have a negative polarity.

The overall area equals the sum of the posi-

tive and the negative areas.
Second, the area in each lead (typically, two are chosen) is repre-
Superior sented as a vector oriented along the appropriate lead axis in the
hexaxial reference system (see Fig. 12-6), and the mean electrical axis
equals the resultant or vector sum of the two vectors. An axis directed
− 90°
− 120° − 60° toward the positive end of the lead axis of lead I—that DIAGNOSTIC
is, oriented
directly away from the right arm and toward the left arm—is desig-
CRITERIA FOR RIGHT VENTRICULAR HYPERTHROPHY
− 30°
R IN V
nated as an axis of 0 degrees. Axes oriented in a clockwise 1 ≥ 0.7 mV
direction R in V5 or V6 ≥ 0.4mV with S in V1 ≤
− 150° from this zero level are assigned positive values, and those oriented
aV
R aV
L
in a counterclockwise direction are assigned negative values.
0.2 mV
I
QR
The mean electrical axis during ventricular activation inhorizon-
in the V1 Right axis deviation ( > 90 degrees)
± 180° 0° tal plane can be computed in an analogous manner by using the areas
under and lead axes of the six precordial leads (see R/S in V
Fig. 12-4, 1 > 1 with R > 0.5
right). S1Q3 pattern
A horizontal plane axis located along the lead axis R/Sof lead
in VV56 oris V < 1 S1S2S3 pattern
assigned a value of 0 degrees, and those directed more anteriorly have 6
+ 30°
+ 150° S in V5 or V6 > 0.7 mV P pulmonale

aVF
positive values.

II
III
This process can be applied to compute the mean electrical axis for
other phases of cardiac activity. Thus the mean force during atrial
+ 120° + 60°
activation is represented by the areas under the P wave, and the mean
+ 90° DIAGNOSTIC CRITERIA
force during ventricular recovery is represented by the areas under the
FOR LEFT VENTRICULAR HYPERTHROPHY
ST-T wave. Sokolow-lyon voltage SV1 + RV5 > 3.5 mV
Electrocardiographic Processing and Display Systems RaVL > 1.1 mV
Right Inferior Left ECG recording using computerized systems involves six steps: (1) signal
Cornell voltage criteria SV3 + RaVL ≥ 2.8 mV (for men)
acquisition; (2) data transformation; (3) waveform recognition and
FIGURE 12-6 The hexaxial reference system constructed from the lead axes of
ECG LESION
the six frontal plane leads. The lead axes of the six frontal plane leads have been
feature extraction; (4) diagnostic classification; (5) data compression
1
SV3 + RaVL > 2.0 mV (for women)
and storage; and (6) display of the final ECG.
PATTERNS
rearranged so that OF LOCATION
their centers overlie one another. These axes divide the plane Cornell
Signal Acquisition. Signal acquisition steps include amplifying regression
the equation Risk of LVH = 1/(1+e –exp)
ST12ELEVATION
into segments, each subtending 30 degrees. Positive ends of each axis are
recorded signals, converting the analog signals into Cornell
digital form,voltage
labeled with the name of the lead.
OR Q-WAVES filtering the signals to reduce noise. The standard amplifier gain for
and duration QRS duration x cornell voltage > 2,436
V1-2 Septal routine electrocardiography is 1000. Lower (e.g., 500measurement
or half-standard) mm-sec
Hexaxial Reference Frame and Electrical Axis. The Apical
lead axes of
or higher (e.g., 2000 or double-standard) gains may be used to com-
pensate for unusually large or small signals, respectively.
QRS duration x sum of voltage in all
theV1-2 to V4-6plane leads can be superimposed to produce the
six frontal anteroseptal Analog signals are converted to a digital form at rates of 1000/ leads > 1,742 mm-sec
hexaxial reference system. As depicted in Figure 12-6, the six lead second (1000 Hz) to as high as 15,000 Hz. Too low a sampling rate
V1-6the frontal plane into 12 segments, each
axes divide Extensive
subtending 30 will miss brief signals such as notches in QRS complexes or pacemaker
occasionally
degrees. LAD spikes and will result in altered waveform morphologies. Too fast a
These concepts allow calculation of the mean anterior
electrical axis of the
DIAGNOSTIC
sampling rate may introduce artifacts, including high-frequency noise,
CRITERIA FOR LEFT BUNDLE BRANCH BLOCK
aVL and I
heart. The orientation of the mean electrical axis represents the direc- and will generate excessive amounts of data necessitating extensive
aVI and I, V2-3 Limited
tion of activation in an “average” cardiac fiber. This direction is deter- digital storage capacity. - QRS duration ≥ 120 msec
mined by the properties of the cardiac conduction anterior
system and ECG potentials are then filtered to reduce unwanted, distorting
- Broad, notched, or slurred R waves in leads I, aVL V5 and V6
activation properties of the myocardium. Differences in the relation signals. Low-pass filters reduce the distortions caused by high-
I and
of aVL,
cardiac to V5-6 LCX relatively littleLateral
torso anatomy contribute to shifts in the frequency interference from, for example, muscle tremor- Small or absent initial r waves in right precordial leads (V1 and V2) followed
and external
axis.Reciprocal
As described further on, this measurement is an important part electrical devices; high-pass filters reduce the effects of body motion
changes
of diagnostic in criteria
V1-2 for chamber enlargement and conduction system by deep
or respiration. For routine electrocardiography, the standards set byS waves
defects. professional groups require an overall bandwidth of- 0.05 Absent
to 150 Hzseptal q waves in leads I, V5 and V6
II, III, aVF RCA, LCX Inferior
The process for computing the mean electrical axis during ventricu- 1
for adults. Narrower filter settings, such as 1 to 30 Hz, as commonly
II,
lar III, aVF. I inand
activation Infero-lateral
the frontal plane is illustrated in Figure 12-7. First, used in rhythm monitoring, will reduce baseline wander - Prolonged
related to time to peak R wave (>60 msec) in V5 and V6
the aVL,
mean V5-6force during activation is represented by the area under the motion and respiration but may result in significant distortion of both
QRSReciprocal
waveform, measured as millivolt-milliseconds. Areas above the the QRS complex (including width, amplitude, and Q wave patterns)
baseline are assigned a positive polarity and those below the baseline
changes in V1-2
and the ST-T wave.1 DIAGNOSTIC CRITERIA FOR RIGHT BUNDLE BRANCH BLOCK
- QRS duration ≥ 0.12 sec (3 small boxes)
DIAGNOSTIC CRITERIA FOR RIGHT ATRIAL ABNORMALITY - Rsr’ , rsR’ , or rSR’ , patterns in lead V1 and V2
- S waves in leads I and V6 ≥ 0.4 sec (1 small box) wide
- Peaked P waves with amplitude in lead II to > 0.25 mV (“P pulmonale”)
- Normal time to peak R wave in leads V5 and V6, > 50 msec in V1
- Prominent initial positivity in lead V1 or V2 > 0.15 mV
(1.5 mm at usual gain)
- Increased area under initial positive portion of the P wave in lead V1 to > 0.06 DIAGNOSTIC CRITERIA FOR LEFT POSTERIOR FASCICULAR BLOCK
mm-sec - Frontal plane mean QRS axis deviation between +90 and +180 degrees
- Rightward shift of mean P wave axis to more than +75 degrees - rS pattern in leads I and aVL with qR patterns in leads III and aVF
- QRS duration < 0.12 sec (3 small boxes)
- Exclusion of other factors causing right axis deviation (e.g. right ventricular
DIAGNOSTIC CRITERIA FOR LEFT ATRIAL ABNORMALITY overload patterns, lateral infarction)
- Prolonged P wave duration to > 0.12 sec in lead II
- Prominent notching of P wave, usually most obvious in lead II, while the DIAGNOSTIC CRITERIA FOR LEFT ANTERIOR FASCICULAR BLOCK
interval between notches of > 0.40 sec (“P mitrale’) - Frontal plane mean QRS axis deviation -45 and -90 degrees
- Ratio between the duration of the P wave in lead II and duration of the PR - qR pattern in lead aVL
segment > 1.6 - QRS duration < 0.12 msec
- Increased duration and depth of terminal-negative portion of P wave in lead - Time to peak R wave in aVL ≥ 0.45 sec
V1 (P terminal force) so that area subtended by it > 0.04mm-sec
- Leftward shift of mean P wave axis between -30 and -45 degrees
 DIAGNOSTIC CRITERIA FOR LOW VOLTAGE LIMB LEADS UNIVERSITY OF SANTO TOMAS HOSPITAL
- Amplitude of the QRS complex in each of the 3 standard limb leads (I, II, III) is DEPARTMENT OF MEDICINE
<5 mm
- Average voltage in the limb leads is <5 mm SECTION OF CARDIOLOGY
- Average voltage in the chest leads is <10 mm

DIAGNOSTIC CRITERIA FOR OLD INFARCT

-
-
-
Presence of abnormal Q waves (≥ 0.04 secs) in the ff leads:
II, III, aVF (inferior wall)
V1-V4 (anterior wall)
ECG @ 2018
- I, avL, V5-V6 (lateral wall)
Keep It Short & Simple
Benavides Cancer Institute Auditorium
DIAGNOSTIC CRITERIA FOR MYOCARDIAL INFARCTION
November 23, 2018
0.1 mV or 1 mm ST-segment elevation in ALL LEADS except V2 and V3

ST-segment elevation in leads V2 and V3 of:

- 0.2 mV or 2 mm in Men ≥ 40 years old
- 0.25 mV or 2.5 mm in Men < 40 years old
- 0.15 mV or 1.5 mm in Women

DIAGNOSTIC CRITERIA FOR MYOCARDIAL ISCHEMIA

Abnormal ST depression:
- 0.05 mV or 0.5 mm (1/2 small box) in leads V2 and V3
- 0.1 mV or 1 mm (1 small box) in all other leads

T wave inversion of > 0.2 mV or 2 mm (2 small boxes)

NORMAL VALUES FOR DURATION OF ELECTROCARDIOGRAM WAVES

AND INTERVALS IN ADULTS
References:
• Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 10th Edition P wave ≤ 0.12 sec
• AHA/ACC/HRS Recommendations for Standardization and Interpretation of the ≤ 3 small boxes
Electrocardiogram (2009) PR interval ≤ 0.20 sec
• O’Connor, Robert E., William Brady, Steven C. Brooks, Deborah Diercks, ≤ 5 small boxes
Jonathan Egan, Chris Ghaemmaghami, Venu Menon, Brian J. O’Neil, Andrew H. QRS duration ≤ 0.10-0.12 sec
Travers, and Demetris Yannopoulos. 2010. “Part 10: Acute Coronary ≤ 3 small boxes
Syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary QT interval (Corrected) ≤ 0.45 sec or 11.25 small boxes (men)
Resuscitation and Emergency Cardiovascular Care.” Circulation. ≤ 0.46 sec or 11.5 small boxes (women)