You are on page 1of 25

ECG diagnosis

Aims

• 10 ECG rules
• ECG signs of M.I.
• Evolution of changes in M.I.
• Classical Appearences
QRS waveform nomenclature

R r qR qRs Qrs QS

Qr Rs rS qs rSr’ rSR’
The 10 rules for a normal ECG

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

.2
Rule 1

1.0 R

PR
interval
0.5
T
PR interval should be 120 to
Millivolts

P 200 milliseconds or 3 to 5 little


Q
0 squares

-0.5 S

0 200 400 600

Milliseconds
Rule 2

1.0 R

0.5
T
The width of the QRS complex
Millivolts

P should not exceed 110 ms, less


Q
0 than 3 little squares

-0.5 S
QRS

0 200 400 600

Milliseconds
Rule 3

I II III aVR aVL aVF

The QRS complex should be


dominantly upright in leads I and II
Rule 4

I II III aVR aVL aVF

QRS and T waves tend to have the


same general direction in the limb
leads
Rule 5

P All waves are negative in lead aVR

Q S
Rule 6
V6
V5
V4
V3
V2
V1

The R wave in the precordial leads must grow from V1 to at least V4


Rule 7

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

The ST segment should start isoelectric except in V1 and


V2 where it may be elevated
Rule 8

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

The P waves should be upright in I, II, and V2 to V6


Rule 9

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

There should be no Q wave or only a small q less than


0.04 seconds in width in I, II, V2 to V6
Rule 10

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

The T wave must be upright in I, II, V2 to V6


Characteristic changes in AMI

• ST segment elevation over area of damage


• ST depression in leads opposite infarction
• Pathological Q waves
• Reduced R waves
• Inverted T waves
ST elevation

R • Occurs in the early stages


ST • Occurs in the leads facing the
P infarction
• Slight ST elevation may be
Q
normal in V1 or V2
Deep Q wave

• Only diagnostic change of


R myocardial infarction
ST

P
• At least 0.04 seconds in duration

T
• Depth of more than 25% of
Q
ensuing R wave
T wave changes

• Late change
R
• Occurs as ST elevation is
ST
P returning to normal
• Apparent in many leads
T
Q
Bundle branch block
Anterior wall MI Left bundle branch block
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Sequence of changes in evolving AMI

R
R R
ST ST
T
P P P

T
Q S Q
Q

1 minute after onset 1 hour or so after onset A few hours after onset

ST T
P P ST
P

T T
Q Q Q

A day or so after onset Later changes A few months after AMI


Anterior infarction
Anterior infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left
coronary
artery
Inferior infarction
Inferior infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Right
coronary
artery
Lateral infarction
Lateral infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left
circumflex
coronary
artery
Location of infarct combinations

I aVR V1 V4

ANT
LATERAL POST ANT
II aVL V2
SEPTAL
V5

ANT
V3 V6 LAT
III aVF
INFERIOR
Diagnostic criteria for AMI

• Q wave duration of more than 0.04


seconds
• Q wave depth of more than 25% of
ensuing r wave
• ST elevation in leads facing infarct (or
depression in opposite leads)
• Deep T wave inversion overlying and
adjacent to infarct
• Cardiac arrhythmias

You might also like