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ECGPrimer ChristianJacobus,MD RossUniversity IntroductiontoClinicalMedicine WhenIdictateECGsforapatientsmedicalrecord,Iusethefollowingformat:rate,rhythm,axis, intervals,hypertrophy,ischemia.Forexample,Therateis60,therhythmissinus,axisisminus45 degrees,intervalsarenormal,thereisnoevidenceofhypertrophy,andnosignsofischemia.Sothat's theorderinwhichI'mgoingtogooverthesetoday. Rate TherearetwoeasywaystofigureouttheheartratebylookingattheECG. 1) StandardECGsrecordfor10secondssoaneasywaytocalculatetherateistocountthenumber ofQRScomplexesononepageandmultiplybysixtogetthenumberinonefullminute. (#QRScomplexesononepage)*(6)=BPM 2) The300rule:countthenumberofbigboxesbetweentwoadjacentQRScomplexesanddivide 300bythatnumber.

ber.Soonebigboxbetweencomplexeswillmeanaheartrateof300;twobig boxeswouldbe150;threeis100;four is75;fiveis60;sixis50.Thisismost easilydonebyfindingonecomplexthat fallsrightontoadarkerlineand countingthenumberofbigboxesto thenextQRScomplex.Ifthenext complexfallsbetweenthelinesthen youcanestimatebasedontheline beforeandafter.Forexample,ifIfind anRwavethatfallsrightonadarkline, andthenextRwavefallsbetweenfour andfivebigboxeslater,thenIknowthe rateisbetween75and60.Ifitscloser tofourbigboxesthenImightestimate 70,closertofivebigboxesImightestimate65. (300)/(#bigboxesbetween2adjacentQRScomplexes)=BPM Rhythm First,somebasics.ThePwaveisatrialdepolarization;theQRScomplexisventricular depolarization;theTwaveisventricularrepolarization(atrialrepolarizationoccursatthesametimeas ventriculardepolarizationandsoislostintheQRScomplex).Whentheventriclesdepolarizenormally, currentmovesthroughtheHisPurkinjesystem,specializedcellsthatconductelectricalchargequickly, likeelectricalwiringfortheheart.Becausetheypropagatethatwaveofdepolarizationquickly,and becausetimeequalshorizontaldistanceonECG,anormalQRScomplexisnarrow. Incontrast,slowdepolarizationcausesawidenedQRScomplexbecausetimeisonthexaxisof anECG,asstatedabove.Forinstance,whendepolarizationstartsintheventricularmyocardiumand

spreadsfrommyocytetomyocyteitisnotusingtheHisPurkinjesystemandsodischargepropagates moreslowly.TheothercauseforawidenedQRSisablockintheHisPurkinjesystem,delaying depolarizationandwideningthecomplex. SinusrhythmisaregularrhythmwithaPwaveoccurringbeforeeveryQRScomplex.Theseare heartbeatsthatoriginateintheSAnode. JunctionalrhythmisanimpulsethatbeginsintheAVnoderatherthantheSAnode.IftheSA nodeisdiseasedorischemicitwillnotfunctionproperly,causingtheAVnodetohavetotakeover pacemakingduties.TheAVnodehasanintrinsicratethatisslowerthantheSAnode:4060bpm(vs. theSAnodewhichis60100).ThesecomplexesdontusuallyhaveaPwavebecausethechargestarts intheAVnodeandgoesdowntotheventricles.Atthesametime,thecurrentdoesgobackuptothe atria,butbecausethisoccursatthesametimeastheventriculardepolarization,thePwaveislostinthe QRScomplex.Ifthecurrentgetstotheatriaslightlybeforetheventricles,youmayseeinverted (becausethewaveofdepolarizationisgoingup,ratherthandown)Pwavesimmediatelybeforethe QRS.SoontheECGyoullseeslow,regular,narrowQRScomplexeswithnoPwavesbeforethemor invertedPwaves.

Anidioventricularrhythmoriginatesinthemyocardiumoftheventriclesthemselves.Incases wheretheSAnodeandtheAVnodearebothdiseasedorischemicandnotgeneratingimpulses,the ventricularmyocyteshavetotakeover.Theirintrinsicrateis2040bpm.Becausethechargesarenot travelingthroughtheHisPurkinjesystemthesecomplexeswillusuallybewideandbizarrelookingand theratewillbeslow.

Atrialfibrillation:inthisrhythmtheatriahaveuncoordinatedelectricalactivity,kindoflike they'rehavingaseizure.TheAVnodeisgettingbombardedwithelectricalsignalsbecauseofallthis electricalactivity.WhentheAVnoderesetsfromthepreviousfiring,itisreadytofireagainandwilllet thenextchargeitreceivesthrough,whichisthenconducteddowntotheventricles.Becausethecharge goesthroughtheAVnode,therestofthechargeisconductednormally,propagatingdowntheHis Purkinjesystem.AsaresulttheQRScomplexesarenarrow(i.e.normal).EverytimetheAVnoderesets itwaitsforthenextcurrent,whichstartsthecycleoveragain.Becausetheelectricalactivityintheatria

isuncoordinatedandunpredictablethenextchargecouldoccurinonemillisecondor1000.Thus,the frequencywithwhichachargeissentdowntotheventriclestoactuallygenerateaheartbeatis irregular.Sowhatyouseeisawavybaseline,causedbythefibrillatingatria,andirregular,narrow QRScomplexes.

SVT:thisisaprettynondescriptivename.SVTstandsforsupraventriculartachycardia,whichjust meansanytachycardia(rategreaterthan100)causedbydischargesabovetheventricles.Soanything fastandcomingfromabovetheventricleswouldqualify:sinus tachycardia,rapidafib,etc.Whatweusuallymeanwhenwe saySVTisactuallyAVNRT:AVnodalreentrytachycardia.The ideaisthatyouhaveapathwayinoraroundtheAVnode, which,inadditiontoconductingthechargedownthelengthof theventricles,alsoloopsbackuptowardstheAVnode.So whentheAVnodefiresmostofthechargecontinuesdownto theventriclesandmakethemfirenormally,butsomecharge willridethatloopingpathwaybackaround.IftheAVnodeis readytofireagainthatchargewillsetitoffearlierthanusual andyougetafastercycle:theAVnodefires,thechargeloops aroundandmakesitfireagain.Thiscanresultinheartratesof over200.Sothinkaboutwhatwe'dseeonECG.Pwaves? ProbablynotsincethechargeiscomingfromtheAVnodeso thisislikeajunctionalrhythm.SincethechargestartsintheAV nodeitdepolarizestheventriclesthenormalwaybutitdepolarizestheatriagoingup.Soyoumightsee aninvertedPwaverightbeforetheQRS(closerthanusual),youmightseenoPwaves(becauseitislost intheQRScomplex),oryoumightseealittlePwaveaftertheQRS.TheQRSwillbenarrow(normal) sincedepolarizationisoccurringdowntheHisPurkinjesystem.Classicallythiswillbeaveryfastrate withnarrowQRScomplexesandnoPwaves.IntheexamplebelowthesmallwavesbetweentheQRS complexesareTwaves,notPwaves.

Ventriculartachycardia:thisoccurswhenanirritatedareaofmyocardiumsomewhereinthe ventriclesstartstofireonitsown,withoutwaitingforachargefromtheHisPurkinjesystem.Irritation canbecausedbyischemia,electrolyteimbalance,trauma,orotherreasons.Themyocardiumstarts firingandjustkeepsgoing.Becausethecurrentstartsintheventricularmyocardium,thechargeisgoing tospreadmyocytetomyocyteratherthandowntheHisPurkinjesystem.SoonECGyou'llseewideQRS complexesoccurringataveryfastrate.IthinkthatitoftenlookslikeabunchofMcDonaldssignsina row.

Ventricularfibrillation:thisisuncoordinatedelectricalactivityintheventricles,justlikea seizure.Thereisnocoordinatedelectricalactivityatalland,hence,nocontraction.OnECGthisjust lookslikeawavyline.

Asystole:thisisnothing,noelectricalactivityatall.OnECGthislookslikeasimplestraightline.

Axis Meanelectricalaxis(MEA)isprobablythemostdifficultpartofECGinterpretationtoteach.SoIll giveyoumyquickanddirtymethodaswellasmymoreformalway.

Quick kanddirty:lookatleadIandaVFonthe eECG.LeadIisontheleft tsideofthep pagesoyourl left handisgo oingtorepres sentleadI.aV VFisontheri ightsideofth hepagesoyo ourrighthand dwillrepresent aVF.Point tyourthumb bsinthedirec ctionoftheQ QRScomplexineachlead,f forexampleifleadIismos stly positiveth hanyourleftthumbwillbepointingup p,ifleadaVFi isnegativeth henyourright tthumbwillb be pointingd down. Ifbothofyour rthumbsareup,meaningthattheQRScomplexesin nleadIandaVFaremainly y ositive,thenyou'reliketh heFonz(Aaaay!),twothum mbsupandth heaxisisnorm mal. po

humbisdown nthenyouhavealeftaxis Ifyourleftthumbisupandyourrightth deviation.

humbisupan ndyourlefton neisdownth henyouhavearightaxisd deviation. Ifyourrightth

Ifbothofyour rthumbsaredownthenyo ouhaveanex xtremerightaxisdeviatio onwhichisve ery unusual.

Them moreindepth hversion.We eneedtolayd downacoupl leofassumpt tionsfirst. 1) Weonlyusethelimble ) eadstocalculatethemean nelectricalax xis(I,II,III,aV VR,aVL,aVF). 2) AnECGlea ) adislikeaneyeball,itsees selectricity.IfIamanelec ctrodeandIs seeawaveof f depolariza ationcomingt towardsmeI'lldeflectthe eECGtracingup;ifIseeawaveof depolariza ationgoingaw wayfrommeI'lldeflectthe eECGtracing gdown;ifIse eeawaveof depolariza ationgoingpe erpendiculart tomeI'lldeflecteitherequallyupanddownornotatall.

othisismypreferredmethod. So

1) Findthelimbleadthatisthemostisoelectric(i.e.netdepolarizationzero) 2) Weknowfromnumbertwoabovethatthismeansthatthewaveofdepolarizationis travelingperpendiculartothelead,right? 3) Sofromlookingatthediagrambelow(amodificationofEinthovenstriangle)wecansee thatifweknowtheaxisisperpendiculartoaleadthenwehavetwochoices,itcanbe perpendicularcomingfromtherightoftheleadandgoingtotheleftofthelead,orthe otherwayaround.Forexample,lookingatthediagrambelow,iftheaxisisperpendicularto leadIIthenithastobeeither30or+150.Sowhichisit?Well,let'slookatthe perpendicularlead.IftheQRScomplexesaremorepositiveinthatleadthentheaxisis goingtowardthatlead;iftheyremorenegativethentheaxisisgoingawayfromthatlead. 4) Usethisaxisdrawingtohelp:

Examples:

SothemostisoelectricleadhereisaVL.

Sinceweknow,then,thatthemeanelectricalaxismustbegoingperpendiculartoaVL,then(by lookingatourleadsinthediagramabove)itmustbeeither+60or120. Todeterminewhichofthoseitis,welookattheleadthatisperpendiculartoaVL,whichislead II.IftheQRScomplexispositiveinIIthenitmeansthatcurrentiscomingtowardsitandtheaxis mustbe+60.IftheQRScomplexisnegative,thenchargemustbemovingawayfromitandthe axiswouldbe120. TheQRSinleadIIispositive,sotheaxisisabout60,whichisnormal,whichconfirmsour thumbsupmethod. Anotherexample:

ThemostisoelectricleadhereisaVR.aVFisprettyclose,butitseemstomelikeaVRismore equallyupanddown. SotheaxismustbeperpendiculartoaVRwhichwouldbe,whenlookingattheaxisdiagram above,+120or60.SowegototheleadperpendiculartoaVRtodecidewhichwaytheaxisis going,towards+120or60. TheleadperpendiculartoaVRisleadIII.LeadIIIislocatedat+120.Soifthecomplexispositive thenchargeismovingtowardstheleadandtheaxisis120;ifthecomplexisnegative,then chargeismovingawayfromtheleadandtheaxisis60. ThecomplexinleadIIIisnegative,sothatmeansthatthemeanelectricalaxisis60.Thisisaleft axisdeviation,andjiveswithourthumbsupmethod. Onemoreexample:

ThemostisoelectricleadhereisleadII.Soweknowthatthechargeismovingperpendicularto itwhichwouldbe+150or30. TofindoutwhichoneitiswelookattheleadthatisperpendiculartoleadIIwhichisaVL.We knowthataVLislocatedat30soifthecomplexinaVLispositivethenchargeismoving towardsaVLandtheaxisis30;ifthecomplexisnegativethenchargeismovingawayfromit andtheaxisis+150. TheQRScomplexinaVLisnegative,meaningthattheaxisis+150.Thisisarightaxisdeviation andalsocorrespondstoourthumbsupmethod.

Soafterdoingthatwecanseewhythethumbsupmethodworks.IfleadIandaVLarepositive thentheaxismustbesomewhereinthequadrantbetweenzeroand90sincethat'stheonlyareathat willmakebothleadspositive. Onastandard12leadECG,theperpendicularleadsarearrangedlikeso:

Ii isperpendicu ulartoaVF;IIisperpendicu ulartoaVL;IIIisperpendic culartoaVR. Intervals Th hemainECGintervalswemeasure arethePR Rinterval,the eQRSinterva al,andthe QTinterva al.Aquickwo ordondefinit tions, though:asegmentisa astretchofEC CGtracing occurringbetweentwo owaves,anin ntervalisa stretchof fECGtracingthatincludes satleast onewave e.SotheSTse egmentisthe earea betweent theSwavean ndthePwave e;theQT intervalis stheareafromthebeginn ningofthe Qwaveto otheendoft theTwave. Alsonotefrom mthisdiagram msomething thatittoo okmeyearstofigureout:theRwave istheentireportionof ftheQRScom mplexabove thebaseli ine,ratherthanjustthefir rstupslope; thesameappliesforth heQandSwa aves. PRinterval:thisameasureofthetime fromthebeginningofthePwaveto othebeginningoftheQRS Scomplex.A normalPRintervalis3to5 littleboxe esor0.12to0 0.20seconds. .Wewilllook katabnormal litiesofthePRintervalina afewminutes. ThePRint tervalprimar rilyrepresents sthedelayth hattheelectricalsignalund dergoesatth heAVnode.S Soa longPRin ntervalusually yindicatesso omekindofdiseaseattheAVnode. QRSinterval:t Q thisisameasurementfrom mthebeginni ingofthefirstwaveofthe eQRScomple exto theendofthelastwav ve.Itrepresentsthetimei ittakesforth heventriclest tocompletely ydepolarize. Remembe erwhatwesa aidearlier:no ormalconduc ctiontravelsthroughtheH HisPurkinjesy ystemandthus depolarize estheheartq quickly.SotheQRSshould dbenarrow,o orlessthanth hreelittlebox xes,0.12seco onds.

AwiderQRScomplexusuallymeansslowconductionintheventricleseither1)becausetheimpulse startedintheventriclesandisspreadingmyocytetomyocyteratherthanusingtheHisPurkinjesystem or2)becauseofadefectorablockinoneofthebundlebranchesoftheHisPurkinjesystem.Moreon thoseinafewminutes. QTinterval:theQTintervalismeasuredfromthebeginningoftheQRScomplextotheendof theTwave.Itisameasureofthetimefromthebeginningofdepolarizationtotheendofrepolarization butsincedepolarizationissoshortitismainlyameasureofthetimetorepolarizetheventricles.The QTintervalwillchange,though,dependingontheheartrate.Aheartbeatingfastneedsashort repolarizationtimewhileonebeatingslowlycantakelonger.SoweapplyacorrectiontotheQTinterval toaccountfortheheartrate.ItiscalledtheQTc(QTcorrected).TheformulaisQTdividedbythesquare rootoftheRRinterval: AnormalQTcislessthan0.44seconds(11littleboxes).Ausefulquickanddirtymethodfor checkingtheQTcistodrawalineverticallyupfromtheendoftheTwave.Nowdrawalinebetweenthe topoftheRwavebeforeandthetopoftheRwaveafter.IftheendoftheTwaveislessthanhalfthe waytothenextRthenit'slikelyinthenormalrange.LongQTsyndromecanbecongenitaloracquired andisdangerousbecauseitcanleadtoTorsadesdePointe. Example:

Inthisexample,theendoftheTwavefallslessthanhalfwaybetweenthe2Rwaves,andsois mostlikelynormal. Anotherexample:

Inthisexample,theendoftheTwavefallsmorethanhalfofthedistancetothenextRwave andsoisprolonged.

PRintervalabnormalities/AVBlocks:aswesaidbefore,alongPRintervalusuallymeanssome sortofpathologyattheAVnodesincethePRintervalmainlymeasurestimebetweenatrial depolarizationandventriculardepolarization,thetimewhenthechargeisbeingdelayedbytheAV node.Solet'stalkaboutafewblocks,therearefourthatyouneedtoknow. Firstdegree:thisissimplyalongerthanusualdelayattheAVnode,manifestedbyafixedPR intervalthatislongerthan0.20seconds.Itisbenignanddoesn'tneedanyimmediate treatment. 8littleboxes=0.32sec

SeconddegreetypeI:thisisaPRintervalthatgetslongerwitheachbeatuntiliteventually blocksthedepolarizationcompletelyleadingtoadroppedQRScomplex.It'salsoknownas MobitzIorWenckebach.(Ifyouhaven'talreadyseenitIhighlyrecommendwatchingDiagnosis

Normal

Long

Longer

DroppedQRS

WenckebachonYouTube.)Thisisalsoabenignrhythmandneedsnourgentintervention. SeconddegreetypeII:thisisaPRintervalthatisnormalandunchangingwiththeexception thatoccasionallythePwaveswilloccurwithoutaQRSi.e.theAVnodeblockstransmission ofanimpulsefromtheatriatotheventriclescompletely.Thisisconsideredamalignantblock duetoitstendencytodeteriorateintoathirddegreeheartblock. DroppedQRS DroppedQRS

hirddegree(c completehea artblock):thisiswherethereisacomp pleteelectrica aldisconnecti ion Th be etweenthea atriaandthev ventricles.Th heatriacontin nuetobeatas susualprodu ucingregularP wavesbutnon w neofthoseat trialdepolariz zationsarege ettingconduc cteddowntotheventricles.To th heventricles,itappearsas siftheSAand dAVnodesha avestoppedw workingcompletelyandth hus th heventriclesneedtotakeoverpacema akingdutiesthemselves.Sowhatyouse eeonthestri ipis re egularPwavesandregula arQRScompl lexesbutocc curringatcom mpletelydiffe erentrates.There is snoconnectio onbetweent thematall.Th heQRScomp plexescanbenarroworwi ide.Thisisalife th hreateningblockandmandatesurgentintervention, ,usuallyapacemaker.The ePwavesare e markedbelow m w,youcansee ethattheysee emtomarchthroughtheQRScomplex xeswithoutany re egardforano ormalorder.

AshortPRinterval l,inconjuncti ionwithadeltawave(circ cledingreenbelow),impliesthepresen nce ofanacce essorypathwaybetweent theatriaandtheventricles s,suchasinW WolffParkins sonWhite.Th hePR intervalis sshorterbeca ausethedepo olarizationcangostraightfromtheatri iadownintotheventricles s withoutg goingthroughthedelayattheAVnode.

QRSin ntervalabnor rmalities/Bun ndleBranchB Blocks:aswes saidearlier,theQRSinterv valrepresent tsthe timeittak kesfortheve entriclestofullydepolarize e.Thiscanbe edelayedforo oneoftwore easons:1)an impulseth hatstartsint theventricles sandhastospreadmyocytetomyocyte e,whichisslo owerthanthe eHis Purkinjes system,or2)animpulseth hatstartsnor rmallybutthe enhitsacond ductionblockintheHis

Purkinjes systemintheventricles.Th hetwomainconductionb blockswewilldiscussintheventriclesa are leftandri ightbundlebranchblocks. . Asyoumayremem mber,thebun ndleofHissplitsintotwob bundlebranches,thelefta andright.A ofeitheroneofthesebran ncheswillcau useawideQR RScomplexdu uetoadelayincomplete blockingo depolariza ation.Therei isagooddesc criptionofwh hythecharac cteristicECGf findingsoccuronpages15 52to 158ofDavis,Quickand dAccurate12 2LeadECGIn nterpretation. .Forourpurp posesarightb bundlebranc ch blockwillhaveaQRSd durationgrea aterthanthre eelittleboxe es(0.12secon nds)andapo ositiveQRS complex( (oftenwithbunnyears:aQRScomplex xthathastw wopositivede eflections,anRandanR,use yourimag gination)inV V1whichison ntherightsid deoftheches st.Aleftbundlebranchblockwillalsohave aQRScom mplexgreaterthan0.12se econdsanda apositiveQRS Scomplex(al lsooftenwith hbunnyears s)in V6whichisontheleft tsideofthec chest. LBBB: :

RBBB:

Hypertrop phy Ventricularhypertrophyisg goingtobeourmainfocus sbutwewilltouchbriefly onatrial hypertrop phyaswell.D DiagnosingLVHandRVHisreallyjustam matterofrem memberingfo ormulasand countingboxes. LVH:t therearethre eemainform mulastoknow wforLVH;ifan nECGmeetsanyoneofth hesecriteriaitcan bediagno osedasLVH. Sokolow Criteria: 1) Th heSwaveinV1(blue)plustheRwave inV5orV6(g green)isgrea aterthanore equalto35mm(7 bigboxes). 2) Th heRwaveinaVL(red)isg greaterthano orequalto11 1mm

3) TheRwaveinV5orV6(purple)isgreaterthanorequalto27mm.

25mm

22mm

21mm

37mm

Ifyounotice,allofthesecriteriahaveincommonthatyouarelookingforabigpositivedeflection ontheleft(aVLandV5andV6)andabignegativedeflectionintherightleads(V1). RVH:sameidea,youonlyneedtomeetoneofthecriteriabelow,buttheformulasare:

1. RwaveinV1(purple)isgre eaterthanthe eSwaveinV1 1 2. th heRwaveinV V1plustheSwaveinV6is sgreaterthan norequalto11mm.

Again,hereweareloo okingforabig gpositivedefl lectionintherightsidedle eads(V1)and dabignegativ ve deflection nintheleftsi idedleads(V6 6). Leftatrialhypertro ophy:therearetwomainc criteriatoloo okforinlefta atrialhypertro ophy: 1) anotchedorM MshapedPw waveinleadII.Theleftatrialdepolarizationisdelaye eddueto hypertrophya andsothefirs stpeakisthe edepolarizatio onoftherigh htatrium,the e distentionorh se econdpeakis sthedepolari izationoftheleftatrium.T Theyareboth hpositivewhenseenfrom mthe bo ottomleftofthebodywhichiswherel leadIIislookingfrom.This sfindingisca alledPmitrale e whichishandy w ybecausethe eleadIIPwaveslookslike eanM. 2) Alargenegativ veportionofthePwavein nV1.V1ison ntheanterior rchestsowhe entheright triumdepolarizesthechar rgemovestow wardsthelea adgivingapo ositivedeflect tion.Whenth heleft at at triumdepolarizes,because etheleftatriumismorep posterior,thechargemove esposteriorly y re esultinginan negativedefle ection.Soifth heleftatrium mishypertrop phiedyou'llge etalarge ne egativedefle ectionintheP Pwaveoflea adV1.

Rightatrialhypertrophy:therig ghtatriumde epolarizesdow wnandtothe eleft,almostdirectlytowa ards leadII.So oinrightatria alhypertrophy ytherewillbetallPwave esinleadII,b biggerthan2. .4mm.

Ischemia Th herearethre eemainECGs signstolookf forwhenconcernedabout tischemiaorinfarction: 1) T waveinversions:Ihavebeenunableto ofindasatisf factoryelectrophysiologica alexplanation nfor whythisoccur w rs,butitdoes s.Ischemiaha ascomplexef ffectsonthed depolarizatio onand re epolarizationofcardiacmy yocytes.Inm myocardialisch hemiaorinfarctionthedir rectionof re epolarizationreversesand dtheTwave,normallyupr rightinalllea adsexceptaVR,inverts.Th hese ch hangescanre epresentcurr rentorrecent tischemia.Us sually,inthecaseofaninf farction,they ywill pe ersistforwee ekstomonths sbeforenorm malizing.

2) Q Qwaves:Qwa aves(theinitialnegativedeflectionofa aQRScomple ex)areconsideredpatholo ogicif th heyare: a. widerthan0.04sec conds(onelit ttlebox)or b. greate erthanoneth hirdoftheheightoftheR wave fromt thesamecom mplex.

Th heydevelopb becauseanin nfarctingorin nfarctedareaofmyocardiu umdoesnotconduct el lectricity.Sow whenanelec ctrodeisoveranareaofin nfarctionther reisnowaveofdepolariza ation movingtoward m dsitbuttheo oppositevent triclehasawaveofdepola arizationmov vingaway,soyou ge etanegativedeflection.T ThepresenceoftheQwavesindicatesa afullthicknes ssortransmu ural in nfarction.The eyusuallyper rsistforthere estofthepatient'slife.Sothepresence eofQwaveswith no oothersigns sofischemia(Twaveinve ersionorSTse egmentchan nges)indicate esanold tr ransmuralinf farction.Note ethepresenc ceofQwaves sinIII,aVF,V1,V2,andV3below.

3) ST Tsegmentch hanges:aswe ementionedinthesectiononTwavein nversions,ischemiaand in nfarctionhave easignificant teffectonthewayapiece eofmyocardi iumcanhand dlecharge.Inan ac cuteinfarctio onthechange einpotentialbetweenthe eischemicmy yocardiumandhealthy myocardiumcreatesanelectrochemicalgradientand m dchargeflowsbetweenth hoseareas.Th hisis ca alledthecur rrentofinjury y.Thesecurr rentsareman nifestedasST Tsegmentele evationsor de epressions.Forreasonsto oodetailedfo orinclusionhe ere,afullthic cknessinfarct tionwillgene erate ST Televationso overtheaffectedregiona andasubend docardialinfa arctionwillge enerateST de epressions.K Keepinmind,though,theS STdepression nscanbe"rec ciprocalchan nges"ofST el levations.The eideaisthatthataleadth hat'slookingintheopposi itedirectionf fromthelead dwith ST Televationsw willseetheopposite:STdepression.Intheexamplebelownotet thepresenceof se evereSTelevationsinII,III,andaVF,withreciprocal lSTdepressio onsinV1V3 3.