ECG

Significance of the various waveforms

+
Chamber Enlargement
Introduction
There are many waves that we
must know in an ECG which is:

P wave
QRS wave
T wave
 01
About the P wave
What is the significance of
it?
 About the P wave

Positive Atrial Time

The first positive It represents atrial Normal duration
deflection on the depolarisation. is <0.12s
ECG.
 Key Notes
Left atrial abnormalities such as hypertrophy and/or dilation are
sometimes identifiable on ECG by P wave morphology.

A large negative deflection can indicate a left atrial abnormality

Prolongation of the P wave to a duration exceeding 120 ms classically

associates with left atrial abnormality and is referred to as P mitrale.

Right atrial abnormalities are also identifiable on ECG

 02
About the QRS wave
What is the significance of
it?
 Key Notes
- includes the Q wave, R wave, and S wave. These three waves occur
in rapid succession.
- The QRS complex represents the electrical impulse as it spreads
through the ventricles and indicates ventricular depolarization. As with
the P wave, the QRS complex starts just before ventricular contraction.
- the duration of the QRS complex in an adult patient will be between
0.06 and 0.10 seconds
- The J-point is the point where the QRS complex and the ST segment
meet. It can also be thought of as the start of the ST segment. The J-
point (also known as Junction) is important because it can be used to
diagnose an ST segment elevation myocardial infarction
 03
About the T wave
What is the significance of
it?
 Key Notes
- The T wave occurs after the QRS complex and is a result of ventricular
repolarization
- a normal T wave is slightly asymmetric; the peak of the wave is a little
closer to its end than to its beginning.
- T waves are normally positive in leads I, II, and V2 through V6 and
negative in aVR, and will normally follow the same direction as the
QRS complex that preceded it (positive or negative/up or down).
 04
About the PR intervals
What is the significance of
it?
 Key Notes
- The PR interval is the time from the beginning of the P wave (atrial
depolarization) to the beginning of the QRS complex (ventricular
depolarization).
- The normal PR interval measures 0.12-0.20 seconds (120-200
milliseconds)
- A prolonged or shortened PR interval can indicate certain disease.
 Key Notes
- The PR interval is the time from the beginning of the P wave (atrial
depolarization) to the beginning of the QRS complex (ventricular
depolarization).
- The normal PR interval measures 0.12-0.20 seconds (120-200
milliseconds)
- A prolonged or shortened PR interval can indicate certain disease.
 05
About the QT intervals
What is the significance of
it?
 Key Notes
- The QT interval is the time from the beginning of the QRS complex,
representing ventricular depolarization, to the end of the T wave,
resulting from ventricular repolarization.
- the normal QT interval is below 400 to 440 milliseconds (ms), or 0.4 to
0.44 seconds
- A quick way to distinguish a prolonged QT interval is to examine if the
T wave ends beyond the halfway point between the RR interval. If the
T wave ends past the halfway point of the RR interval, it is prolonged.
 Key Notes
- Due to the effects of heart rate, the corrected QT interval (QTc) is
frequently used
 06
About the ST segments
What is the significance of
it?
 Key Notes
- The ST segment is the flat, isoelectric section of the ECG between the
end of the S wave (the J point) and the beginning of the T wave
- The ST Segment represents the interval between ventricular
depolarization and repolarization.
- The most important cause of ST segment abnormality (elevation or
depression) is myocardial ischaemia or infarction.
 07
Electrical Axis
What is the significance of
it?
 Electrical Axis

Normal LAD RAD Indeterminate

If the QRS complex If the QRS is upright If the QRS is If the QRS is
is upright (positive) in lead I (positive) predominantly downward (negative)
in both lead I and and downward in in lead I and
lead aVF (negative),
negative in lead I
lead aVF, then the downward (negative)
lead II is downward and positive in in lead aVF
axis is normal lead aVF
(negative)
 Chamber
Enlargement
Atrium & Ventricular
hypertrophy
4 types of Chamber Enlargement

Left atrial enlargement

wide P wave > 120 ms
Right atrial enlargement
M shaped P wave in lead II
P wave taller than 2.5 mm in lead II
biphasic P wave in lead V1 (initally
P wave is usually pointy
upward, terminal portion downward)
(P wave taller than 1.5 mm in lead
terminal portion of V1 is at least 1 little
V1 )
square wide
(P wave duration < 120 ms)
LAE
LAE (M-shaped P wave)
RAE
RAE
 4 types of Chamber Enlargement

Left Ventricular Hypertrophy Right Ventricular Hypertrophy

voltage criteria:
S in V1/2 + R in V5/6 > 35 or
R in aVL > 11 or tall upgoing R wave in V1 > 6 mm
R in aVL + S in V3 > 20 (women) or > 28 (men) R:S ratio > 1 in V1
ST segment changes typically will show:
ST segment deviation away from the QRS R:S ratio < 1 in V6
ST segment deviation is proportional to size of QRS in that lead right axis deviation (RAD)
ST depression will be concave away from the QRS in that lead
right atrial enlargement (RAE)
LVH (Sokolow and Lyons Criteria)
LVH (Cornell Criteria)
LVH (aVL Criteria)
ST and T changes
ST and T changes
ST and T changes
RVH
 Thanks
Do you have any questions?

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