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SIMPLIFYING ECG INTERPRETATION

Module 1:

DON ROBESPIERRE C. REYES, PTRP, MD, FPCP, FPCC Section of Cardiology, UST Hospital España, Manila

The Electrocardiogram
• is a graphic recording of the electrical potentials produced by the cardiac tissue  useful screening tool for a variety of cardiac abnormalities
 most commonly performed cardiac test

Arrhythmia Recognition

How is ECG performed? • The ECG is recorded by applying electrodes to various locations on the body surface and connecting them to a recording apparatus .

Clinical Values of ECG  Atrial and ventricular hypertrophy/enlargement  Myocardial ischemia and infarction Pericarditis   Systemic diseases that affect the heart Determination of the effect of cardiac drugs Disturbances in electrolyte balance Evaluation of function of cardiac pacemakers Prediction of Sudden Cardiac Death     .

The ECG Leads • 3 limb leads (Bipolar) • 3 agmented limb leads (Unipolar) • 6 precordial leads (Unipolar) .

Lead Placement  Limb Leads RA LA LL RL Red Yellow Green Black Red Yellow Green Brown Black Violet Right arm Left arm Left leg Right leg 4th ICS RPSB  Chest Leads V1 V2 4th ICS LPSB Midway between V2 and V4 5th ICS LMCL LAAL Lateral & horizontal to V4 LMAL Lateral & horizontal to V4 V3 V4 V5 V6 .

Current Direction and Wave Deflection  Upward deflection  + Downward deflection  + Diphasic deflection - + .

Locations of Electrodes and Lead Connections for the Standard 12 Lead ECG and Additional Leads LEAD TYPE Bipolar Limb Leads Aug Unipolar Limb Leads Precordi ial Leads Lead I Lead II Lead III aVR aVL aVF V1 V2 V3 V4 V5 V6 V7 V8 V9 POSITIVE INPUT Left Arm Left Leg Left Leg Right Arm Left Arm Left Leg Right Sternal Margin. 4th ICS Left Sternal Margin. 5th ICS Left Posterior Scapular line. 5th ICS Left Mid Axillary line. 5th ICS Left Anterior Axillary line. 5th ICS Left Posterior Axillary line. 4th ICS Midway between V2 and V4 Left Midclavicular line. 5th ICS Left Lateral Border of Spine. 5th ICS NEGATIVE INPUT Right Arm Right Arm Left Arm Left Arm + Left Leg Right Arm + Left Leg Left Arm + Left Leg Wilson Central Terminal Wilson Central Terminal Wilson Central Terminal Wilson Central Terminal Wilson Central Terminal Wilson Central Terminal Wilson Central Terminal Wilson Central Terminal Wilson Central Terminal .

LET’S REVIEW!!! .

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Hexaxial System • lead axes of the six frontal plane leads have been rearranged • centers overlay one another • axes divide the plane into 12 segments. each subtending 30 degrees • Positive ends of each axis are labeled with the name of the lead .

Terminology  Waveform  Movement away from the baseline in either a positive or negative direction A line between wave forms    Segment  Interval  A waveform and a segment Consists of several waveforms Complex  .

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The ECG Paper .

Review: Electrophysiology BEFORE THE HEART CONTRACTS IT MUST BE ELECTRICALLY STIMULATED DEPOLARIZATION .

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60-100 BPM at rest LA RA RV LV .Anatomy and Physiology of Cardiac Conduction SINUS NODE • The Heart’s ‘Natural Pacemaker’ Sinus Node (SA Node) .

Anatomy and Physiology of Cardiac Conduction AV NODE Sinus Node (SA Node) • Receives impulse from SA Node • Delivers impulse to the HisPurkinje System • 40-60 BPM if SA Node fails to deliver an impulse Atrioventricular Node (AV Node) .

Anatomy and Physiology of Cardiac Conduction BUNDLE OF HIS Sinus Node (SA Node) • Begins conduction to the Ventricles • AV Junctional Tissue: 40-60 BPM Atrioventricular Node (AV Node) Bundle of His .

Anatomy and Physiology of Cardiac Conduction THE PURKINJE NETWORK Sinus Node (SA Node) Atrioventricular Node (AV Node) Bundle of His Bundle Branches • Bundle Branches • Purkinje Fibers • Moves the impulse through the ventricles for contraction • Provides ‘Escape Rhythm’: 20-40 BPM Purkinje Fibers .

Impulse Formation In SA Node .

2 mV (2 mm) Duration < 0.Atrial Depolarization  The P wave    Atrial activation Height < 0.12 sec .

Delay At AV Node .

His purkinje conduction Duration 0.Conduction Through Bundle Branches  P-R Interval   Intraatrial.22 sec .20 or 0. internodal.12 to 0.

Conduction Through Purkinje Fibers .

Ventricular Depolarization  The QRS Complex   Ventricular activation Duration of 100 msec .

Plateau Phase of Repolarization  The ST-segment   Phase 2 of transmembrane potential Isoelectric in normal subjects .

Final Rapid (Phase 3) Repolarization  The  T wave  Upright after the age of 16 Juvenile T wave .

 The U wave    Surface reflection of negative after potential Repolarization of Purkinje fibers Ventricular relaxation  The QT Interval    From beginning of QRS to end of T wave Reflects the duration of depolarization and repolarization Bazett: Q-Tc Interval = Q-Ta / √R-R .

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200 <120 < 440 .) P wave duration PR interval QRS duration QT interval (corrected) < 120 120 .Normal Values WAVE/INTERVAL DURATION (msec.550 .

“The recognition of the normal electrocardiogram is made by excluding any recognized abnormality.” NORMAL SINUS RHYTHM • each P wave is followed by a QRS • P waves normal for the subject • P wave rate 60-100 bpm with <10% variation * rate <60 = sinus bradycardia * rate >100 = sinus tachycardia * variation >10% = sinus arrhythmia NORMAL QRS AXIS .

11 s in lead II * for abnormal P waves = right atrial hypertrophy. atrial premature beat. left atrial hypertrophy.” NORMAL P WAVES • height <2.“The recognition of the normal electrocardiogram is made by excluding any recognized abnormality. hyperkalemia .5 mm in lead II • width <0.

trifasicular block .20 s ( 3-5 small squares) * for short PR segment consider Wolff-Parkinson-White syndrome or Lown-Ganong-Levine syndrome * for long PR interval = first degree heart block.” NORMAL PR INTERVAL • 0.“The recognition of the normal electrocardiogram is made by excluding any recognized abnormality.12 to 0.

ventricular rhythm.” NORMAL QRS COMPLEX • <0. hyperkalaemia.“The recognition of the normal electrocardiogram is made by excluding any recognized abnormality. etc.12 s duration ( 3 small squares) * for abnormally wide QRS consider right or left bundle branch block. • no pathological Q waves • no evidence of left or right ventricular hypertrophy .

diffuse myocardial disease * hypocalcemia. myocarditis. amiodarone) * hereditary * Romano Ward syndrome (autosomal dominant) * Jervill + Lange Nielson syndrome (autosomal recessive) associated with sensorineural deafness) ..NORMAL QT INTERVAL • calculate the corrected QT interval (QTc) by dividing the QT interval by the square root of the preceding R-R interval. hypothyroidism * subarachnoid haemorrhage. Normal = 0. sotalol. • Causes of long QT interval * myocardial infarction.g. intracerebral haemorrhage * drugs ( e.42 s.

acute pericarditis * causes of depression include myocardial ischaemia. Edeiken pattern. acute posterior MI.g. digoxin effect.. left bundle branch block . athletic heart.NORMAL ST SEGMENT • no ST elevation or depression * causes of elevation include acute MI (e. normal variants (e. high-take off).g. inferior). pulmonary embolus. ventricular hypertrophy. left bundle branch block. anterior.

g. anxiety. hyperventilation... LVH. RBB) and electrolyte disturbance. hyperacute myocardial infaction. flattened or inverted T waves are numerous and include ischaemia.g. and left bundle branch block * causes of small. NORMAL U WAVE . PE. drinking iced water. drugs (e. race. digoxin). pericarditis. age. intraventricular conduction delay (e.NORMAL T WAVE * causes of tall T waves include hyperkalaemia.

Analyzing a Rhythm Strip         Rhythm/ Regularity Rate Axis P wave PR Interval QRS Complex T wave Q-T Interval .

  . For atrial rhythm. measure the distance between 2 consecutive P-P intervals. Generally. a variation of up to 0. The slower the heart rate. measure the distance between 2 consecutive R-R intervals and compare that distance with the other R-R intervals. the more acceptable the variation.Analyzing a Rhythm Strip  Is  the rhythm regular or irregular? To determine if the ventricular rhythm is regular or irregular.12 seconds (3 small boxes) is acceptable.

Regular or Irregular? • Beat to beat interval(R to R intervals or P to P intervals) the same .

Regular or Irregular? .

Regular or Irregular? .

Regular or Irregular? .

Regular or Irregular? .

Regular or Irregular? .

Analyzing a Rhythm Strip  What  is the rate? Regular Rhythms  To determine the ventricular rate. measure the distance between 2 consecutive P-waves (P-P interval) . measure the distance between 2 consecutive R-waves (R-R interval) To determine the atrial rate.

What is the Rate?  Ventricular   Rate 1500 300 Small squares (R-R Interval) Big squares (R-R Interval) .

What is the Rate? 1 2 3 4 1500 / 23 = 65/min .

What is the Rate? FAST METHOD 300 150 100 75 60 50 Start 300 150 100 75 60 50 ~63 BPM .

300 – 150 – 100 .50 .REMEMBER….75 – 60 .

What is the Rate? 300 150 100 75 1500 / 23 = 65/min .

What is the Rate? Irregular Rhythm 3 second strip Rate /min = Number of complexes x 20 Or if 6 second strip: Rate/min = number or complexes x 10 .

What is the Rate? .

What is the Rate?  Sinus rhythm  Atrial Fibrillation  QRS complexes in 6-sec strip X 10 .

Analyzing a Rhythm Strip  What Is The Axis? Normal 0 – (+90) Left axis 0 – (-90) AVL Right axis (+90) – (+180) I Extreme axis (-90) – (-180) AVF AVR .

Hexaxial System -150 o -120 o -90 o -60 o avR avL -30 o +180 o I 0 o +150 o II III +120 o +30 o avF +60 +90 o o .

The Normal QRS Axis -30 +90 0 +105 +90 .

What is the Axis? } Lead I 10 AVL I } AVF AVR 10 AVF .

What is the Axis? } Lead I 10 AVL I } AVF AVR 10 AVF .

What is the Axis? } 10 AVL I Lead I } AVF AVR 10 AVF .

What is the Axis? } 10 AVL I Lead I } AVF AVR 10 AVF .

Identify the lead that is most equipotential or has the smallest potential .Hexaxial Method For Estimating Electrical Axis 1.

Hexaxial Method For Estimating Electrical Axis 2. Identify the lead axis that runs perpendicular to that lead (avL). II avL + + .

Look at the tracing in that lead (II) if it is positive or negative. .Hexaxial Method For Estimating Electrical Axis 3.

Hexaxial Method For Estimating Electrical Axis + avL + + II + + + +60 + 20 .

Confirm estimate by examining the orientation and QRS potentials of other leads.Hexaxial Method For Estimating Electrical Axis 4. .

Hexaxial Method For Estimating Electrical Axis
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avL I

+ +

II

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avF +60 + 20

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Analyzing a Rhythm Strip
 Is

there 1 P wave before each QRS?
Are P waves present and uniform in appearance? Is there a P wave before each QRS or are there P waves that are not followed by QRS complexes? Is the atrial activity occurring so rapidly that there are more atrial beats than QRS complexes?

Analyzing a Rhythm Strip
 Is

the PR interval within normal limits?
If the PR interval is less than 0.12 or more than 0.20 second, conduction followed an abnormal pathway or the impulse was delayed in the area of the AV node. Is the PR interval of conducted beats constant or does it vary?

Analyzing a Rhythm Strip
 Is

the QRS narrow or wide?
What is the duration of the QRS complex? • If it is 0.10 second or less (narrow), it is presumed to be supraventricular in origin. • If it is greater than 0.12 second (wide), it is probably ventricular in origin. Do the QRS’s occur uniformly throughout the strip?

the mechanism (bradycardia).Analyzing a Rhythm Strip  Interpret  the rhythm  Specifying the site where the dysrrhythmia originated (sinus). “sinus bradycardia with a ventricular response (rate) of 38/min” . and the ventricular rate For example.

AVL AVL  High lateral  II. AVF Inferior I AVR AVF .  III.Analyzing a Rhythm Strip LOCALIZATION  I.

Lateral    V3.AVL.V4  V5.V5.V6  V1-V3 or V4   V3 or V4-V6  .V2  Septal Anterior Apicolateral Anteroseptal Anterolateral V1-V6 – Extensive anterior I.V6 .Analyzing a Rhythm Strip LOCALIZATION  V1.

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The recognition of the normal electrocardiogram is made by excluding any recognized abnormality. .