Basics of Electrocardiogram

CHAMBER ENLARGEMENT
 Chamber Enlargement
The ECG criteria for diagnosing right or left
ventricular hypertrophy are very insensitive (i.e.,
sensitivity ~50%, which means that ~50% of
patients with ventricular hypertrophy cannot be
recognized by ECG criteria). However, the
criteria are very specific (i.e., specificity >90%,
which means if the criteria are met, it is very
likely that ventricular hypertrophy is present).
 LVH - 1
S in V1 + R in V5 or V6 > 35 mm
R in aVL >11 mm or, if left axis deviation,
R in aVL >13 mm plus S in III >15 mm
CORNELL Voltage Criteria for LVH
(sensitivity = 22%, specificity = 95%)  
S in V3 + R in aVL > 24 mm (men)
S in V3 + R in aVL > 20 mm (women)
 LVH - 2
ECG Criteria Points

R or S in limb leads Any criteria positive

ESTES Criteria for LVH > 20mm 3 points
S in V1 or V2 > 30mm
("diagnostic", >5 points; R in V5 or V6 > 30mm

"probable", 4 points) ST – T abnormalities

Without digoxin 3 points
With digoxin 1 point

Left Atrial Enlargement 3 points

inV1

Left Axis Deviation 2 points

QRS duration 0.09sec 1 point

Delayed intrinsicoid 1 point

deflection in V5 or V6
> 0.05SEC
 RVH
V1 Lead:
- R/S ratio > 1 and negative T wave
- R > 6 mm, or S < 2mm,
- rSR' with R' >10 mm
R in V1 + S in V5 (or V6) > 10 mm
V5 or V6
- R/S ratio in V5 or V6 < 1
  - R in V5 or V6 < 5 mm
  - S in V5 or V6 > 7 mm
 LAE
Sensitivity = 50%; Specificity = 90%

P wave duration > 0.12s in frontal plane (usually

lead II)
Terminal P negativity in lead V1 (i.e., "P-terminal
force") duration >0.04s, depth >1 mm.
 RAE
P wave amplitude >2.5 mm in II and/or >1.5 mm
in V1 (Sensitivity = 50%; Specificity = 90%)
QRS voltage in V1 is <5 mm and V2/V1
voltage ratio is >6 (Sensitivity = 50%;
Specificity = 90%)
Criteria derived from the QRS complex are
due to both the high incidence of RVH
when RAE is present, and the RV
displacement by an enlarged right atrium.
BUNDLE BRANCH BLOCKS
 Left Bundle Branch Block
Electrocardiographic Criteria
1.The QRS duration is >/- 120 ms
2.Leads V5,V6 and AVL show broad and notched
or slurred R waves
3.With the possible exception of lead AVL, the Q
wave is absent in left-sided leads
4.Reciprocal changes in V1 and V2
5.Left axis deviation may be present
 Right Bundle Branch Block
The diagnostic criteria include

1.QRS duration is >/- 120 ms

2.An rsr’,rsR’ or rSR’ pattern in lead V1 or
V2 and occasionally a wide and notched R
wave.
3.Reciprocal changes in V5,V6,I and AVL
 12 Lead ECG Basics
Bundle Branch Block
Step 1. Determine that the rhythm is
supraventricular in origin and has a QRS that
is > 0.12 secs in lead V1 or MCL1 .
 Step 2. Locate the J point in the ECG cycle
(end of the QRS and beginning of the ST).
 Step 3. Draw a line backward into the terminal
component of the QRS.
 Step 4. Shade in the triangle created by this
line and the terminal component of the QRS.
 
12 Lead ECG Basics
Bundle Branch Block

Shade this area

Step 5. If the triangle
points up then it is
a Right BBB.
 
 12 Lead ECG Basics
Bundle Branch Block

Shade this area

Step 6. If the triangle

points down then it
is a Left BBB.
Left Anterior Fascicular Block
Left axis deviation , usually -45 to -90 degrees

QRS duration usually <0.12s unless coexisting RBBB

Poor R wave progression in leads V1-V3 and deeper S

waves in leads V5 and V6

There is RS pattern with R wave in lead II > lead III

S wave in lead III > lead II

QR pattern in lead I and AVL,with small Q wave

No other causes of left axis deviation
Left Posterior Fascicular Block
Diagnostic Criteria include
1.QRS duration 100- <120 ms
2.No ST segment or T wave changes
3.Right axis deviation (100 degree)
4.QR pattern in inferior leads (II,III,AVF) small q
wave
5.RS patter in lead lead I and AVL(small R with
deep S)
6.No other causes of right axis deviation
 Bifascicular Bundle Branch
Block
RBBB with either left anterior or left posterior
fascicular block
Diagnostic criteria
1.Prolongation of the QRS duration to 0.12 second
or longer
2.RSR’ pattern in lead V1,with the R’ being broad
and slurred
3.Wide,slurred S wave in leads I,V5 and V6
4.Left axis or right axis deviation
 Trifascicular Block

The combination of RBBB, LAFB and long

PR interval

Implies that conduction is delayed in the

third fascicle
ST Elevation and non-ST Elevation MIs

When myocardial blood supply is abruptly

reduced or cut off to a region of the heart, a
sequence of injurious events occur beginning
with ischemia (inadequate tissue perfusion),
followed by necrosis (infarction), and eventual
fibrosis (scarring) if the blood supply isn't
restored in an appropriate period of time.

The ECG changes over time with each of

these events…
 E

INFARCTION INJURY ISCHAEMIA

 INFARCTED MYOCARDIUM
(STEMI)
myocardium electrically dead

The electrode lying over the area of

infarction has the effect of looking through
the infarcted area as a window. This
therefore will detect and record potentials
from the myocardium directly opposite.
 INJURED MYOCARDIUM
myocardium is never completely polarized

The electrode lying over the area of injury

will record ST Segment elevation on the
ECG because of the myocardium retaining
its polarity.
 ISCHAEMIC MYOCARDIUM

myocardium exhibits impaired

repolarisation

The electrode lying over the area of

ischaemia will record T wave changes on
the ECG
 STAGE 1
ACUTE STAGE - HOURS OLD

Acute stage of injury – The myocardium is

not yet dead and unless rapid intervention
is possible then death of the affected area
of muscle will certainly follow. In the case
of rapid intervention then the area of death
may be reduced although even with
treatment some necrosis will take place
The typical shape of the ECG leads which are
positioned directly over the injured area of
myocardium will show significant ST segment
elevation of greater than 2 mm, there may also
be a reduction in the size of the R wave.

There will be ST segment depression in the

areas of myocardium opposite the injured area
these are known as RECIPROCAL CHANGES
 STAGE 2
LATER PATTERN - DAYS OLD

In stage 2 the injured myocardium is now

starting to necrose and this results in Q
waves beginning to appear on the ECG
which are representations of
depolarization on the opposite wall of the
heart, this is due to the window effect over
the area of dead myocardium
The electrode is looking through the
electrical window where no electrical
activity occurs

The ST segment elevation will lessen as

the area of injury either becomes Ischaemic
or dies

T waves now begin to appear representing

the area of ischaemia which is surrounding
the infarcted muscle
 STAGE 3
LATE PATTERN - WEEKS OLD
In stage three, the zone of injury has now
evolved into infarcted myocardium
There is a pathological Q wave seen on the
ECG due to the electrical window being
present
The ST segment has now returned to
normal/Iso-electric line because the injured
area has now necrosed or become ischaemic
There is now a symmetrically inverted T wave
present on the ECG which represents
persistent ischaemia surrounding the area of
infarct
 STAGE 4
OLD INFARCT -MONTHS TO YEARS
In stage 4 the zone of ischaemia has recovered
and the ECG returns to almost normal
However there are changes which allow us to
identify a previous infarct on the ECG
The pathological Q wave is considered the
finger print for life of a previous myocardial
infarction
The R wave height is reduced in the leads
positioned directly over the area of infarct
 ST Elevation Infarction
Here’s a diagram depicting an evolving infarction:
A. Normal ECG prior to MI

B. Ischemia from coronary artery occlusion

results in ST depression (not shown) and
peaked T-waves

C. Infarction from ongoing ischemia results in

marked ST elevation

D/E. Ongoing infarction with appearance of

pathologic Q-waves and T-wave inversion

F. Fibrosis (months later) with persistent Q-

waves, but normal ST segment and T-
waves
 ST Elevation Infarction
Here’s an ECG of an inferior MI:
Look at the
inferior leads
(II, III, aVF).

Question:
What ECG
changes do
you see?
ST elevation
and Q-waves
Extra credit:
What is the
rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!
 ST Elevation Infarction
Here’s an ECG of an inferior MI later in time:
Now what do
you see in the
inferior leads?

ST elevation,
Q-waves and
T-wave
inversion
 Non-ST Elevation Infarction
The ECG changes seen with a non-ST elevation infarction are:

Before injury Normal ECG

Ischemia ST depression & T-wave inversion

Infarction ST depression & T-wave inversion

Fibrosis ST returns to baseline, but T-wave

inversion persists
 Non-ST Elevation Infarction
Here’s an ECG of an evolving non-ST elevation MI:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.

Question:
What area of
the heart is
infarcting?

Anterolateral
ECG
ECG
ECG
ECG
ECG
ECG
ECG
ECG
Rhythm disorders
Normal Sinus Rhythm

Rate 60-100bpm
P-P Regularity Regular
R-R Regularity Regular
P wave Present
P:QRS Ratio 1:1, associated
PR Interval Normal
QRS Width Normal
 Sinus Bradycardia

Rate Less than 60bpm

P-P Regularity Regular

R-R Regularity Regular

P wave Present
P:QRS Ratio 1:1, associated
PR Interval Normal, gradually lengthens with HR decrease
QRS Width Normal
 Sinus Tachycardia

Rate Greater than 100bpm, Gradual onset

P-P Regularity Regular
R-R Regularity Regular
P wave Present
P:QRS Ratio 1:1, associated
PR Interval Normal, gradually shortens with HR increase
QRS Width Normal
Sinus Arrhythmia

Rate 60-100bpm
P-P Regularity Irregular
R-R Regularity Irregular
P wave Present
P:QRS Ratio 1:1, associated
PR Interval Normal
QRS Width Normal
 Sinus Pause/Arrest

Rate Varies
P-P Regularity Irregular
R-R Regularity Irregular
P wave Present, except during pause
P:QRS Ratio 1:1, associated
PR Interval Normal
QRS Width Normal
Sinus Node Exit Block

Rate Varies
P-P Regularity Irregular
R-R Regularity Irregular
P wave Present, except during dropped beats
P:QRS Ratio 1:1, associated
PR Interval Normal
QRS Width Normal
 Sinus Rhythm w/ PAC
(Premature Atrial Contraction)

Rate Depends on underlying sinus rate

P-P Regularity Irregular
R-R Regularity Irregular
P wave Present, may be different morphology during PAC
P:QRS Ratio 1:1, associated
PR Interval Normal, varies during PAC
QRS Width Normal
 Atrial Tachycardia

Rate 100-180bpm, Sudden onset

P-P Regularity Regular
R-R Regularity Regular
P wave Morphology will differ from sinus p-wave
P:QRS Ratio 1:1, associated
PR Interval Interval of ectopic focus will differ from sinus PR
QRS Width Normal, but can develop aberrant (wide) complexes
Multifocal Atrial Tachycardia

Rate Greater than 100bpm

P-P Regularity Irregularly irregular
R-R Regularity Irregularly irregular

P wave At least 3 different p-wave morphologies

P:QRS Ratio 1:1, associated
PR Interval Varies
QRS Width Normal
 Atrial Flutter

Atrial Rate Atrial Rate commonly 250-350bpm

Ventricular Rate Ventricular Rate will vary with conduction
P-P Regularity Regular
R-R Regularity Usually regular, but may be variable
P wave “Saw-tooth” p-wave morphology
P:QRS Ratio Varies, can be 1:1, 2:1, 3:1, 4:1, etc.
PR Interval Varies
QRS Width Normal
 Atrial Fibrillation

Rate Varies, ventricular response can be fast or slow

P-P Regularity Chaotic atrial activity
R-R Regularity Irregularly irregular
P wave No discernable p-waves
P:QRS Ratio None
PR Interval None
QRS Width Normal, but can develop aberrant (wide) complexes
 Junctional Rhythm

Rate 40-60bpm
P-P Regularity None, or Regular if antegrade or retrograde
R-R Regularity Regular
P wave Variable (none, antegrade, or retrograde)
P:QRS Ratio None, or 1:1 if antegrade or retrograde
PR Interval None, short, or retrograde
QRS Width Normal
Accelerated Junctional Rhythm
Supraventricular Tachycardia
(SVT)

60-100bpm (Accelerated Junctional Rhythm)

Rate
Greater than 100bpm (Supraventricular
Tachycardia)
P-P Regularity None, or Regular if antegrade or retrograde
R-R Regularity Regular
P wave Variable (none, antegrade, or retrograde)
P:QRS Ratio None, or 1:1 if antegrade or retrograde
PR Interval None, short, or retrograde
QRS Width Normal
Sinus Rhythm w/ PVC
(Premature Ventricular Contraction)

Rate Depends on underlying sinus rate

P-P Regularity Irregular
R-R Regularity Irregular
P wave No P-waves with the PVC
P:QRS Ratio No P-waves with the PVC
PR Interval None
QRS Width Wide complex (>/= 0.12sec).
Ventricular Rhythm

Rate 20-40bpm
P-P Regularity None
R-R Regularity Regular
P wave None
P:QRS Ratio None
PR Interval None
QRS Width Wide complex (>/= 0.12sec).
Accelerated Ventricular Rhythm

Rate 40-100bpm
P-P Regularity None
R-R Regularity Regular
P wave None
P:QRS Ratio None
PR Interval None
QRS Width Wide complex (>/= 0.12sec).
Ventricular Tachycardia

Rate 100-200bpm
P-P Regularity Variable
R-R Regularity Regular
P wave Dissociated atrial rate
P:QRS Ratio Variable
PR Interval None
QRS Width Wide complex (>/= 0.12sec).
Fast VT (Ventricular Flutter)

Rate 200-300bpm
P-P Regularity None
R-R Regularity Regular
P wave None
P:QRS Ratio None
PR Interval None
QRS Width Wide complex (>/= 0.12sec).
Polymorphic VT (Torsades)

Rate 200-250bpm
P-P Regularity None
R-R Regularity Irregular
P wave None
P:QRS Ratio None
PR Interval None
QRS Width Variable with wide complexes
Ventricular Fibrillation

Rate Indeterminate
P-P Regularity None
R-R Regularity Chaotic Rhythm
P wave None
P:QRS Ratio None
PR Interval None
QRS Width None
 Sinus Rhythm
w/ 1st Degree AV Block

Rate Depends on underlying rhythm

P-P Regularity Regular
R-R Regularity Regular
P wave Present, Normal
P:QRS Ratio 1:1, associated
PR Interval Prolonged, > 0.20sec
QRS Width Normal
Sinus Rhythm
w/ 2nd Degree AV Block Type I (Wenckebach)

Rate Depends on underlying rhythm

P-P Regularity Regular
R-R Regularity Regularly irregular
P wave Present
P:QRS Ratio Variable; 2:1, 3:2, 4:3, etc
PR Interval Variable, gradually lengthens until dropped
QRS Width Normal
Sinus Rhythm
w/ 2nd Degree AV Block Type II

Rate Depends on underlying rhythm

P-P Regularity Regular
R-R Regularity Regularly irregular
P wave Present
P:QRS Ratio Variable; 2:1, 3:2, 4:3, etc
PR Interval Normal for conducted beats
QRS Width Normal
Sinus Rhythm
w/ 3rd Degree AV Block (Complete Heart Block)

Atrial Rate Atrial rate is the underlying rhythm (i.e, Sinus, Atrial Fib, etc.)
Ventricular Rate Ventricular rate is from the dissociated escape rhythm
P-P Regularity Regular
R-R Regularity Regular
P wave Present
P:QRS Ratio Variable, dissociated
PR Interval Variable, No pattern
QRS Width Normal (Junctional escape rhythm)
Wide (Ventricular escape rhythm)
Sinus Rhythm w/ BBB
(Bundle Branch Block)

Rate Depends on the underlying sinus rhythm

P-P Regularity Regular
R-R Regularity Regular
P wave Present
P:QRS Ratio 1:1, associated
PR Interval Normal
QRS Width Wide (>0.12ms)
Atrial Fib w/ BBB
(Bundle Branch Block)

Rate Depends on the underlying Atrial Fibrillation,

Ventricular rate can be fast or slow.
P-P Regularity Chaotic atrial activity
R-R Regularity Irregularly irregular
P wave Present
P:QRS Ratio None
PR Interval None
QRS Width Wide (>0.12ms)
 Knowledge Checkpoint
Identify the Rhythm:

Ventricular Tachycardia
A.
Sinus Bradycardia
B.
Complete Heart Block
C.
Atrial Fibrillation
D.
Ventricular Fibrillation
E.
 Knowledge Checkpoint

Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete
Complete Heart Block
D.Atrial
Atrial Fibrillation
E.Ventricular Fibrillation
 Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation
 Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation
 Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation
PRACTICE RHYTHM STRIPS
Practice Rhythm
Strips
• On the following rhythm strips in subsequent slides,
determine rhythm presented.

• Consider the following:

 What is the atrial and ventricular rate? Is it normal?
 What is the regularity (P-P and R-R)
 Are any AV and/or Bundle branch blocks present?
 Does the rhythm have a clinical significance?

• Answers can be found in the notes section of the slides.

Practice Rhythm Strips
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