ECG

By Amit Pannu
 AIMS

 To discuss how an ECG works

 How to perform an ECG
 A closer look at the ECG
 To develop a systematic approach to interpret
an ECG
 HOW THE ECG WORKS
 Contraction of any muscle is associated with
electrical changes called ‘depolarisation’
 The electrical changes associated with
contraction of the heart muscle will only be
clear if the patient is fully relaxed.
 From electrical point of view the heart has two
chambers.
 HOW THE ECG WORKS
 Muscle mass of atria is relatively small,
contraction causes the ECG wave called ‘P’.
 Ventricular mass is large, when contraction
occurs there is a large deflection called the
‘QRS complex’.
 The ‘T’ wave is caused by the return of
ventricular mass to the resting electrical state
(repolarisation).
WAVES OF THE ECG
 THE LEADS
 The word ‘lead’
- Sometimes it is used to mean the pieces of wire
that connect the patient to the ECG.
- Properly, a ‘lead’ is an electrical picture of the
heart.
 The electrical signal is detected through ten
electrodes
- One attached to each limb.
- Six attached to the patients chest.
CHEST LEADS
 RATE

 ECG machines all run at a standard rate and use paper

with standard squares:-
- Each large square is equivalent to 0.2 seconds
- 5 large squares per second
- 300 large squares per minute.
 P WAVE
 Normal atrial activation is over in about 0.10s,
starting in the right atrium.

- A good place to look at P waves is in II.

- P shouldn't be more than 2.5mm tall.
- 0.11 seconds in duration.
 P WAVE

 A tall P wave (3 blocks or more) signifies

right atrial enlargement.
 a widened bifid P wave signifies left atrial
enlargement.
 Absence of P waves, varying completely
irregular baseline signifies atrial fibrillation
RIGHT ATRIAL ENLARGEMENT
 P WAVE

 A tall P wave (3 blocks or more) signifies right

atrial enlargement.
 A widened bifid P wave signifies left atrial
enlargement.
 Absence of P waves, varying completely
irregular baseline signifies atrial fibrillation
LEFT ATRIAL ENLARGEMENT
 P WAVE

 A tall P wave (3 blocks or more) signifies right

atrial enlargement.
 A widened bifid P wave signifies left atrial
enlargement.
 Absence of P waves, varying completely
irregular baseline signifies atrial fibrillation
ATRIAL FIBRILLATION
 PR INTERVAL
 The PR interval extends from the start of the P
wave to the very start of the QRS complex.

- A normal value is 3 to 5 ‘little blocks’ (0.12 to

0.20 seconds).
- Abnormalities that occur:-

(a) Sino-atrial node block

(b) Atrio-ventricular node block

 PR INTERVAL
 AV nodal blocks
- There are three types of AV nodal block:
(a) First degree block:
- Simply slowed conduction.
- This is manifest by a prolonged PR interval;
 PR INTERVAL
(b) Second degree block:
- Conduction intermittently fails completely.

- This may be in a constant ratio (more

ominous, Type II second degree block),
 PR INTERVAL
(b) Second degree block:
- Or progressive (The Wenckebach
phenomenon, characterised by
progressively increasing PR interval
culminating in a dropped beat.
 PR INTERVAL
(c) Third degree block:
- There is complete dissociation of atria and
ventricles.
- Requiring temporary or even permanent
pacing.
 QRS COMPLEX
 Q waves - myocardial infarction
- Many people who have had a prior MI will
have an ECG that appears normal.
- A Q wave is a typical feature of a previous MI
- Another feature of previous MI is loss of R
wave amplitude.
 QRS COMPLEX
 Bundle branch blocks
- A broadened QRS complex suggests a
bundle branch block

(a) RBBB (Right Bundle Branch Block)

(b) LBBB (Left Bundle Branch Block)
 QRS COMPLEX
RBBB (Right Bundle Branch Block)
 Diagnostic criteria for RBBB:
- Tall R' in V1;
- QRS duration 0.12s or greater (some say, >=
0.14s);
- Sometimes seen in normal people
 QRS COMPLEX
LBBB (Left Bundle Branch Block)
 Diagnose this as follows:
- No RBBB can be present;
- QRS duration is 0.12s or more;
- Evidence of abnormal septal depolarization.
- Tall, notched R waves are seen in the lateral leads.
 ST SEGMENT
 Acute myocardial infarction - the
‘hyper acute phase’
- There are four main features of early
myocardial infarction (as per Schamroth):
 Increased R wave amplitude
 ST elevation sloped upwards

 Tall, widened T waves

 Q waves are not seen early on

 ST SEGMENT
 Established acute myocardial
infarction
- The features of ‘full blown’ MI may be:
 Prominent Q waves;

 Elevated ST segments;

 Inverted ‘arrowhead’ T waves.

 ST SEGMENT
 Posterior MI
- Realise that posterior wall changes will be
mirrored in the leads opposite to the lesion -
V1 and V2.
- A tall R (corresponding to a Q);

- ST depression;

- Upright arrowhead T waves:

POSTERIOR MI
 ST SEGMENT
 Angina and stress testing
- Findings may be:
- ST segment depression;
- Failure of the blood pressure to rise with exercise;
- ST segment elevation;
- T-wave changes;
- Development of inverted U waves.
 T WAVES
 Hyperkalaemia
- Initial features are tall "tented" T waves.
- Later the P waves disappear;
- Finally
(a) QRS complexes broaden and become bizarre,
(b) ST segment almost vanishes,
(c) Ventricular arrhythmia or cardiac standstill.
 U WAVES
 Hypokalaemia
- T waves flatten;
- U waves become prominent;
- there may even be first or second degree AV
block.
 SYNDROMES
 Pulmonary thromboembolism
- Apart from sinus tachycardia, ECG abnormalities
are not common.
- The ‘classical’ S1Q3T3 syndrome occurs in under
10%.
- Other features may be those of right atrial
enlargement, RV hypertrophy or ischaemia, RBBB
and atrial tachyarrhythmias.
 SUMMARY

 Check the patient details - is the ECG correctly

labelled?
 What is the rate?
 Is this sinus rhythm? If not, what is going on?
 What is the mean QRS axis
 Are the P waves normal?
 What is the PR interval?
 SUMMARY

 Are the QRS complexes normal?

 Are the ST segments normal, depressed or
elevated?
 Are the T waves normal?
 Are there abnormal U waves?
 REFERENCES
 The ECG made easy - Hampton
 An Introduction to Electrocardiography - Leo
Schamroth
ANY QUESTIONS?
THE END