). In isolated
dextrocardia,theheartisrotatedtotherightsideoIthechest
butothervisceraremainintheirusuallocations.ThistypeoI
dextrocardia is almost always associated with serious
congenital cardiac abnormalities, resulting in clinical
diIIicultiesininIancyorearlychildhood.
81. Chronic lung disease
• ECGIeaturessuggestiveoICOPDinclude:
Rightventricularhypertrophy(item41)
Rightaxisdeviation(item37)
Rightatrialabnormality/enlargement(item05)
PoorprecordialRwaveprogression
Lowvoltage(item39)
Pseudo-anteroseptal inIarct pattern (low anterior
Iorces)
The Complete Guide to ECGs
—550—
SwavesinleadsI,II,andIII(S
1
S
2
S
3
pattern)
• May also see sinus tachycardia (item 10), junctional
rhythm(item22),multiIocalatrialtachycardia(item16),
various degrees oI AV block, nonspeciIic IVCD (item
49),orbundlebranchblock(item43,44,47,48)
Note:RightventricularhypertrophyinthesettingoIchronic
lungdiseaseissuggestedby:
RightwardshiItoIQRS
TwaveinversioninV
1,
V
2
STdepressioninleadsII,III,aVF
TransientRBBB
RSRorQRcomplexinV
1
82. Acute cor pulmonale including pulmonary embolus
• ECGchange