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Summary of ECG Abnormalities

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This summary of ECG abnormalities is part of the almostadoctor ECG series. For a more in
depth explanation of ECG abnormalities, see ECG abnormalities. To learn about the basic
principle of an ECG, see Understanding ECGs

Abnormality ECG sign Seen in Pathology

Sinus rhythm regular p waves, and each p All leads None
wave is followed by a QRS. 60- (best to look
100bpm at the
rhythm strip)

Sinus Tachycardia Same as above, except All leads Does not represent cardiac
>100bpm (best to look patholoy. May be a sign of
at the anxiety, dehydration, recent
rhythm strip) exercise, or general illness
(e.g. sepsis, pneumonia,
respiratory pathology, other
illness)

Sinus bradycardia Same as above except <60bpm All leads This is normal in young fit
(best to look people
at the
rhythm strip)

Right ventricular hypertrophy Negative QRS Lead I Because the cardiac axis has
shifted from 11-5 o’clock to 1-
7 o’clock, thus lead I which
measures laterally from right
to left now gets a negative
signal because the signal is
going from left to right. This
axis shift is called right axis
deviation.

Right ventricular hypertrophy Taller QRS Lead III – Because lead III measures
becomes vertically but also slightly left
taller than to right, and this is pretty
lead II much the exact direction of
the new shifted axis. Lead II,
measuring from right arm to
left leg is no longer lined up
as well. This axis shift is
called right axis deviation.

Transition point moved to the Equally
left – equal sized R and S sized R and
(normally seen in V3/V4) S now seen
in V5/V6

Left Ventricular Hypertrophy Small lead I QRS, negative Leads I-III Left axis deviation – this is
leads II and lead III QRS often the results of a
conduction defect, and not an
increased bulk of left
ventricular tissue.

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normal QRS best seen depolarising quickly Junctional tachycardia P waves very close to QRS. there are QRS visible – you The QRS can be regular or complexes at a lower rate than should use irregular. or electrolyte disturbance 1st Degree Heart Block It is NOT an medical emergency 2/8 . The p waves occur at what is very regular intervals. 100 or 75 (250bpm). there no QRS visible. There will be a Irregularly Irregular.2s (one big Allover – This is an AV node block square) best in I or Can be caused by CAD. Can’t tell if T/P waves are Lead where but the QRS complexes will present – rhythm is too fast p waves are only be at 150. rhythm will be irregularly irregular. p waves Any where p Caused by a foci of the atria superimposed over t waves of waves are (outside of the SA node) preceding beat. Thyrotoxicosis (hyperthyroidism) 3. Generally 1. PE Note that AF can also co- exist with complete heart block. in which case the QRS will be regular! Atrial Flutter Tachycardia Rhythm strip There will be saw tooth p waves that occur at 300bpm. Ischaemic heart disease 2. going on Atrial tachycardia >150bpm. Atrial fibrillation Absent P waves – just an some? As well as no p waves. or Anywhere Due to a ‘re-entry’ loop. the irregular baseline. V1 acute rheumatic carditis.e. this not only transmits a signal throughout the rest of the ventricles to depolarise them 1st degree heart block PR interval >0. Sepsis 4. block. Often associated most easily bpm due to various blocks. Valvular heart disease 5. QRS is is an area of depolarisation normal near the AV node. digoxin toxicity. i. irregular Rhythm strip fibrillating baseline due to QRS (but QRS is normal uncoordinated activity.g. Alcohol excess 6. the p waves drugs to It can be very difficult to see t slow down waves – what looks like a T the heart wave will probably just be a p rate to see wave. shape) The causes of atrial fibrillation are: Might look messy! E.

and thus this needs treatment! the definitive treatment is an implanted pacemaker. shape. QRS will conductivity does not pass often have an abnormal into the ventricles. usually repeats. R-R interval shortens require specific treatment. However. the P-P underlying disease – the intervals will be regular. from which there is often no 2:1 and 3:1 conduction escape rhythm. other. It is usually symptomless. or far more commonly infra-Hisian block (distal block). but it just not in time with each can occur in MI. and be broad This always indicates (>120ms). Cycles are variable in benign and generally doesn’t length. 2nd degree heart block Progressive lengthening of Anywhere This can be an AV node Mobitz type 1 – the PR interval followed by block (nearly always). then cycle SA node block. with lengthening of PR can be caused by CHD or interval acute MI. 3/8 . but this QRS complexes. heart block QRS/min. particularly if the rate is slow Complete (third degree) 90 P waves/min. and not relationship and V1 Atrial activity will be between the P waves and the completely normal. Can be caused by CHD or MI This is the ratio of P:QRS Anywhere May require a pacemaker. The rhythm of the ventricles is the escape rhythm. only about 38 Best in II This is an AV node block. but can present with: –Dizziness / light- Mobitz type 2 headedness / syncope Absent QRS every now and Anywhere This can be an SA node again block. It can progress to complete heart block. as will disease is often fibrosis the R-R intervals – they are rather than ischaemia. or an Wencebach absent QRS.

This creates a blockages. but it is most sided disease. You can remember the pattern with the word MarroW – there is M in V1. pain. and it is often caused by an atrial septal defect. In These are infra-Hisian block some people there may be 2 R blocks. acute MI. Those with syncope and / or heart failure will usually be treated with a pacemaker. thyrotoxicosis Supraventricular rhythms This is any rhythm that Examples include: originates outside the –Sinus rhythms ventricle –LBBB –RBBB 4/8 . fainting. The two R commonly normal waves indicate the depolarisation of the right and left sides of the heart at different times (the right depolarises after the left). Sinus bradycardia Normal rhythm <60bpm Anywhere Associated with. heart failure. V6 – there is a W shaped QRS the time taken for the Wide QRS (120ms) depolarisation to spread throughout the ventricles is LBBB – left bundle branch V1 – there is an W shaped longer – thus QRS complex block QRS duration is lengthened. CAD Symptoms: Syncope. In the acute setting it may be caused by MI LBBB – often indicates left sided heart disease. V6 – there is a M shaped QRS In the acute setting it may be Wide QRS (>120ms) caused by MI The axis can be deviated either RBBB – may indicate right way in BBB’s.RBBB – right bundle branch ECG may appear normal. the wave of distinctive pattern: depolarisation can still V1 – there is an M shaped reach the IV septum. and the ‘rr’ tells you it is on the right! There is NOT specific treatment. athletic training. However. and W in v6. hypothermia. Causes: Aortic stenosis. haemorrhage. In bundle branch waves. dilated cardiomyopathy. exercise. and in more severe cases. seen immediately after MI Sinus Tachycardia Normal rhythm >100bpm Anywhere Associated with. then QRS – this is sometimes called the PR interval will be an RSR pattern normal – and it is. fear. myxedema (hypothyroidism). Remember the pattern with WillaM.

The presence of Q descending) leads waves implies a full thickness infarction. Usually benign and does not need to be treated. Ventricular rhythms Wide QRS complexes Anywhere (aka escape rhythms) Atrial escape Abnormal p wave (e. some other part of Accelerated idioventricular Some normal beats after the the atrium depolarises and rhythm abnormal one sends the signal to the ventricles. The QRS complexes are the same as those of sinus rhythm. 5/8 . but there are usually abnormal p waves that tend to come immediately before or immediately after the QRS. III. and then a depolarise at their normal ventricular QRS. It occurs when the rate of depolarisation of the SA node falls below the rate of the AV node. Inferior MI ST elevation II.g. Also associated with MI Extrasystoles These are easy – they are the same as ventricular escapes. Ventricular escape Normal QRS Instead. Anywhere This occurs when the SA Junctional escape inverted) node fails to depolarise. and possibly in lead I and aVL Anterior MI ST elevation V2-5 – the This will also cause deep q (probably the left anterior anterior waves. –Occasional missing p wave. aVF The ST elevation in these (probably the right coronary (the inferior leads is often accompanied artery) leads) by ST depression in the antero-lateral leads – V1- V6. then normal escape rate. thus the AV node starts the beat instead. and thus the ventricles followed by long gap. there is an abnormal beat earlier than expected. in extrasystole. The resulting bradycardia reduces cardiac output and can cause symptoms similar to other bradycardias such as: –Dizziness –Light-headedness –Syncope –Hypotension Usually the bradycardia can be tolerated as long as it is above 50bpm Two types: Somewhere along the line –Many p waves per QRS the p waves isn’t getting (complete heart block) conducted to the ventricles. No p waves The escape occurs Normal QRS somewhere at the AV Slightly slow rate (max 75bpm) junction. Otherwise it looks very similar. except that where (aka ectopics) in escapes the escape beat comes after a pause in the rhythm. rhythm Wide QRS Don’t confuse this with Rhythm of about 75bpm ventricular tachycardia – No p waves which requires a HR of Abnormal T waves >125pbm.

rate from BBB. bypassing the AV node. most patients are symptomless and live with no problems. right axis Accessory pathway. from the left atria to the left short QRS ventricle allows direct transition of the signal. no Patient is very likely to lose QRS. T ? Can be difficult to differentiate waves difficult to identify. Posterior MI ST depression. It has a risk of mortality as it can cause re- entry tachycardia. usually SYndrome deviation. In a limb leads. The digoxin effect Depression of ST. (similarly. no P. if they occur. tall R waves V1-V3 Posterior MI is unusual! The changes that occur are opposite to the changes of other type of MI. Q waves. (STEMI) chest leads OR >1mm in 2+ inversion are usually permanent. and has QRS >160ms Supraventricular Narrow QRS tachycardia Ventricular fibrillation No discernable pattern. however. ischaemia causes reduced production of ATP. BBB has p waves. and ST depression occurs in place of ST elevation ST elevation MI ST elevation >2mm in 2+ T wave Both factors. This occurs because digoxin blocks the na/K pump. occurs full thickness infarction T-wave inversion (after several within a few then there are pathological hours) hours of MI. >200bpm and a QRS generally 120- 160ms. and thus reduced pump activity) 6/8 . short PR interval. which increases intracellular Ca2+ concentrations. inverted T widespread This causes a sloping ST waves segment that has a ‘reversed tick’ look. VT is more likely scenario after MI. no p waves. but in a non-full +) Q waves thickness MI then there is occur only T wave inversion. thus the tall R waves are the opposite of Q waves (remember Q waves are negative). no T consciousness – thus the diagnosis is easy! Wolff-Parkinson-White Delta waves present. The several days differentiation between full after initial /thickness and non full MI thickness is pretty much the same as ST elevation / non- NSTEMI Pathological Q waves only ST elevation Ventricular tachycardia Wide QRS. hence the shortened PR interval. and T wave Pathological Q waves (24 hours pathological inversion.

it could be due to incorrect limb lead placement. also. broad ? Left ventricular – looks like an ‘M’. It can be congenital. Carotid sinus pressure 7/8 . small or absent p waves. it is called north-west axis. but also caused by drugs Hyperkalaemia Wide. wide QRS Left ventricular S wave in V1 or V2 >35mm AND R wave in V5 or V6 hypertrophy >35mm R in aVF >20mm R in aVL >11mm Any chest lead >45mm R in lead I >12mm Pacemaker Occasional P waves. the elevation in MI tends to be confined to a certain area. ‘tented’ T waves. then there is a risk of sudden cardiac death. not related ? The large spike is pacemaker to QRS. elevation) then the ST waves will appear ‘saddle shaped’ thus helping you to differentiate it from MI. it is widespread P pulmonale Tall . but in pericarditis. tall. QRS complexes broad because the stimulus originates in the ventricles Axis deviation Lead I Lead II Axis + + Normal + – LAD – Either RAD aVR should always be negative! If it is positive. or height >2mm in lead II pretty much anything that causes right atrial enlargement (or hypertrophy) – such as tricuspid stenosis or pulmonary hypertension Bifid P waves (‘P-Mitrale’) P waves with two peaks. QRS precede by large stimulus. The QRS’s are wide spike. due to the pacemaker wire – this enters the heart at the apex.peaked T waves. or artificial pacing. hence the hypertrophy name ‘Mitrale’ Bi-phasic T waves T waves with t peaks Can occur as a result of MI Prolonged QT interval Prolonged QT The corrected QT. is the QT interval as it would be at 60bpm. dextrocardia. p wave Lead II Seen in cor pulmonale. ? Can lead to VF and AF shortened/absent ST segment. Pericarditis T wave inversion (rare: also ST Widespread If ST elevation does occur. if this is long.

and allows the underlying atrial arrhythmia to become more visible. This will reduce the frequency of discharge of the SA node. Thus. and increase the time of conduction across the AV node. by applying pressure to the carotid sinus you can: Reduce the rate of some arrhythmias Completely stop some arrhythmias It will have NO EFFECT ON VENTRICULAR TACHYCARDIAS – thus is can help you differentiate these from supraventricular tachycardias (SVT) Applying the pressure reduces the frequency of QRS complexes.By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via vagal stimulation. Related Articles ECG Abnormalities Understanding ECGs Angiotensin II Receptor Blockers (ARBs) Amiodarone Cardiac Tamponade 8/8 .