ECG 101 v2 - tcm309 32330

ECG 101
Yale University School of Medicine

Section of Cardiovascular Medicine
james.revkin@yale.edu
Course Outline
• Basic ECG analysis and sinus rhythm

• Intervals, Bundle Branch Block, Hypertrophy and
Enlargement
• Supraventricular arrhythmias
• Ventricular arrhythmias
• Bradyarrhythmias
• Heart Blocks
• Ischemia and Infarction
• Miscellaneous Abnormalities
Course Outline

Enlargement
• Heart Blocks
Basic analysis
• Rate (fast or slow)

• Rhythm (atrial, ventricular, regular, irregular)
• Axis
• Conduction disease (atrial or ventricular)
• Hypertrophy
• Ischemia, infarction
• Other abnormalities (QT interval, repolarization
changes)
EKG history
Charles Einthoven
electrophysiology
ECG as an “imaging tool”
ECG as an “imaging tool”
Right side Left side

Basic ECG
P wave
Septal Q Wave
Q R wave
repolarization
Basic ECG
Basic analysis
• Rate (fast or slow)

• Rhythm (atrial, ventricular, regular, irregular)
• Axis
• Conduction disease (atrial or ventricular)
• Hypertrophy
• Ischemia, infarction
• Other abnormalities (QT interval, repolarization
changes)
Normal 12 Lead ECG
300 bpm
150 bpm
100 bpm
75 bpm
60 bpm
50 bpm
~ 45 bpm
Calculating rate of an irregular
rhythm
Count number of beats in two 3 sec intervals

( = 6 sec total) and multiply times 10
Rate approx 60 bpm
Normal Frontal Axis
Lead I
Lead aVF
Lead V1 Normal precordial Axis
Lead V6
1F Frontal Plane Axis Calculator
1G Precordial Axis
1H
Frontal Plane Axis Calculation
Course Outline

Enlargement
• Heart Blocks
Session 1 ECGs
1A
1B
1C
1D
1E
1I
1J
1K
Course Outline

Enlargement
• Heart Blocks
electrophysiology
PR Interval
 PR 
A – V Block
• At level of A-V node

– 1st degree
• Prolongation of PR interval > 0.2 ms
– 2nd degree
• Mobitz Type I - Wenckebach, progressive prolongation of
PR interval, then dropped beat
• Mobitz Type II
– 3rd degree
• Complete heart block, independent atrial and ventricular
rates
QRS Interval
QRS
Ventricular (bundle branch)
blocks
• LBBB
– Hemiblocks
• Left anterior fascicular block (left anterior
hemiblock)
• Left posterior fascicular block (left posterior
hemiblock
• RBBB
LBBB
RBBB
Hemi-blocks
• Within the Left Bundle

– Hemiblocks
• Left anterior fascicular block (left anterior
hemiblock)
• Left posterior fascicular block (left posterior
hemiblock
Left anterior hemi-block
Left posterior hemi-block
Hypertrophy
• Atrial
– Left atrial hypertrophy
– Right atrial hypertrophy
• Ventricualr
– LVH
– RVH
Left Atrial Hypertrophy
Right Atrial Hypertrophy
Ventricular Hypertrophy
• RVH
– R > S in V1
– Right axis deviation
• LVD
– R wave 15 mm high in lead I
– Sum deepest S wave V1 or V2 and add to
tallest R wave in V5 or V6 > 35 mm
Course Outline

Enlargement
• Heart Blocks
Session 2 ECGs
2A
2B
2C
2D
2E
2F
2G
2H
2I
2J
2K
Course Outline

Enlargement
• Heart Blocks
Sinus arrhythmia
Non-sinus atrial rhythm
Multi-focal atrial tachycardia (MAT)
Junctional rhythm
Paroxysmal supraventricular tachycardia
PSVT
atrial flutter
atrial fibrillation
Session 3 ECGs
3A
3B
3C
3D1
3D2
3E
3F
3G
3H1
3I-1
3I-2
3I-3
3J
3K1
3K2
3L1
3L2
3M
3N
3O
Course Outline

Enlargement
• Heart Blocks
ECG Basics
• What does the QRS complex represent?

• What should the axis of a normal QRS
complex be:
– in the frontal plane?
– in the precordial plane?
• What would make the QRS complex wide?
Assessment of WCT
• definition of wide complex tachycardia

– QRS duration greater than 0.12 seconds
– heart rate greater than 100 bpm
• differential diagnosis of WCT
– supraventricular tachycardia with:
• preexisting bundle branch block
• aberrant conduction (rate related)
• accessory pathway
– ventricular tachycardia
ECG Basics

complex be:
Normal Frontal Axis
Lead I
Lead aVF
Lead V6
LBBB
RBBB
Stepwise Assessment of Wide Complex
Tachycardia
• Goal: develop easier more accurate criteria for

analysis.
• Applied guidelines to 554 WCT patients who’d
had previous EP studies (384 VT and 170 SVT).
• Analyze ECGs using a four step algorithm.
• Observers would stop when a positive analysis of
VT was made.
• SVT with aberrant conduction was the diagnosis
of exclusion.
Brugada P, Brugada J, et al
Circulation 1991;83:1649-1659
Tachycardia
• Are RS complexes absent in all precordial leads?

• Does any RS interval exceed 100 msec in the
precordial leads?
• Is A-V dissociation present?
• Do the QRS complexes in V1/V2 fulfill the classic
criteria?
Tachycardia
N = 554 (384 VT, 170 SVT with aberration)
83 Yes 471 No
83 VT
SN = 0.21 SP = 1.0
Go to next step
Absence of precordial RS complexes
V1
V6
Tachycardia
83 Yes 471 No
83 VT
SN = 0.21 SP = 1.0
Go to next step
Tachycardia
N = 554 (83 VT, 471 unknown)
• RS Interval > 100 ms in one precordial lead?
175 Yes 296 No
172 VT 3 SVT
SN = 0.66 SP = 0.98
Go to next step
Hypothesis: prolongation of
the intrinsicoid deflection--
RS interval > 0.1 sec--
could be a marker for VT
RS Interval: measured from

beginning of R wave to nadir
of the S wave.
RS = 0.080
or 80 ms
Tachycardia
N = 554 (83 VT, 471 unknown)
175 Yes 296 No
172 VT 3 SVT
SN = 0.66 SP = 0.98
Go to next step
Tachycardia
N = 554 (255 VT, 3 SVT, 296 unknown)
• Is AV Dissociation Present?
59 Yes 237 No
59 VT
SN = 0.82 SP = 0.98
Go to next step
Tachycardia
N = 554 (314 VT, 3 SVT, 237 unknown)
• Are classic morphology criteria for VT

present in both V1- V2 and V6?
68 Yes 169 No
65 VT 3 SVT 164 SVT 5 VT

SN = 0.987 SP = 0.965 SN = 0.965 SP = 0.987
Classic Criteria Suggesting VT
• QRS duration > 0.14 s

• Superior QRS axis
• Morphology in precordial leads:
RBBB-like pattern LBBB-like pattern

V1 V1
r = 30 ms
notched S wave
RS > 70 ms
V6 R/S ratio < 1 V6 :qR

Classic Criteria Suggesting SVT
• QRS duration < 0.14 s

• Normal QRS axis

V1:
V1: triphasic absent or narrow R wave
no S wave notch
V6 R/S ratio > 1 steep S wave descent
V6 : no Q wave
Tachycardia
N = 554 (314 VT, 3 SVT, 237 unknown)

68 Yes 169 No

SN = 0.987 SP = 0.965 SN = 0.965 SP = 0.987
Treatment of Wide Complex Tachycardia of
indeterminate etiology
• Is patient unstable?
– Immediate synchronized cardioversion
– 100, 200, 300, 360 joules
• Borderline or stable?
– amiodarone
Tachycardia

precordial leads?
criteria?
Session 4 ECGs
4A
4B
4C
4D
4E
4G1
4G2
4H1
4H2
4I1
4J
4K
4L
4M1
4M2
4M3
4N1
4N2
Course Outline

Enlargement
• Heart Blocks
ECG Basics

complex be:
Assessment of WCT
• definition of wide complex tachycardia

– QRS duration greater than 0.12 seconds
– heart rate greater than 100 bpm
• differential diagnosis of WCT
– supraventricular tachycardia with:
• preexisting bundle branch block
• aberrant conduction (rate related)
• accessory pathway
– ventricular tachycardia
ECG Basics

complex be:
Normal Frontal Axis
Lead I
Lead aVF
Lead V6
LBBB
RBBB
Tachycardia
• Goal: develop easier more accurate criteria for

analysis.
• Applied guidelines to 554 WCT patients who’d
had previous EP studies (384 VT and 170 SVT).
• Analyze ECGs using a four step algorithm.
• Observers would stop when a positive analysis of
VT was made.
• SVT with aberrant conduction was the diagnosis
of exclusion. Brugada P, Brugada J, et al
Circulation 1991;83:1649-1659
Tachycardia

precordial leads?
criteria?
Tachycardia
83 Yes 471 No
83 VT
SN = 0.21 SP = 1.0
Go to next step
Absence of precordial RS complexes
V1
V6
Tachycardia
83 Yes 471 No
83 VT
SN = 0.21 SP = 1.0
Go to next step
Tachycardia
N = 554 (83 VT, 471 unknown)
175 Yes 296 No
172 VT 3 SVT
SN = 0.66 SP = 0.98
Go to next step
Hypothesis: prolongation of
the intrinsicoid deflection--
RS interval > 0.1 sec--
could be a marker for VT
RS Interval: measured from

beginning of R wave to nadir
of the S wave.
RS = 0.080
or 80 ms
Tachycardia
N = 554 (83 VT, 471 unknown)
175 Yes 296 No
172 VT 3 SVT
SN = 0.66 SP = 0.98
Go to next step
Tachycardia
N = 554 (255 VT, 3 SVT, 296 unknown)
• Is AV Dissociation Present?
59 Yes 237 No
59 VT
SN = 0.82 SP = 0.98
Go to next step
Tachycardia
N = 554 (314 VT, 3 SVT, 237 unknown)

68 Yes 169 No

SN = 0.987 SP = 0.965 SN = 0.965 SP = 0.987
Classic Criteria Suggesting VT
• QRS duration > 0.14 s

• Superior QRS axis

V1 V1
r = 30 ms
notched S wave
RS > 70 ms
V6 R/S ratio < 1 V6 :qR

Classic Criteria Suggesting SVT
• QRS duration < 0.14 s

• Normal QRS axis

V1:
V1: triphasic absent or narrow R wave
no S wave notch
V6 R/S ratio > 1 steep S wave descent
V6 : no Q wave
Tachycardia
N = 554 (314 VT, 3 SVT, 237 unknown)

68 Yes 169 No

SN = 0.987 SP = 0.965 SN = 0.965 SP = 0.987
Treatment of Wide Complex Tachycardia of
indeterminate etiology
• Is patient unstable?
– Immediate synchronized cardioversion
– 100, 200, 300, 360 joules
• Borderline or stable?
– amiodarone
Tachycardia

precordial leads?
criteria?
Wide Complex Tachycardia
Case 1
• 66 year old retired businessman with a history of

hypertension and a subarachnoid hemorrhage
who presented with dizziness and an episode of
chest pain.
• Patient has a lipid disorder, smokes 2 packs of
cigarettes a day, and has a son with coronary
disease.
• Exam showed HR of 210 BPM, BP 70/50, resp
12/min
Case 1
Case 1
Tachycardia: Case 1

Tachycardia: Case 1

precordial leads?
Tachycardia: Case 1

Tachycardia: Case 1

criteria?
Case 1 Typical RBBB
Case 1
• Received adenosine 6 mg, 12 mg

• Received lidocaine 100 mg, then 2 mg/min,
converting briefly to NSR.
• Labs showed normal electrolytes and CK.
• Received bretylium 200 mg, then 500 mg.
• Received procainamide 1 gm, then 2 mg/min and
metoprolol
• Cardiac catheterization showed total RCA
occlusion and 90% LAD stenosis.
Case 1: normal sinus rhythm
Case 1
NSR Frontal Axis
Case 1
NSR precordial Axis
Case 2
• 76 yr. old woman with an extensive history of

coronary artery disease presented with
palpitations.
• had CABG in 1992, recent history of cough felt to
be bronchitis, treated with amoxicillin, history of
hypothyroidism.
32/min
• labs: K+ 3.7; Mg2+; T4 10.3; TSH 0.05
Case 2
Case 2
Tachycardia: Case 2

Tachycardia: Case 2

precordial leads?
Tachycardia: Case 2

Tachycardia: Case 2

criteria?
Case 2 Typical LBBB
Case 2
• Treated with adenosine 6 mg, repeated once, then

NSR
• Loaded with digoxin, 0.5 mg, then 0.25 mg, and
final dose of 0.25 mg
Case 2
NSR Frontal Axis
Case 2
NSR precordial Axis
Case 3
• 29 yr. old previously healthy woman, noted

dizziness and fatigue at work.
• She’d had similar symptoms, episodically, over the
prior two weeks.
• Medications included Zoloft, oral contraceptives,
and occasional Sudafed. She rarely used cocaine
18/min
Case 3
Case 3
Tachycardia: Case 3

Tachycardia: Case 3

precordial leads?
Tachycardia: Case 3

Tachycardia: Case 3

criteria?
Case 3 Typical LBBB
Case 3
• Treated with adenosine 6 mg, 12 mg
• Received Versed 1 mg, then direct current cardioversion

100 J, without success
• Received Versed 1 mg, then direct current cardioversion

200 J, without success
• Received Propofol, then direct current cardioversion 350 J,

with success
Case 3
NSR Frontal Axis
Case 3 NSR precordial Axis
Tachycardia

precordial leads?
criteria?
summary
• WCT can be VT or SVT

• Knowledge of basic appearance of “normal”
RBBB and LBBB can be helpful
• Hemodynamic stability does NOT help make the
diagnosis
• If hemodynamically stable and in doubt, treat as
VT
• If unstable, apply direct current cardioversion
Session 5 ECGs
5A
5B
5C
5D
5E
5F
5G
5H
5I
5J
5K
5L
5M
5N
Course Outline

Enlargement
• Heart Blocks
Course Outline

Enlargement
• Heart Blocks
Session 6 ECGs
6A
6B
6C
6D
6E
6F
6G
6H1
6H2
6H3
Course Outline

Enlargement
• Heart Blocks
Session 7 ECGs
7A
7B
7C
7D
7E
7F1
7F2
7F3
7F4
7F5
7G1
7G2
7G3
7H
7I
7J
7K
7L1
7L2
7L3
7M
Course Outline

Enlargement
• Heart Blocks
Session 8 ECGs
8A
8B
8C
8D
8E
8F
8G
8H
8I
8J
8K
8L
8M
8N
8O1
8O2
8P1
8P2

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ECG 101

Yale University School of Medicine

• Basic ECG analysis and sinus rhythm

• Basic ECG analysis and sinus rhythm

• Rate (fast or slow)

Right side Left side

• Rate (fast or slow)

Count number of beats in two 3 sec intervals

• Basic ECG analysis and sinus rhythm

• Basic ECG analysis and sinus rhythm

• At level of A-V node

• Within the Left Bundle

• Basic ECG analysis and sinus rhythm

• Basic ECG analysis and sinus rhythm

• Basic ECG analysis and sinus rhythm

• What does the QRS complex represent?

• definition of wide complex tachycardia

• What does the QRS complex represent?

• Goal: develop easier more accurate criteria for

• Are RS complexes absent in all precordial leads?

N = 554 (384 VT, 170 SVT with aberration)

• Are RS complexes absent in all precordial leads?

N = 554 (384 VT, 170 SVT with aberration)

• Are RS complexes absent in all precordial leads?

N = 554 (83 VT, 471 unknown)

• RS Interval > 100 ms in one precordial lead?

175 Yes 296 No

RS Interval: measured from

N = 554 (83 VT, 471 unknown)

• RS Interval > 100 ms in one precordial lead?

175 Yes 296 No

N = 554 (255 VT, 3 SVT, 296 unknown)

• Are classic morphology criteria for VT

65 VT 3 SVT 164 SVT 5 VT

• QRS duration > 0.14 s

RBBB-like pattern LBBB-like pattern

V6 R/S ratio < 1 V6 :qR

• QRS duration < 0.14 s

RBBB-like pattern LBBB-like pattern

• Are classic morphology criteria for VT

65 VT 3 SVT 164 SVT 5 VT

• Are RS complexes absent in all precordial leads?

• Basic ECG analysis and sinus rhythm

• What does the QRS complex represent?

• definition of wide complex tachycardia

• What does the QRS complex represent?

• Goal: develop easier more accurate criteria for

• Are RS complexes absent in all precordial leads?

N = 554 (384 VT, 170 SVT with aberration)

• Are RS complexes absent in all precordial leads?

N = 554 (384 VT, 170 SVT with aberration)

• Are RS complexes absent in all precordial leads?

N = 554 (83 VT, 471 unknown)

• RS Interval > 100 ms in one precordial lead?

175 Yes 296 No

RS Interval: measured from

N = 554 (83 VT, 471 unknown)

• RS Interval > 100 ms in one precordial lead?

175 Yes 296 No

N = 554 (255 VT, 3 SVT, 296 unknown)

• Are classic morphology criteria for VT

65 VT 3 SVT 164 SVT 5 VT

• QRS duration > 0.14 s