L SS BASIC PRINCIPLES | 05 ¢ Justification | 09 ¢ Electrocardiogram waves |12 © How to interpret an ECG? | fifteen ¢ Rhythms you should know | 19 ANATOMY AND PHYSIOLOGY | twenty-one © Heart cells | 22 © Cardiac electrical system | 24 © Understanding blood supply | 25 NORMAL ECG | 26 €) HYPERTROPHY AND DILATION OF THE HEART | 32 © Definitions | 33 ¢ Atrial overload | 36L SS ARRHYTHMIAS | 42 ¢ Clinical manifestations | 43 * 5 basic types of arrhythmias | 47 DRIVING LOCK | FIFTY © Definitions and types of locks | 51 ¢ Atrioventricular block | 52 ¢ Branch Block|56 ¢ Hemiblock | 58 BRAND - STEPS | 61 * Contextualization | 62 © Clinical evidence | Sixty-five PRE-EXCITATION SYNDROME | 66 © Definition | 67 © Wolff-Parkinson-White syndrome | 68 e Lown-Ganong-Levine syndrome | 69 ISCHEMIA AND MYOCARDIAL INFARCTION | 70 © Myocardial infarction| 71 ¢ anginal 76SS ARRHYTHMIAS | 42 e Electrolyte disturbances and hypothermia | 79 ¢ Drugs and other disorders | 81 ¢ Lung disorders, CNS diseases and athlete's heart | 83 @) ECG CLINICAL CASESBASIC PRINCIPLES)... Fundamental reason © electrocardiogram waves © How to interpret an ECG? Rhythms you should knowElectrocardiogram: The ECG is a simple, low-cost test that records traces related to the electrical activity of the heart. The ECG looks at where electrical impulses start and how they flow through the heart. PAPER MILLIMETER of electrodes The father of the electrocardiogram was the Six limb leads: first to use graph paper. r ! | | | Clear lines: - t | small squares of 1x1 mm Dark lines: large5xSmmsquares LAES © Leftarm © Leftleg a Right arm Right leg s ° 4th EIC; Right parasternal v2 © Ath EIC; Left parasternal v3 |* Between V2 and V4 = © Sth EIC; Left mid-clavicular line vs © Between V4 and V6 v6 | © Sth EIC, mid-axillary line vr * Between V6 and V8 va © Inferior to the tip of the scapula i © Medial to V8 V3R © Between vil and VAR van © Sth EIC; Right mid-clavicular line Ath intercostal space “at 4 Shouderlade ieeever easSa aa a yt Chest pain vt palpitations Fainting: syncope or unexplained fall Difficulty breathing or dizziness mentioned above. Ventricular rate >120 bpm or <45 bpm atrial fibrillation complete heart block ST segment elevation or depression, Abnormal T wave inversion Excess full QRS width | a © eee’ © The patient's symptoms and physical examination guidel the interpretation of the | ECG. \ =! CP warnnasiens “> queues * The clinical status of the patient must always be taken into account. And any of these abnormalities can occur in a patient who presents with the signs and symptoms Ischemia, hypertension, sepsis Valvulopathy, alcoholism, ischemia infection. Any heart disease Infarction, ischemia Heart attack, ischemia, pulmonary embolism Any heart diseaseaa Ea) @ The waves are formed through electrical events in the heart, which produce basic ECG waves and lines. These events are made up of the following activities, in sequence: © Depolarization of the atria (first to the right, then to the left) - P wave ¢ Atrioventricular interval - PR interval * Depolarization of the ventricles - QRS complex * Repolarization of the atria - QRS © Repolarization of the ventricles: ST segment and T wave. PP interval distance between P waves) PQ lor A) Segment ee ‘TPinterval Pwave duration ® ‘wotz0ons | [2S] \\ wesenesy s QTintervalaCe) Ajd | + | 4 Qs kiy iti a ‘The fist wave is fe |The first (and only) The first wave is rR’ | ~ Baseline, so it should not be called an wave We'have ark Fragmented QRS complexes Note that we must obey three rules or the correct nomenclature of this complex. The first i: always fallow the alphabetical order, The second is: the "wave is always negative, the "r wave is always positive, and che "s* wave is always negative The third rule is: if a wave is not wide, it wil be 0 ¢ Always follow alphabetical order. © The “q” wave is always negative, the “r” wave is always positive, and the “s” wave is always negative. © Not very wide wave - lowercase letter, and if very wide wave - capital letter.L aT ‘SUMMARY © P wave: the first part of the wave reflects the activity of the right atrium and the second the left; PR segment: stops when the electrical current reaches the AV node; QRS complex: ventricular depolarization; T wave: ventricular repolarization; PR interval: time between the onset of atrial depolarization and the onset of ventricular depolarization; ST segment: time from the end of ventricular depolarization to the beginning of ventricular repolarization; QT interval: time from the beginning of ventricular depolarization to the end of ventricular repolarization; QRS interval: ventricular depolarization time.L ew BASIC NOTIONS aie 5 squares: 1s — ‘hig square : 200 ms n Mlitte square :40 ms R 10mm 1mv Normal appearance of an ECG T 1mm E | - 201 mv 2bigsquare 400 ms : Ky Normal heartbeat: P wave Q An ECG complex consists of 5 parts. followed by a QRS complex and a T wave. y ---4 RHYTHM ep FREQUENCY: — © Regular rhythm: the same ee 1 The closer the QRS complexes number of squares between each QRS complex. © Irregular rhythm: variable will be. number of squares between 1 1 are, the fasterthe heartbeat | 1 1 1 1 1 each QRS complex.L ew FREQUENCIES Irregular rhythm OC jane Regular rhythm / Frequency > 100 bpm and <4 large squares Sinus bradycardia Examples of P wave heart block SSS | bet { Abnormal conduction to the ' \ ventricles. iaihl SaBRS SUB SESIA SSENG ESSE Multiple P waves per QRS complex normal rytm Pees aus 2 hunaumee dunemee A : Absence of p waveECG INTERPRETATION © QRS complexes with more than © Ifthe QRS complex begins 3 small squares, the with a deep downward conduction of the ventricles is deviation, it may turn out abnormal. Perhaps because that this is an old electrical propagation is slow myocardial infarction. or because the electrical impulse started incorrectly. Ss Examples of width and Q wave Width changed fae eh Hillel QRS 23 cuadrados pequerios Ondas Q profundas Conduccién ventricular anormalL PAT sinus rhythm ECG CHANGES ct a the i | i fe One P wave for each QRS I Hee sudimuels complex. narrow complex tachycardia The P wave may or may not be visible. | L LI The QRS complex is narrow and the Halla rate >120 bpm. Wide complex tachycardia AA dL P waves are not visible. The JUGS vay vue QRS complex is wide and | the rate >120 bpm. complete heart block P P waves visible but not related to Soa QRS complexes. These can be $ eat ppd wide (frequent) or narrow. V vf PAT sinus arrhythmia inspiration expiration tH | ray ra One P wave for each QRS complex, but the complex is smaller during inspiration. extrasystoles \ PTT * supraventricular extrasystole ventricular extrasystole Irregular sinus rhythm with occasional extrasystoles. atrial fibrillation i LA Le ee Absence of P waves and generally narrow QRS complex. Ventricular fibrillation vertricubrentasrsle —yenrriular fbilation start SToegnenteevaion | tit t Absence of P waves and visible QRS complexes. Chaotic and irregular waveANATOMY ,, PHYSIOLOGY @ heart cells © cardiac electrical system © Understanding blood oyaa a CELL TYPES pacemaker cells Small cells that are capable of repeatedly and spontaneously depolarizing. Each depolarization serves as a normal wave source, which initiates the cardiac cycle of contraction and relaxation. * The group of these dominant cells in the heart is located in an elevated position in the right atrium, also called the sinoatrial (SA) node. Electrical conduction cells. pacemaker * Long, thin cells, like the wires in an electrical circuit, that carry current quickly and efficiently to different regions of the heart. The cells join together to form electrical pathways and ventricular conduction fibers, which make up the Purkinje system. © The atrial conduction pathways have greater anatomical variability and the fibers in the upper part of the septum allow rapid activation of the left atrium from the right. driving routes myocardic cells Atrial conduction system 5 Ventricular conduction systemaa a myocardial cells Cells responsible for the "heavy" work of the heart: contracting and relaxing repeatedly to supply blood to the entire body. They contain in abundance the contractile proteins actin and myosin, hence this function, and they also constitute the vast majority of cardiac tissue. © When depolarization reaches a myocardial cell, calcium is released into the cell. This mineral has the main role of mediator, which is why it is called excitation-contraction coupling. ° actina —miosina However, myocardial cells slowly spread throughout the myocardium.eee ELECTRIC SYSTEM © With the cycle of contraction (systole) and relaxation (diastole) of the heart, it is possible to concentrate the events of the electrical circuit of this organ, thus producing waves and basic lines of the ECG. * The entire cardiac electrical system has the ability to generate impulses, however, the sinus node, located in the right atrium, is the conductor of the heart. heart muscle cells Generation of impulse: N (action potential) a They form knots and bundles. There is, physiologically, a delay that the AV node imposes on the De conduction of the nervous impulse, In normal situations, there is only one way for the electrical stimulus to pass 1 ! and this is responsible for the | pale I from the atrium to the ventricle: itis L electrical silence between the P wave and the QRS complex.L CARDIAC SUPPLY SEQUENCE OF CARDIAC ELECTRICAL ACTIVITY AND ITS PRESENTATION IN THE ECG. Atal Ventricular myocardium myocar impute aves a AV nce Sinatra node depolarices Il Poe: i capctrzabn (cate Il ors complex: ert depart (ator) woe: veer apteton coven Tice * In some ECG cases a U wave can be observed at the end of the T wave. Its origin is still uncertain, however, if it follows a T wave it is considered normal, if it follows a flat T wave it may be pathological. Any deviation below the baseline that follows an R wave is called an S wave, regardless of whether or notit is preceded by a Q wave. aNORMAL ECG ‘Average axis Between Amplitude (mm) Up to |g ang 90° (positive in Onda P Up to 100 25 in 02 and 1.5 in V1. tes enev PR Interval 1200 200 > 5 in any derivative tion QRS complex Up to 120 of the frontal plane | Between -30° and + 90° (Position tive in D1 and 02). 8 in any derivation of the horizontal plane Up to 450 in men and QT Interval 460 in women Difference of up to 1 mm (V2 and V3 ST segment depend on sex and age) Follows the QRS axis. twave Up to 25% of the | Follows the T axis. Then U Up to 200 ms T wave * Normal pathway of cardiac electrical activation and the names of the segments, waves and intervals that are generated; * Orientation of all leads, in the horizontal plane; © Simple concept that each faucet records the average current flow at a given time;L UC \ ’ & * S> ital starts with the BASICS: : identify the patient, sex, age and past E 4 i history. 1500/19 = 79 bpm In an ECG with a speed of 25 mmis, one second will be recorded in 1500 squares. So 1500/X = heart rate Examples: 1500/5 = 300 0 1500/10 = 150 or 1500/15 =L UC Do waves and complexes always appear at equal intervals? SU a a Re eB Calculate the average heartbeat in 6 seconds and multiply it by 10. So how many beats are there in 6? x10 Image example: 7 beats x 10 = 70 bpm © Cannot exceed 100 ms in duration (2.5 squares)NORMAL ECG © It normally ranges between 121 and 200 ms, ie. > 3 and <5 “squares”, or better, 1 square. ® Itnormally lasts less than 100 ms, and should not exceed 120 ms, that is, three squares. ® As for the amplitude, it must be at least 5 mm in at least one cable in the frontal plane and 8 mm in at least one cable in the horizontal plane. © The end of the QRS complex is called the "J point." © Typically, the J point is at the same level as the baseline (PR interval isoelectric line) of the ECG, or up to 1mm offset up or down. t naentamenta de pont unevenness of point jNORMAL ECG * The normal T wave is concordant with the QRS and asymmetric. * Normal values for the QT interval are: above 450 ms for men and 460 ms for women. * Values less than 350 ms for men and 360 ms for women are considered abnormal. © It has the same polarity as the T wave. It lasts about 170 ms (¢ 30 ms) in adults and has an amplitude of up to 25% of the T wave amplitude. NORMAL 12-LEAD ECG -AA satel kG AND DILATION Ady © Definition e Atrial overload L \ y 'DEFINITIONS ®@ Itis the increase in muscle mass, in which the wall of your ventricle is thick and powerful. Normally, the heart is affected by pressure overload and is forced to pump blood against increased resistance. ® Itcan occur in patients with systemic hypertension or aortic stenosis. Dilatation Hypertrophy * Dilation and hypertrophy often coexist, as they are ways in which the heart attempts to increase cardiac output. @ Itis the enlargement of a certain chamber, in which the ventricle can contain more blood than a normal one. Normally, the heart is affected by volume overload and is forced to dilate to accommodate the volume.DEFINITIONS The ECG is not very good at distinguishing the two, however, the P wave represents atrial depolarization and assesses atrial enlargement, and the QRS complex to determine if there is ventricular hypertrophy. =I Three situations can occur with an ECG wave: © The chamber may take longer to depolarize and the wave may last longer. ¢@ The chamber can generate more current and consequently higher voltage and increase the amplitude. © A greater % of electrical current can flow through the expanded chamber and the electrical vector or axis of the wave can deviate. Normal wave on ECG ono | A duragao ECG wave with dilated or hypertrophied chamber. amplitude duragao. durationL DEFINITIONS © The term axis refers to the direction of the mean electrical vector, with the normal QRS axis being between 0° and 90°. ®@ Ifitis between 90° and 180°, there is a deviation to the right; between 0° and -90° there is a deviation to the left; and in rare cases, between -90° and 180°, it is called extreme right axis deviation. x0 Derivagao1 Derivagao avF e The concept of axis Eixo normal Positive Positivo deviation applies more to ventricular hypertrophy. Vector that represents the average of all others. ' It is the direction of the mean vector.a a © The normal P wave has a duration of less than 0.12 s anda greater deflection, positive or negative, and should not exceed 2.5mm; ® Lead Ilis useful because it registers a greater positive deflection and is sensitive to atrial depolarization. © Lead V1is useful because it is biphasic, allowing easy separation of the right and left atria. ‘tial dirsito atrial esquerdo ‘tral dreto atrial esquerdo right atrial left atrial right atrial left atrial component component component — component ]Pa mowrarmacoventoas © The amplitude of the first portion of the P wave increases - >2.5 mm, however, the width does not change, because the terminal componentis the left atrium. NORMAL RIGHT ATRIAL t ENLARGEMENT engtott erate t 4 tot f\ © There may also be indirect changes to the QRS complex, including: © qR morphology in V1; © >2x increase in amplitude from v1 to v2; © R>S in V1 and axis deviated to the right (> +90°) = lo | | Sodi Pallares's zodiac sign: ! ( a ) [ndicative of right ventricular} | ve = = | overload,duetogR | “™*” Cw) ! morphology in V1. vi vw ee -L a a i © Pwave 2 120 ms associated with another criterion that demonstrates that the left atrium has grown in its posterior axis. ¢ There may be changes, such as: © The negative portion of V1 lasts more than 40 ms and has an amplitude > 1mm (Morris index); * Pwave 2 120 ms in D2 + negative portion of the P wave in V1 2 40 ms; © Pwave 2 120 ms in D2, D3 or aVF alone (no association with prolonged duration in V1). LEFT ATRIAL ENLARGEMENT Morris sign is present in V1 and extends to V2, increasing its 1 1 specificity. Additionally, the duration of the P wave in the inferior 1 I leads is > 3 squares.