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ECG INTERPRETATION

dr. Infan Ketaren SpJP-FIHA


SMF Kardiologi & Pembuluh Darah
RSUD Soedarso/FK Untan
Pontianak
The ECG

The ECG (electrocardiogram) is a transthoracic


interpretation of the electrical activity of the
heart.
The ECG
Why perform an ECG?
Its part of the admission bundle
Indicated by the patients symptoms
- symptoms of IHD/MI
- symptoms associated with dysrhythmias
Indicated by the patients examination findings
- cardiac murmur
Lead Placement

aVF
All Limb Leads
Precordial Leads
EKG Distributions

Anteroseptal: V1, V2, V3, V4


Anterior: V1V4
Anterolateral: V4V6, I, aVL
Lateral: I and aVL
Inferior: II, III, and aVF
Inferolateral: II, III, aVF, and V5
and V6
ECG interpretation
Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval
Quality of the ECG
Patient name
Date of the ECG
Is there any interference?
Is there electrical activity from all 12 leads?

Calibration:
- speed = 25mm/second
- height = 1cm/mV
Calibration
Calibration
ECG interpretation
Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval
Rate
300/number of big squares between R waves

Rate is either:
- normal
- bradycardic
- tachycardic
Rate
Rule of 300- Divide 300 by the number of
boxes between each QRS = rate
Number of big Rate
boxes
1 300
2 150
3 100
4 75
5 60
6 50
Rate
HR of 60-100 per minute is normal
HR > 100 = tachycardia
HR < 60 = bradycardia
Differential Diagnosis of Tachycardia

Tachycardia Narrow Complex Wide Complex


Regular ST ST w/ aberrancy
SVT SVT w/ aberrancy
Atrial flutter VT
Irregular A-fib A-fib w/ aberrancy
A-flutter w/ A-fib w/ WPW
variable conduction VT
MAT
What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm
Rate
Rhythm

Are there P waves?


Are they regular?
Does one precede every QRS complex?

Regular vs. irregular


Rhythm

Sinus
Originating from SA
node
P wave before
every QRS
P wave in same
direction as QRS
What is this rhythm?
Normal sinus rhythm
Axis
Axis
The QRS Axis
Represents the overall direction of the hearts activity
Axis of 30 to +90 degrees is normal
The Quadrant Approach

QRS up in I and up in aVF = Normal


Axis

Positive in I and
II = NORMAL

Positive in I and
negative in II =
LAD

Negative in I and
positive in II =
RAD
Axis
ECG interpretation
Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval
P wave
Are there P waves present?

Bifid = P mitrale (LA hypertrophy)


Pointy = P pulmonale (RA hypertrophy)
P mitrale
P pulmonale
PR interval
Start of P wave to start of QRS complex

Normal = 0.12 - 0.2 seconds (3-5 small squares)

Decreased = can indicate an accessory pathway

Increased = indicates AV block (1st/2nd/3rd)


Normal Intervals

PR
0.20 sec (less than one
large box)
QRS
0.08 0.10 sec (1-2 small
boxes)
QT
450 ms in men, 460 ms in
women
Based on sex / heart rate
Half the R-R interval with
normal HR
ECG interpretation
Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval
QRS complex
Normal = <0.12 seconds

>0.12 seconds = Bundle Branch Block


QRS complex

W I LL ia m = LBBB

M a RR o w = RBBB
QRS complex
Is there LVH?

Sum of the Q or S wave in V1 and the tallest R


wave in V5 or V6
>35mm is suggestive of LVH
Hypertrophy
Add the larger S wave of V1 or V2 in mm, to
the larger R wave of V5 or V6.
Sum is > 35mm = LVH
Q waves
Q waves are allowed in V1, aVR & III

Pathological Q waves can indicate previous MI


ECG interpretation
Quality of ECG?

Rate
Rhythm
Axis

P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval
ST segment
ST depression
- downsloping or horizontal = ABNORMAL

ST elevation
- infarction
- pericarditis (widespread)
Ischemia
Usually indicated by ST changes
Elevation = Acute infarction
Depression = Ischemia
Can manifest as T wave changes
Remote ischemia shown by q waves
ST segment
ST segment
ST segment
What is the diagnosis?
Acute inferior MI with ST elevation in leads
II, III, aVF
What do you see in this EKG?
ST depression II, III, aVF, V3-V6 = ischemia
T wave
Small = hypokalaemia

Tall = hyperkalaemia

Inverted/biphasic = ischaemia/previous infarct


T wave
T wave
T wave
QT interval
Start of QRS to end of T wave

Needs to be corrected for HR

Normal QTc = < 400ms

Long QT can be genetic or iatrogenic


QT interval
Prolonged QT
Normal
Men 450ms
Women 460ms
Corrected QT (QTc)
QTm/(R-R)
Causes
Drugs (Na channel blockers)
Hypocalcemia, hypomagnesemia, hypokalemia
Hypothermia
AMI
Congenital
Increased ICP
Blocks
AV blocks
First degree block
PR interval fixed and > 0.2 sec
Second degree block, Mobitz type 1
PR gradually lengthened, then drop QRS
Second degree block, Mobitz type 2
PR fixed, but drop QRS randomly
Type 3 block
PR and QRS dissociated
What is this rhythm?
First degree AV block PR is fixed
and longer than 0.2 sec
What is this rhythm?

Type 1 second degree block (Wenckebach)


What is this rhythm?

Type 2 second degree AV block Dropped QRS


What is this rhythm?
3rd degree heart block (complete)
ECG quiz
ECG 1
ECG 2
ECG 3
ECG 4
Normal Sinus Rhythm

Mattu, 2003
First Degree Heart Block

PR interval >200ms
Accelerated Idioventricular

Ventricular escape rhythm, 40-110 bpm


Seen in AMI, a marker of reperfusion
Junctional Rhythm

Rate 40-60, no p waves, narrow complex QRS


Hyperkalemia

Tall, narrow and symmetric T waves


Premature Atrial Contractions

Trigeminy pattern
Atrial Flutter with Variable Block

Sawtooth waves
Typically at HR of 150
Torsades de Pointes

Notice twisting pattern


Treatment: Magnesium 2 grams IV
Digitalis

Dubin, 4th ed. 1989


Lateral MI

Reciprocal changes
Inferolateral MI

ST elevation II, III, aVF


ST depression in aVL, V1-V3 are reciprocal changes
Anterolateral / Inferior Ischemia

LVH, AV junctional rhythm, bradycardia


Left Bundle Branch Block

Monophasic R wave in I and V6, QRS > 0.12


sec
Loss of R wave in precordial leads
QRS T wave discordance I, V1, V6
Right Bundle Branch Block

V1: RSR prime pattern with inverted T wave


V6: Wide deep slurred S wave
Supraventricular Tachycardia

Retrograde P waves

Narrow complex, regular; retrograde P waves, rate <220


Wolff-Parkinson-White Syndrome

Short PR interval <0.12 sec


Prolonged QRS >0.10 sec
Delta wave
Can simulate ventricular hypertrophy, BBB and previous MI
Hypokalemia

U waves
Can also see PVCs, ST depression, small T waves
Summary

Discussed the indications for performing an ECG

Introduced an approach to interpreting ECGs

Discussed common ECG abnormalities