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Summary of ECG Abnormalities Search

 1 Nov, 2020 /  Dr Tom Leach (https:/almostadoctor.co.uk/about-drtomleach) /  23 mins read / BROWSE

 3 (https://almostadoctor.co.uk/encyclopedia/summary-of-ecg-abnormalities#comments) /
CARDIOLOGY (HTTPS://ALMOSTADOCTOR.CO.UK/ENCYCLOPEDIA/CATEGORY/CARDIOLOGY)

This summary of ECG abnormalities is part of the almostadoctor ECG series.

(https://almostadoctor.co.uk/encyclopedia/tag/ecg) For a more in depth explanation of ECG
abnormalities, see ECG abnormalities (https://almostadoctor.co.uk/encyclopedia/ecg-abnormalities).
To learn about the basic principle of an ECG, see Understanding ECGs
(https://almostadoctor.co.uk/encyclopedia/understanding-ecgs)

ABNORMALITY ECG SIGN SEEN IN PATHOLOGY

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

Does not represent cardiac

Same as above, except
Sinus Tachycardia
>100bpm
patholoy. May be a sign of anxiety
All leads (/encyclopedia/anxiety-and-
(best to generalised-anxiety-disorder-gad),
look at the dehydration, recent exercise, or
rhythm general illness (e.g. sepsis
strip) (/encyclopedia/sepsis-and-sirs),
pneumonia, respiratory pathology,
other illness) SOURCES

Read more about our sources

Same as above except
Sinus bradycardia
<60bpm
Right ventricular hypertrophy Negative QRS
All leads (http://almostadoctor.co.uk/sources)
(best to
look at the This is normal in young
PAGE TOOLS fit people
rhythm
strip)
Reference Ranges
(https://almostadoctor.co.uk/encyclopedia/n
Because the cardiac axis has
ormal-values-references-ranges)
shifted from 11-5 o’clock to 1-7
o’clock, thus lead I which measures
laterally from right to left now gets
Lead I
a negative signal because the
signal is going from left to right.
This axis shift is called right axis
deviation.

Right ventricular hypertrophy
Left Ventricular Hypertrophy
Atrial fibrillation
Atrial Flutter
Atrial tachycardia
Because lead III measures
vertically but also slightly left to
Lead III – right, and this is pretty much the
becomes exact direction of the new shifted
Taller QRS
taller than axis. Lead II, measuring from right
lead II arm to left leg is no longer lined up
as well. This axis shift is called
right axis deviation.
Transition point moved Equally
to the left – equal sized sized R and
R and S (normally seen S now seen
in V3/V4) in V5/V6
Left axis deviation – this is often
Small lead I QRS,
the results of a conduction defect,
negative leads II and Leads I-III
and not an increased bulk of left
lead III QRS
ventricular tissue.
As well as no p waves, the rhythm
will be irregularly irregular. There
Absent P waves – just Likely all will be a fibrillating baseline due to
an irregular baseline. leads uncoordinated activity.
The causes of atrial fibrillation are:
1. Ischaemic heart disease
2. Thyrotoxicosis (hyperthyroidism
(/encyclopedia/hyperthyroidism-
thyrotoxicosis))
Irregularly Irregular, 3. Sepsis
Rhythm
irregular QRS (but QRS is 4. Valvular heart disease
strip
normal shape) 5. Alcohol (/encyclopedia/alcohol-
and-alcohol-abuse) excess
6. PE
Note that AF (/encyclopedia/atrial-
fibrillation) can also co-exist with
Might look messy! Generally
complete heart block, in which
case the QRS will be regular!
Rhythm There will be saw tooth p waves
Tachycardia
strip that occur at 300bpm, but the QRS
complexes will only be at 150, 100
Can’t tell if T/P waves or 75 bpm due to various blocks.
Lead where
are present – rhythm is The QRS can be regular or irregular.
p waves are It can be very difficult to see t
too fast (250bpm). Often
most easily
associated block; i.e. waves – what looks like a T wave
visible –
there are QRS complexes will probably just be a p wave. The
usually lead p waves occur at very regular
at a lower rate than the p
II
waves intervals.
>150bpm, p waves
Any where p Caused by a foci of the atria
superimposed over t
waves are (outside of the SA node)
waves of preceding
best seen depolarising quickly
beat, normal QRS

P waves very close to
Junctional tachycardia QRS, or no QRS visible. Anywhere
QRS is normal
Due to a ‘re-entry’ loop; there is an
area of depolarisation near the AV
node; this not only transmits a
signal throughout the rest of the
ventricles to depolarise them

1st degree heart block

This is an AV node block
Can be caused by CAD, acute
1st Degree Heart Block Allover –
PR interval >0.2s (one rheumatic carditis, digoxin
best in I or
big square) (/encyclopedia/diphtheria) toxicity,
V1
or electrolyte disturbance
1st Degree Heart Block
It is NOT an medical emergency

This can be an AV node block

(nearly always), or an SA node
block. usually benign and generally
 
doesn’t require specific treatment.
Progressive
can be caused by CHD
lengthening of the PR
(/encyclopedia/atherosclerosis-
interval followed by
and-coronary-heart-disease-chd) or
absent QRS, then cycle
Anywhere acute MI
2nd degree heart block repeats. Cycles are
(/encyclopedia/myocardial-
variable in length. R-R
Mobitz type 1 – Wencebach infarction-and-acute-coronary-
interval shortens with
syndromes-acs).
  lengthening of PR
It is usually symptomless, but can
interval
present with:
 
–          Dizziness / light-
Mobitz type 2
headedness / syncope

 
This can be an SA node block, or
far more commonly infra-Hisian
 
block (distal block). It can progress
 
to complete heart block, from
2:1 and 3:1 conduction Absent QRS every now
Anywhere which there is often no escape
and again
rhythm; and thus this needs
treatment! the definitive treatment
is an implanted pacemaker.
Can be caused by CHD or MI

This is the ratio of May require a pacemaker,

Anywhere
P:QRS particularly if the rate is slow

Complete (third degree) heart block
RBBB – right bundle branch block
LBBB – left bundle branch block
90 P waves/min, only
about 38 QRS/min, and
not relationship
between the P waves
and the QRS complexes. This is an AV node block. Atrial
QRS will often have an activity will be completely normal,
abnormal shape, and be but this conductivity does not pass
broad (>120ms into the ventricles.
(/encyclopedia/multiple- Best in II This always indicates underlying
sclerosis-ms)). and V1 disease – the disease is often
However, the P-P fibrosis (/encyclopedia/interstitial-
intervals will be regular, lung-disease-pulmonary-fibrosis)
as will the R-R intervals rather than ischaemia, but it can
– they are just not in occur in MI.
time with each other.
The rhythm of the
ventricles is the escape
rhythm.
These are infra-Hisian blocks. In
bundle branch blockages, the wave
of depolarisation can still reach
the IV septum, then the PR interval
will be normal – and it is. However,
the time taken for the
ECG may appear
depolarisation to spread
normal. In some people
throughout the ventricles is longer
there may be 2 R waves.
– thus QRS complex duration is
This creates a
lengthened.
distinctive pattern:
In the acute setting it may be
V1 – there is an M
caused by MI
shaped QRS – this is
RBBB – may indicate right sided
sometimes called an
disease. The two R waves indicate
RSR pattern
the depolarisation of the right and
V6 – there is a W
left sides of the heart at different
shaped QRS
times (the right depolarises after
Wide QRS (120ms)
the left).
You can remember the pattern with
the word MarroW – there is M in
V1, and W in v6, and the ‘rr’ tells
you it is on the right!
There is NOT specific treatment,
and it is often caused by an atrial
septal defect (/encyclopedia/asd-
atrial-septal-defect).
In the acute setting it may be
caused by MI
LBBB – often indicates left sided
V1 – there is an W heart disease. Remember the
shaped QRS
pattern with WillaM.
V6 – there is a M
Causes:
shaped QRS Aortic stenosis
Wide QRS (>120ms) (/encyclopedia/aortic-stenosis),
The axis can be
dilated cardiomyopathy, acute MI,
deviated either way in CAD
BBB’s, but it is most Symptoms:
commonly normal
Syncope, and in more severe
cases; heart failure (/heart-failure).
Those with syncope and / or heart
failure will usually be treated with
a pacemaker.
 Associated with; athletic training,
fainting, hypothermia, myxedema
Sinus bradycardia Normal rhythm <60bpm Anywhere (hypothyroidism
(/encyclopedia/hypothyroidism)),
seen immediately after MI

Normal rhythm Associated with; exercise, fear,

Sinus Tachycardia Anywhere
>100bpm pain, haemorrhage, thyrotoxicosis

Examples include:
This is any rhythm that
–          Sinus rhythms
Supraventricular rhythms originates outside the
–          LBBB
ventricle
–          RBBB

Wide QRS complexes Anywhere

Abnormal p wave (e.g.

This occurs when the SA node fails
inverted)
to depolarise. Instead, some other
Normal QRS
part of the atrium depolarises and
Some normal beats after
sends the signal to the ventricles.
the abnormal one

Ventricular rhythms The escape occurs somewhere at

(aka escape rhythms) the AV junction. It occurs when the
Atrial escape rate of depolarisation of the SA
  node falls (/encyclopedia/falls)
  below the rate of the AV node, thus
  the AV node starts the beat
Junctional escape instead. The resulting bradycardia
No p waves
  reduces cardiac output and can
Normal QRS
  cause symptoms similar to other
Slightly slow rate (max
  bradycardias such as:
75bpm)
  –          Dizziness
  –          Light-headedness
  –          Syncope
  –          Hypotension
  Anywhere Usually the bradycardia can be
  tolerated as long as it is above
  50bpm
 
Ventricular escape Two types:
  –          Many p waves per
  QRS (complete heart Somewhere along the line the p
  block) waves isn’t getting conducted to
  –          Occasional the ventricles, and thus the
  missing p wave, followed ventricles depolarise at their
  by long gap, and then a normal escape rate.
  ventricular QRS, then
Accelerated idioventricular rhythm normal rhythm

Don’t confuse this with ventricular

tachycardia – which requires a HR
Wide QRS
of >125pbm. Otherwise it looks
Rhythm of about 75bpm
very similar.
No p waves
Usually benign and does not need
Abnormal T waves
to be treated. Also associated with
MI
 These are easy – they are the same as ventricular escapes, except that where in
escapes the escape beat comes after a pause in the rhythm, in extrasystole,
Extrasystoles
there is an abnormal beat earlier than expected.
(aka ectopics)
The QRS complexes are the same as those of sinus rhythm, but there are usually
 
abnormal p waves that tend to come immediately before or immediately after the
QRS.

The ST elevation in these leads is

often accompanied by ST
II, III, aVF
Inferior MI depression
ST elevation (the inferior
(probably the right coronary artery) (/encyclopedia/depression) in the
leads)
antero-lateral leads – V1-V6, and
possibly in lead I and aVL

V2-5 – the This will also cause deep q waves.

Anterior MI
ST elevation anterior The presence of Q waves implies a
(probably the left anterior descending)
leads full thickness infarction.

Posterior MI is unusual! The

changes that occur are opposite to
the changes of other type of MI.
ST depression, tall R thus the tall R waves are the
Posterior MI V1-V3
waves opposite of Q waves (remember Q
waves are negative), and ST
depression occurs in place of ST
elevation

T wave
inversion
Both factors, if they occur, are
ST elevation >2mm in occurs
usually permanent. In a full
2+ chest leads OR within a few
thickness infarction then there are
>1mm in 2+ limb leads, hours of MI,
ST elevation MI pathological Q waves, and T wave
T-wave inversion (after pathological
(STEMI) inversion, but in a non-full
several hours) Q waves
thickness MI then there is only T
Pathological Q waves occur
wave inversion. The differentiation
(24 hours +) several
between full /thickness and non
days after
full thickness is pretty much the
initial MI
same as ST elevation / non-ST
elevation
Pathological Q waves
NSTEMI  
only

Can be difficult to differentiate

Wide QRS, no p waves, T from BBB. BBB has p waves, and a
Ventricular tachycardia waves difficult to ? QRS generally 120-160ms. VT is
identify, rate >200bpm more likely scenario after MI, and
has QRS >160ms

Supraventricular tachycardia
(https://almostadoctor.co.uk/encyclopedia/supraventricular- Narrow QRS    
tachycardia-svt)

Patient is very likely to lose

No discernable pattern,
Ventricular fibrillation   consciousness – thus the
no QRS, no P, no T
diagnosis is easy!

Delta waves present,
Wolff-Parkinson-White Syndrome
right axis deviation,
(https://almostadoctor.co.uk/encyclopedia/wolff-parkinson-  
short PR interval, short
white-syndrome)
QRS
Accessory pathway, usually from
the left atria to the left ventricle
allows direct transition of the
signal, bypassing the AV node,
hence the shortened PR interval. It
has a risk of mortality as it can
cause re-entry tachycardia;
however, most patients are
symptomless and live with no
problems.

This causes a sloping ST segment

that has a ‘reversed tick’ look. This
occurs because digoxin blocks the
na/K pump, which increases
Depression of ST, intracellular Ca2
The digoxin effect widespread
inverted T waves (/encyclopedia/calcium)+
concentrations. (similarly,
ischaemia causes reduced
production of ATP, and thus
reduced pump activity)

If ST elevation does occur, then the

ST waves will appear ‘saddle
shaped’ thus helping you to
T wave inversion (rare:
Pericarditis Widespread differentiate it from MI. also, the
also ST elevation)
elevation in MI tends to be
confined to a certain area, but in
pericarditis, it is widespread

Seen in cor pulmonale

(/encyclopedia/heart-failure), or
pretty much anything that causes
right atrial enlargement (or
Tall ,peaked T waves, p
hypertrophy) – such as tricuspid
P pulmonale wave height >2mm in Lead II
stenosis or pulmonary
lead II
hypertension
(/encyclopedia/diagnosis-
pathology-and-management-of-
hypertension)

P waves with two peaks,

broad – looks like an
Bifid P waves (‘P-Mitrale’) ? Left ventricular hypertrophy
‘M’; hence the name
‘Mitrale’

Bi-phasic T waves T waves with t peaks   Can occur as a result of MI

The corrected QT, is the QT interval

as it would be at 60bpm. if this is
Prolonged QT interval Prolonged QT   long, then there is a risk of sudden
cardiac death. It can be congenital,
but also caused by drugs

Wide, tall, ‘tented’ T

waves,
shortened/absent ST
Hyperkalaemia (/encyclopedia/potassium) ? Can lead to VF and AF
segment, small or
absent p waves, wide
QRS
 S wave in V1 or V2 >35mm AND R wave in V5 or V6
>35mm                                             R in aVF >20mm
R in aVL
Left ventricular hypertrophy
>11mm                                                                                                                     Any
chest lead >45mm
R in lead I >12mm

Occasional P waves, not The large spike is pacemaker

related to QRS, QRS stimulus. The QRS’s are wide
Pacemaker ?
precede by large spike, because the stimulus originates in
QRS complexes broad the ventricles

 
 
Axis deviation

LEAD I LEAD II AXIS

+ + Normal

+ – LAD

– Either RAD

aVR should always be negative!

If it is positive, it is called north-west axis. it could be due to incorrect limb lead placement,
dextrocardia, or artificial pacing, due to the pacemaker wire – this enters the heart at the apex.
Carotid sinus pressure
By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via vagal
stimulation. This will reduce the frequency of discharge of the SA node, and increase the time of
conduction across the AV node.
Thus, 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, and allows the underlying atrial
arrhythmia to become more visible.
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TAGS: CARDIOLOGY (HTTPS://ALMOSTADOCTOR.CO.UK/ENCYCLOPEDIA/TAG/CARDIOLOGY), ECG

(HTTPS://ALMOSTADOCTOR.CO.UK/ENCYCLOPEDIA/TAG/ECG)
 Dr Tom Leach (Https://Almostadoctor.Co.Uk/Author/Tom)
Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an
Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at
(https://al the Australian National University, and is studying for a Masters of Sports Medicine at
mostadoct the University of Queensland. After graduating from his medical degree at the
or.co.uk/a University of Manchester in 2011, Tom completed his Foundation Training at Bolton
uthor/tom) Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a
third year medical student in 2009. Read full bio (/about-drtomleach)

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 THIS POST H AS 3 COMMENTS

Anandprakash (http://No) 3RD S EPT EMBE R 2017 REPLY

Very useful to all doctors,

Trish 16T H S EPT EMBE R 2022 REPLY

Hello Doctor,
my lead 2 on EKG is usually just a wavy line- Does that mean anything.
Thank you, Trish
 Dr Tom Leach (https:/almostadoctor.co.uk/about-drtomleach)
16T H S EPT EMBE R 2022 REPLY

Hi Trish,
I’m sorry I can’t provide any personalised medical advice through almostadoctor. If
you have any concerns about your ECG please consult your doctor / or the medical
practitioner who requested the investigation.
Tom

Reply to Trish CANCE L RE P LY ( /E NCYCLO P E D I A/S UMM ARY- O F - E CG - ABNO RM AL ITIE S #RE S P O ND)

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