Clinical course on ECG

interpretation: Basics of ECG

Dr Md Nazmul Hasan
MBBS(CMC),MRCP(UK)
MCPS(Medicine)
MD(Cardiology),FESC
Precordial electrodes and leads
Standardization
Isoelectric line
aVR!!
Everything down in aVR. If up then either lead
misplacement/dextrocardia.
Upright QRS in aVR in
dextrocardia!!
How to interpret an ECG??
The plan: (confirm it’s a standard ECG by checking aVR!)
Rate
Rhythm
Axis
Watch out the leads: Inferior (II, III, aVF) then lateral (I, aVL, V5, V6) then anterior
(V1-V4) > P, QRS and T morphology and intervals PR, QRS, QT & segments eg. ST
segment.
Interpretation:
Compare with previous ECG
Conclusion with consideration of patient presentation!!! (Very important!!).
Calculation of the heart rate
Calculation of the heart rate
Calculation of Heart Rate
Calculation of heart rate
What is the heart rate?
What is the heart rate?
Summary of the heart rate Calculation

Regular rhythms:
◦ Rate = 300 / number of large squares in between each consecutive R wave.

Very fast rhythms:

◦ Rate = 1500 / number of small squares in between each consecutive R wave.

Slow or irregular rhythms:

◦ Rate = number of complexes on the rhythm strip x 6 (this gives the average
rate over a ten-second period).
◦ Calculate atrial and ventricular rates separately if they are different (e.g.
complete heart block, atrial flutter)
Waves & Intervals
P wave abnormality
P wave (Lead II)
▪ Duration < 120 ms or <3 small squares.
▪Amplitude < 2.5 mm/2.5 small squares in the limb leads, < 1.5 mm/ 1.5
small squares in the precordial leads
▪P pulmonale: Tall, peaked P waves in lead II.
▪P mitrale: Broad, notched (bifid) P waves in lead II
▪P wave replaced by saw tooth like flutter wave: Atrial flutter.
▪Absence of P wave: Atrial fibrillation.
Clinical case
A 56 y/o man presented with history of cough productive of
mucopurulent sputum and SOB on exertion. He has a history of smoking
for 20 pack years.
His ECG is shown in the next slide
P pulmonale
Clinical Case
A 35 y/o man comes with history of occasional SOB and cough
productive of bloody sputum. He has history of multiple fever and joint
pain episodes during his childhood. On examination he has a
mid-diastolic murmur on the apex.
His ECG is presented in the next slide.
P mitrale
The Q wave
Any negative deflection that precedes an R wave.
Any negative deflection just after P wave.
Q waves in different leads
Small Q waves are normal in most leads (esp. lateral) except V1-V3
Deeper Q waves (>2 mm) may be seen in leads III and as a normal
variant
Normal Q wave in V6
Pathological Q wave
Q waves are considered pathological if:
> Seen in leads V1-3
> 2 mm/2 small box deep (except III)
> 40 ms (1 mm)/One small box wide
> 25% of depth of QRS complex (Tough)

Indicate current or prior myocardial infarction.

Clinical case
A 50 y/o man has history of severe chest pain 1 year back. He got
admitted in a local hospital where he got primary management and was
referred to NICVD. He did not get any Streptokinase as he presented 15
hr after pain. He was given Enoxaparin along with regular management.
This is his follow up ECG
R wave
R Wave Overview
The first upward deflection after the P wave

•Normal R wave progression:

Progressively larger R waves (V1-V6)
R is larger than the S in V4.

* Abnormalities of the R wave:

Dominant R wave in V1 (R wave >S wave)
Poor R wave progression: When the R wave remains small in leads V3 to V4
— that is, smaller than 3 small box.
Poor R wave progression
Poor R wave progression
R wave ≤ 3 mm/3 small squares in V3 or R is less than S in V4
Causes:
Prior anteroseptal MI
Left Ventricular Hypertrophy.
Inaccurate lead placement
Normal variant
QRS voltage
Low voltage in precordial leads
Dominant R wave in V1
Right Ventricular Hypertrophy (RVH)
Right Bundle Branch Block (RBBB)
RVH
Narrow vs Broad QRS!!
T wave
Characteristics of the normal T wave
Upright in all leads except aVR and V1
Amplitude < 5mm/5 small squares in limb leads, < 10mm/10 small
squares in precordial leads (But rarely it is >10 mm)
T wave abnormalities
Hyperacute T waves
Inverted T waves/T wave inversion.
Biphasic T waves
Flattened T waves
Hyperacute anterolateral MI
Hyperacute T wave in
Anterior STEMI
Peaked/Hyperacute T wave in
hyperkalemia
Inverted T waves
Causes:
Myocardial ischemia and infarction
Bundle branch block
Ventricular hypertrophy (‘strain’ patterns)
Raised intracranial pressure (Cerebral T wave)
T wave inversion in lead III is a normal variant. (also deep Q is a normal
variant in lead III)
New T-wave inversion (compared with prior ECGs) is always abnormal.
Pathological T wave inversion is usually symmetrical and deep
(>3mm/>3 small box).
Clinical case
50 y/o diabetic woman comes with severe chest pain which did not
respond to NSAID. She has anorexia and vomited twice en route.
ECG is presented in next slide.
Inferior T inversion due to
prior infarction
Clinical case
A 50 y/o man comes to the hospital with a very severe headache
(10/10, worst headache of his life). He becomes unconscious en route
and has an episode of seizure. His temperature is normal but has neck
rigidity.
Cerebral T wave (Raised ICP)
Biphasic T waves
There are two main causes of biphasic T waves:
Myocardial ischemia
Hypokalemia
The two waves go in opposite directions:
Ischemic T waves go up then down
Hypokalemic T waves go down then up
Biphasic T, Ischemia
Biphasic T, hypokalemia
Flattened T waves
Cause:
Ischemia
Electrolyte abnormality, e.g. hypokalemia
U wave
U waves in hypokalemia
Prolonged PR interval
QT Interval
Normal QTc values
QTc is prolonged if > 440ms/11 small
box>2 large box in men
or > 460ms/11+small box >2 large box
in women
QTc > 500 is associated with increased
risk of torsades de pointes
QTc is abnormally short if < 350ms
A useful rule of thumb is that a normal
QT is less than half the preceding RR
interval
Axis of the heart (Consider
QRS axis)
Axis determination in ECG
Normal axis
Left axis deviation
Causes of left axis deviation
Normal variant.
Left ventricular hypertrophy.
Left bundle branch block.
Left anterior fascicular block.
Right axis deviation
Causes of right axis deviation
Normal variant.
Right ventricular hypertrophy.
Right bundle branch block.
Left posterior fascicular block.
Pulmonary embolism.
Cor pulmonale.
NORMAL ECG
Quiz 1 (What is the axis?)
Quiz 2 (What is the axis?)
Quiz 4: Which lead represents
which area?
Quiz 5: Calculate the heart
rate
Quiz 6: What is the abnormality?
Quiz 7: What is the abnormality?
Quiz 8: What are the abnormalities?
Quiz 9: What is the problem?