ECG: BASICS

Dr. Isaak Mohamed (Dr. Afgaab)

15th Sept. 2020
PR Interval
• Represents the time from the start of atrial depolarization
to the start of ventricular depolarization.

• Includes the delay in conduction that occurs at the AV node.

• The normal PR interval is between 120 – 200 ms (0.12-

0.20s) in duration (three to five small squares).

• PR interval > 200 ms-first degree heart block 

• PR interval < 120 ms suggests pre-excitation  or AV nodal

(junctional) rhythm.
PR Segment

• Represents the time from the end of atrial depolarization

to the beginning of ventricular depolarization.

• It is usually horizontal and runs along the same baseline

as the start of the P wave.
Prolonged PR Interval – AV block (PR >200ms)

• Delayed conduction through the AV node or His

bundle
• May occur in isolation or co-exist with other
blocks (e.g., second-degree AV block)
 First degree AV block

• Characterized by a prolonged delay in conduction

at the AV node or His bundle

• The diagnosis requires only that PR interval is

longer than 0.2 seconds.

• Every atrial impulse does eventually make it

through the AV node to activate the ventricles.

• Every QRS complex is preceded by a single P wave.

• 1st degree heart block (PR interval 340ms)
First degree AV block cont.

• First-degree AV block is a common finding in

normal hearts

• It can also be an early sign of degenerative

disease of the conduction system or a transient
manifestation of myocarditis or drug toxicity.

• By itself, it does not require treatment.

Second degree AV block 

• Not every atrial impulse is able to pass through

the AV node into the ventricles.
• Some P waves fail to conduct through to the
ventricles, the ratio of P waves to QRS complexes
is greater than 1:1.
• There are two types of second-degree AV block:
– Mobitz type I second-degree AV block (Wenckebach
block)
– Mobitz type II second-degree AV block.
Mobitz type I second-degree AV block (Wenckebach block)
• Almost always due to a block within the AV node
• The block or delay is variable

• There is progressive lengthening of P-R interval followed by a

drop beat

• The following tracing shows a 4:3 Wenckebach block

Mobitz Type II Block
• Usually due to a block below the AV node in the His bundle

• It resembles Wenckebach block in that some, but not all, of the

atrial impulses are transmitted to the ventricles.

• However, progressive lengthening of the PR interval does not

occur

• The EKG shows two or more normal beats with normal PR

intervals and then a P wave that is not followed by a QRS
complex (a dropped beat).

• The ratio of P waves to QRS complexes constantly varying, from

2:1 to 3:2 and so on.
Is It a Wenckebach Block or a Mobitz Type II Block?
Wenckebach block or Mobitz type II block?
 Wenckebach block or Mobitz type II block?

• The distinction between the two types of 2 nd-degree heart block

depends on whether or not there is progressive PR lengthening

• Wenckebach block is typically transient and benign and rarely

progresses to third-degree heart block

• Although less common than Wenckebach block, Mobitz type II

block is far more serious, often signifying serious heart disease
and capable of progressing suddenly to third-degree heart block.

• Pacemaker placement is uncommonly needed for Wenckebach

block

• Mobitz type II heart block mandates insertion of a pacemaker.

 Third-Degree AV Block- complete heart block
• No atrial impulses make it through to activate the ventricles
• The site of the block can be either at the AV node or lower.

• The ventricles generate an escape rhythm (idioventricular

escape).

• The atria and ventricles continue to contract at their own intrinsic

rates—about 60 to 100 bpm for the atria and 30 to 45 bpm for
the ventricles.

• The atria and ventricles have virtually nothing to do with each

other - AV dissociation; refers to any circumstance in which the
atria and ventricles are being driven by independent pacemakers.
 Third-degree AV block.
• ECG: The QRS complexes appear wide and bizarre, just
like premature ventricular contractions (PVCs), because
they arise from a ventricular source.
 QRS Interval

• A normal QRS interval, representing the duration of the QRS

complex, is 0.06 to 0.1 seconds in duration.
• N.B: Duration of 0.11 ms is sometimes observed in healthy
subjects
 QT Interval
• The QT interval encompasses the time from the beginning of
ventricular depolarization to the end of ventricular repolarization.

• The duration of the QT interval is proportionate to the heart rate.

• The faster the heart beats, the faster it must repolarize to prepare
for the next contraction; thus, the shorter the QT interval.

• Conversely, when the heart is beating slowly, there is little

urgency to repolarize, and the QT interval
• is long.
QT Interval

• An abnormally prolonged QT is associated with

an increased risk of ventricular arrhythmias,
especially Torsades de Pointes.

• Congenital short QT syndrome has been found

to be associated with an increased risk of
paroxysmal atrial and ventricular fibrillation and
sudden cardiac death.
• Corrected QT interval (QTc)
• Formulas used to estimate QTc:
– Bazett formula: QTC = QT / √ RR
– Fridericia formula: QTC = QT / RR 1/3
– Framingham formula: QTC = QT + 0.154 (1 – RR)
– Hodges formula: QTC = QT + 1.75 (heart rate – 60)
• Normal QTc values
– QTc is prolonged if > 440ms in men or > 460ms in
women
– QTc > 500 is associated with increased risk of
torsades de pointes
– QTc is abnormally short if < 350ms
• END