BASIC

ECG NOTES FOR HOUSE

OFFICERS

☺Special thanks to:

Dr. Mohd Anizan Aziz, Dr. Amal Mattu, Dr. Jeff Tabas
A compilation by Dr. Nor Asilah Abd Rahman
 BASIC ECG
What to comment? 5. ST segment
- elevation
1. Sinus Rhythm or not
2. Rate. - depression
- Tachy/ Brady/ Normal 6. T Abnormalities
3. Rhythm - Tall tented T
- Regular - Biphasic T wave
- Irregular - T inversion
✔ Iregularly irregular 7. Q wave
✔ Regularly irregular
8. QT interval
4. QRS Complex
- Narrow 9. PR interval
- Wide 10. R Wave Progression

V7, V8, V9 (post Chest

lead)

☺Special thanks to:

Dr. Mohd Anizan Aziz, Dr. Amal Mattu, Dr. Jeff Tabas
 ISCHEMIA Comment on;
BASIC ECG ▪Wide QRS (> 3 small box = 120ms)

6 CAUSES:
Rule out 2 things:
1. Bundle Branch Block
1. Arrhythmia 2. TCA Overdose
2. Ischemia 3. Hyperkalemia
4. Pace Rhythm
5. WPW
6. Ventricular Rhythm
ARRYTHMIA
Comment on; •ST elevation
-Rate: 6 CAUSES:
- Look at the computer 1. Benign early repolarization (BER)
reading,(HR can 2. Acute MI
be very accurate) 3. Pericarditis
-Calculation: 4. LV Aneurysm
300/ R-R interval 5. Printzmental’s Angina (Vasopasm)
6. Bundle Branch Block
- Rhythm:
Sinus rhythm or not •ST Depression
*Sinus Rhythm:
-P wave followed by QRS
complex 6 CAUSES:
- P wave must be upright 1. Reciprocal Changes/ Posterior MI
in V2
2. Subendocardial MI
- And P wave must be
downward in aVR. 3. Ischemia
4. LVH with repolarization abnormality
- Regularity: 5. Digoxin
A. Regular
B. Irregular:
6. Hypokalemia
I)Irregularly irregular
∆ 1. AF •T waves abnormality
2. Atrial Flutter with
variable block •Q wave
II. Regularly irregular •PR interval
∆1. Clumps beat •QT interval
2. Mobitz 1 or 2
•R wave progression
 ST ELEVATION
6 CAUSES:
1. Benign early repolarization (BER)
2. Acute MI
3. Pericarditis
4. LV Aneurysm
5. Printzmental’s Angina (Vasopasm)
6. Bundle Branch Block

Sig. ST Elevation that eligible for Fibrinolytic therapy:

(Ref.: AHA/ ACC 2013 STEMI Guidelines)
1. ST elevation > 2mm (o.2mv) in men
over Leads
OR
V2 and V3
ST elevation > 1.5mm ( 0.15mv) in women
2. ST elevation > 1mm (0.1mv) in other contagious chest leads or limb
leads

BER J point
Cx:
1. Smiley face contour
2. At Anterior Leads ( V1-V4)
3. Does not evolve or present on ACUTE MI
old ECG Cx:
4. Often associated with LVH 1. Frowny face contour
5. “Fishook” contour in V4 2. Presence of reciprocal changes
*Fishook also seen in (*not a definitive sign)
hypothermia - Shows ST depression in
(Osborne J waves) mirror leads

PAILS

Post Ant Inf Lat Septal

3. Contiguous Lead
4. Evolving/ Changing from old ECG
5. Other findings of ischemia
 ST ELEVATION
BRUGADA SYNDROME
Cx:
-Down slopping of ST
elevation
-Sodium channelopathy
-Hx of sudden cardiac
death in the family
-Usually had history of
syncopal attack
-May predisposes to
Torsades de pointes🡪 VT
Mx.:
Placement of internal
cardiac defibrillator (ICD)
LV ANEURYSM
Cx:
1. ST elevation in V1- V4
2. Evidence of previous Ant.
MI
- Big Q waves in V1- V4
- Loss of R waves
3. Lack of New changes or
Evolution or Reciprocal
depression
4. Lack of clinical features
for AMI
PERICARDITIS
Cx:
5. Diffuse ST elevation*
6. PR Depression in Lead II is
Dx*
7. Benign morphology
8. Clinical Presentation;
- Stabbing/ burning pain
- Worse by lying flat
- Relieved with sitting up
- Persistent and prolong
pain
PRINZMENTAL’S ANGINA
Cx:
9. Occur rarely
10. Resolution of ST elevation
without revascularization
 BUNDLE BRANCH BLOCK

TERMINAL END QRS: + VE DEFLATION

The wave before J point
R V1 V6 L
🡪 can be Positive or - VE DEFLATION
Negative
BUNDLE BRANCH BLOCK
Cx:
1. WIDE QRS complex > 0.12 sc
2. Look at terminal end QRS
3. Follow the ROAD (Rule of Appropriate Discordance)
RIGHT BUNDLE BRANCH BLOCK (RBBB)
- V1: POSITIVE and ST segment will be –ve/ depression
- V6: NEGATIVE and ST segment will be +ve/ elevated
• Slurred S wave
• THE RULE (Rule of appropriate discordance) IS APPLICABLE TO LEAD V1, V2 AND V3 ONLY

V1:+VE RBBB LBBB V6:+VE

V6:-VE V1:-VE
LEFT BUNDLE BRANCH BLOCK (LBBB)
- V1: NEGATIVE and ST segment will be +ve/ elevated
- V6: POSITIVE and ST segment will be –ve/ depression (RULE OF APPRIOPIATE DISCORDANCE)
• The RULE (Rule of appropriate discordance) IS applicable to all leads
•No Q wave and giant S wave in Lateral Leads (V5, V6, I, AVL) & Monophasic R
wave
 BUNDLE BRANCH BLOCK
WHEN TO SUSPECT BBB WITH MI???
RBBB WITH MI
-Can still read MI in the setting of RBBB
-ROAD is only applicable for Lead V1, V2, V3
Suspect MI when;
-If there is presence of RBBB with ST elevation in TWO leads
concordance= (IF ROAD not appropriately fullfiled in V1, V2, V3 –
Plse think of AMI )

LBBB WITH MI
Use SGARBOSSA CRITERIA:
•Presence of LBBB with: In ANY
- Concordance ST elevation > 1mm leads
- Concordance ST depression > 1mm
- Discordant ST elevation or depression > 5mm
- Excessive discordance:
• ST elevation: S wave: 0.25 or more
• ST depression: R wave > 1.4

Ex:
 ST DEPRESSION
Look at; 6 CAUSES:
1. Location 1. Reciprocal Changes/ Posterior MI
• Localize 2. Subendocardial MI
Ex: - Posterior MI 3. Ischemia
- NSTEMI 4. LVH with repolarization abnormality
• Diffuse 5. Digoxin
6. Hypokalemia
Ex;- LMCA Stenosis
- Hypokalemia
- Digoxin
- Carbon Monoxide or Cyanide Poisoning
2. Contour
1. UPSLOPPING ( 30% Ischemia)
2. DOWN SLOPPING
- Stop at T-P baseline, then depress
3. FLAT/ PLANAR
- 70% Ischemia
- Bypass T-P baseline

Down slopping
 ST DEPRESSION
ACUTE POSTERIOR MI
CX:
-ST Depression in V1- V3 (at Ant Lead)
-Upright T wave in same leads
-Tall R wave in V2

So, do:
• Posterior Leads (Show ST elevation)
V7 : at post axillary lineLMCA STENOSIS
V8 : at tip of scapula Cx:
V9 : at left paravetebral -DIFFUSE ST depression
• Right sided Leads -Look at AVR/AVL/V1 ST elevation
V4R, V5R, V6R •Complication: Cardiogenic Shock
•Mx: PCI/ CABG
LEFT VENTRICULAR HYPERTHROPHY *• 70%
Medical therapy not useful!
Mortality
Cx: •If a/w ST elevation at aVL and aVR🡪
1. High Voltage 95% Mortality
- S wave (in V1 or V2) + R wave •If a/w ST elevation in aVL and V1 🡪
(in V5 or V6) > 35mm
or (>7 big Box)
75% Mortality
- R amplitude in AVL > 11 mm
- R wave > 20mm in Limb Lead or HYPOKALEMIA
>25mm in Precardial leads. CX:
2. Strain pattern -DIFFUSE ST Depression
- ST depression with assymetrical
invertedT waves -a/w Prolong QT
3. Left Atrial
enlargement DIFFUSED ST
- Terminal P DEPRESSION:
is 1x1 box in V1 1. LMCA Stenosis
2. Hypokalemia
3. Digoxin- “Salvadore
Dolly Mustache’s” appr
4. Carbon Monoxide or
Cyanide Poisoning
 T- ABNORMALITIES
Suggest pathological if T wave: 2. BIPHASIC T- WAVE
1. Tall/tented Differential Diagnosis;
2. Inversion 1. WELLEN’S SIGN
- mid precordial leads findings
3. Biphasic - Associated with critical LAD occlusion
1. T- INVERSION - May be associated with negative
(* Its Normal to be seen in Lead III, V1, Troponin
V2) - 70% develop into Ant MI within 3/52
Tend to be asymmetrical and small - Medical therapy is not effective
Localised (contigous) or Diffuse - Stress test may be fatal
Differential dx: - PCI/CABG are the only effective
therapy
4. PULMONARY EMBOLISM
Cx: -Two type:
- T Inversion at Anteroseptal 1. Type I:
( V1, V2) and Inferior Leads Deeply
(II,III,AVF) and
- SI, QIII, TIII or SI,QIII Symmetrical T
- Right Heart Strain/ new RBBB
- Right Axis Deviation
- Sinus Tachycardia
2. Type II:
2. Intracranial Hemorrhage(ICB) Biphasic T
Cx: wave
- HUGE T wave inversion in all leads
a/w prolonged QT
- tend to occur over anterior leads
- A/w altered mental status (Low Caveat ( looks like Wellen’s but it aint
GCS) Wellen)
- A roller coaster T waves/cerebral ▪ High voltage
T waves ▪ Fish-hook pattern
▪ With smiley concavity- ( normal
3. Myocardial Ischemia
variant for BER)
Cx:
3. REVERSE WELLEN’s Sign
- T wave inversion in any chest
-Suggest HypoK+
lead/ limb leads.
- Type 1 Wellen’s ( T inversion
over mid precordial leads)
 Q WAVE
T- ABNORMALITIES (cont) Normal:
4. BIPHASIC T- WAVE ( Camel hump T) -Q waves <0.04 second. (less than one
Differential Dx; small square duration)
1. Severe hypoK+ -Height <25% or < 1/4 of R wave
Cx: height.
- T wave inversion followed by -Small Q
upright U wave -Wave V5/V6
- A/W prolong QT may resemble
Septal Q.
• Also seen as a
“ Camel-Hump” T wave -Differential Dx;
2. Buried P waves – 2nd Degree AV block
1. Hypertrophic Cardiomyopathy
(HOCM)
- High Voltage
3. TALL TENTED T- WAVE - Deep narrow Q wave at I, AVL,
Differential Dx; V5, V6 (lateral leads)
1. HyperK+ - With history of syncope
- Tall tented t with history that
suggestive for hyperK+ 2. Myocardial Infarction (old Infarct)
QT INTERVAL
•By eyeball;
T must not be half than length of R-R
interval.
•Prolong QT can cause Torsades de
pointes
• Should not be more than >500msec or
2. De-Winter T Waves 0.5sec
- 1-3 mm of ST depression up slopping at
J point in ant precordial leads
Differential dx:
- Tall symmetric T waves 1. ACQUIRED
- Acute occlusion of proximal LAD. (In - Electrolyte imbalance;
contrast to subacute occlusion of Hypocalcaemia, Hypokalemia,
Wellen) Hypomagnesaemia
- Clue : associated with chest pain - Drugs: Ex: TCA,Anti Psycotic
- A/w st depression or reciprocal changes
2. CONGENITAL
elsewhere
- The height of the T waves surpass the
-Ex; Romano Ward Sx Jervel-Lange-
height of the R waves Nielsen Syndrome
 R- WAVE PROGRESSION

• Denotes poor LV function

•R- wave amplitude in lead V3 < 3mm

•LOW Voltage Definition:

• Amplitude of QRS complex in all limb leads < 5mm
or
• When amplitude of QRS complex in all precordial
leads < 10mm

Ex: Massive Pericardial Effusion

Clah :D
NOTES
NOTES