Hello it’s an

ECG

• Electrocardiography (ECG or EKG) is the process of recording the electrical activity of the heart
over a period of time using electrodes placed on a patient's body. These electrodes detect the
electrical changes on the skin that arise from the heart muscle depolarizing during each heart
beat.

• Since all muscular contraction will be detected , the electrical changes associated with
contraction of the heart muscle only will be clear when the pt. is fully relaxed.
THE WIRING DIAGRAM OF THE HEART
Chest leads:
** V1 , V2 : Rt ventricle.
** V3 , V4 : septum and anterior wall of Lt ventricle.
** V5, , V6 : Anterior and lateral wall of Lt ventricle.
Limb leads:
- avR , avL , avF
- lead I , lead II , lead III
-----------------------------------

* aVR : looks at Rt atrium.

* aVF ,II , III : at the inferior surface.
* aVL , I : Lt lateral surface of heart.
ECG paper:
P : atrial depolarization .
PR interval: time taken for
excitation to spread from SA
node > through atrial mass and
AV node > down to bundle of
HIS and ventricular mass.
QRS : ventricular
depolarization.
ST segment: ventricular
contraction.
T : ventricular repolarization.
• PR interval: 0.12- 0.2 sec.
• QRS: 0.12 sec.
RR interval = Heart rate
Axis Deviation
 The cardiac axis is the average direction of spread of depolarization as seen
from the front, and is estimated from leads I,II & III .
 Normally between -30 and + 90
ORS complex in lead I , II , III in case of NORMAL axis:
** lead I , II , III PREDOMINANTLY UPWARD deflection.
** deflection in lead II GREATER than I or III
ORS complex in lead I , II , III in case of RIGHT axis deviation:
** Deflection in lead I become negative.
** Deflection in lead III become MORE positive.
Causes of right axis deviation :
 Right ventricular hypertrophy
 COPD
 PE
ORS complex in lead I , II , III in case of LEFT axis deviation:
** lead III become PREDOMINANTLY NEGATIVE.
** it’s not significant until QRS deflection is NEGATIVE in lead II.
Left axis deviation causes :
May be normal variant in obese .
Left ventricular hypertrophy
Inferior MI
Others ; WPW
Test?
Conduction & its problems
 Depolarization normally begins in the SA node, and spreads to the ventricles
via the AV node, the His bundle, the right and left branches of the His bundle,
and the anterior and posterior fascicles of the left bundle branch.

 A conduction abnormality can develop at any of these point

 Conduction problems in the AV node and His bundle may be partial (first and
second degree block) or complete (third degree block).

 Ifconduction is normal through the AV node, the His bundle and one of its
branches, but is abnormal in the other branch, bundle branch block exists and
the QRS complex is wide
NOTE : the rhythm of the heart is best interrupted from
lead II and lead V1 , which show the P wave most
clearly . “ rhythm strip”
First degree heart block:

if each wave of depolarization that originates in the SA node is

conducted to the ventricles, but there is delay somewhere along the
conduction pathway, then the PR interval is prolonged.
Second degree heart block :

 sometimes excitation completely fails to pass through the AV node or the

bundle of His. When this occurs intermittently, “ second degree heart block” is
said to exist.
 There are 3 variations .
1- Mobitz type 2

• Most beats are conducted with CONSTANT PR interval , but occasionally there is an
atrial contraction without subsequent ventricular contraction.
2- Mobitz type 1”wenckebach phenomenon”

• Progressive lengthening of the PR interval and then failure of conduction of an atrial beat ,
followed by a conducted beat with shorter PR interval and then repetition of the cycle.
3- 2:1 , 3:1 , 4:1 conduction types:

• There may be alternate conducted and non-conducted atrial beats,

• In 2:1 there is one conducted and two non conducted beats , and so on.
Third degree heart block “complete heart block”

• occurs when atrial contraction is normal but no beats are conducted to the
ventricles.
• When this occurs the ventricles are excited by a slow “escape mechanism“, from
a depolarizing focus within the ventricular muscle
• complete heart block may occur as an acute phenomenon in patients with MI
( transient) or it may be chronic, usually due to fibrosis around the bundle
of His. It may also be caused by the block of both bundle branches.
Third degree heart block “complete heart block”
- no relationship between P wave and QRS
- wide QRS
- abnormally shaped QRS
Bundle Branch Block:
 If the depolarization wave reaches the intraventricular septum normally, the
interval between the beginning of the P wave and the first deflection in the QRS
complex (the PR interval) will be normal.

 abnormal conduction through either the right or left bundle branches

(‘bundle branch block’) there will be a delay in the depolarization of part of
the ventricular muscle. The extra time taken for depolarization of the whole
of the ventricular muscle causes widening of the QRS complex.
Bundle Branch Block:
Block of both bundle branches has the same effect as block of the His
bundle, and causes complete (third degree) heart block.

RBBB often indicates problems in the right side of the heart, but RBBB
patterns with a QRS complex of normal duration are quite common in
healthy people.
Sometimes called “partial right bundle branch block”

LBBB is always an indication of heart disease, usually of the left ventricle.

 Right Bundle Branch Block “RBBB” :
• No conduction occurs down the right bundle but septum is depolarized from the left side as usual
causing an R wave in Rt ventricular lead “V1” and Q wave in “V6”
• Excitation then spread to the Lt ventricle causing S wave in “V1” and R wave in “V6”
• Then the excitation spread from Lt ventricle to the Rt causing second R wave in “V1” and wide ,
deep S wave in “V6”

• “rSR1” pattern in lead “V1” is a characteristic to RBBB

 Left Bundle Branch Block “RBBB” :

• No conduction occurs down the left bundle, so septum becomes depolarized from the Right

to Left causing an small Q wave in “V1” and R wave in “V6”

• Excitation then spread to the Right ventricle causing SMALL R wave in “V1” and S wave in
“V6”
• Then the excitation spread from Right ventricle to the Left causing S wave in “V1” and another
R wave in “V6”

• “M” pattern in lead “V6” is a characteristic to LBBB

LBBB
• RBBB is best seen in lead V1 , where there is an RSR1 pattern.
• Think about ASD in case of RBBB.
• There is no specific TT.

• LBBB is best seen in lead V6 , where there is a broad complex with

notched top , which resemble the letter “M” in V6.
• Think about Aortic stenosis and ischemic heart disease.
Ischemic heart diseases
Myocardial Infarction:
 In case of Full thickness myocardial infarction “Transmural MI”, the
- first abnormality seen on the ECG is elevation of the ST segment, convex
peaked T wave
- Subsequently Q waves appear, and the T waves become inverted.
 The ST segment returns to the baseline, the whole process taking a variable
time but usually within the range 24–48 h. T wave inversion is often
permanent. Infarctions causing this pattern of ECG changes are called:
‘ST segment elevation myocardial infarctions’ (STEMIs)

 Ifan infarction is not full thickness “subendocardial infarction” and so does

not cause an electrical window, there will be T wave inversion but no Q waves.
Infarctions with this pattern of ECG change are called:
 “non-ST segment elevation myocardial infarctions’ (NSTEMIs).
Localization ST elevation

Inferior MI II, III, aVF

Lateral MI I, aVL, V5, V6

inferolateral II , III , aVF , aVL , V5, V6

Anterior V1 , V2

Septal V3 , V4

Anterolateral V3,4,5,6, + lead I + aVL

Test?
Test?
Test?
Stable Angina:
Arrhythmia
The rhythm of the heart :
 The keys to rhythm abnormalities are:
1. The P waves – can you find them? Look for the lead in which they are most
obvious.
2. The relationship between the P waves and the QRS complexes – there should
be one P wave per QRS complex.
3. The width of the QRS complex (should be 0.12s or less).
4. Because an arrhythmia should be identified from the lead in which the P
waves can be seen most easily, full 12-lead ECGs are better than rhythm strip.
Abnormal rhythm:
Abnormal cardiac rhythms can begin in one of three places:

1. Atrial muscle
2. region around AV node “ nodal or junctional rhythm ”
3. Ventricular muscle “ idioventricular rhythm”
Sinus rhythm, atrial rhythm and junctional rhythm together
constitute the “supraventricular rhythms”.
In supraventricular rhythms, the depolarization wave spreads to the
ventricles in the normal way via the His bundle and its branches,
The QRS complex is therefore normal, and is the same whether
depolarization was initiated by the SA node, the atrial muscle, or the
junctional region.
In ventricular rhythms, the depolarization wave spreads
through the ventricles by an abnormal, and therefore
slower, pathway through the Purkinje fibres. The QRS
complex is therefore wide and abnormal. Repolarization
is also abnormal, so the T wave is of abnormal shape.
Sinoatrial nodal rhythms
Sinus arrhythmia:

• Phasic alteration of heart rate during respiration , Increase during Inspiration and Decrease
during Expiration.
• Absence of this normal variation in heart rate with breathing may indicate Autonomic
neuropathy.
Sinus bradycardia:

• Sinus rate less than 60/min , may occur in healthy people at rest and it’s a common finding in
athletes.
• Causes of Pathological sinus bradycardia :
1- MI
2-hypothyroidism
3-hypothermia
4-raised ICP
5- drugs “b-blocker”
6-sick sinus syndrome
Sinus Tachycardia:

• Sinus rate more than 100/min,

• Usually due to increase in sympathetic activity “ exercise, pregnancy, emotion”
• May pathological :
1- fever
2- anemia
3-thyrotoxicosis
4-heart failure
5-drugs” B- agonist”
 Supraventricular tachycardia:
• Due to large re-entry circuit involving AV node ,

• ECG ccc: “regular tachycardia with rate of 120-240/min”

• Usually last from a few seconds to many hours.
 Wolff-Parkinson-white syndrome:
• due to Accessory pathway which form a direct connection between atrium and ventricle. and in
the accessory bundle there is no AV node to delay conduction.
• ECG ccc : “shortened P wave” + “slurred initial deflection of QRS= Delta wave”
• It’s important to differentiate it from SVT, because “adenosine , B blocker an calcium channel
blocker” which indicated in SVT , are contraindicated here .
Atrial tachyarrythmia
Atrial Flutter:
• Caused by large re-entry circuit within the Right atrium
• In case of irregular rhythm , we calculate atrial rate which indicated by the frequency of the P waves and
the ventricular rate is indicated by the frequency of the QRS complexes.
1- Atrial rate approximately 300/min,
2- 2:1 , 3:1, 4:1 heart block with corresponding ventricular rate more than 125/min
3- Saw-toothed baseline
re-entry circuit within the Right atrium
Atrial Fibrillation:

• Most common sustained cardiac arrhythmia

• Caused by multiple re-entry circuits looping around the atria, initiated by ectopic beats arising
from conducted tissue in the pulmonary vein or from diseased atrial tissue.
• ECG characterized by “ irregular irregular pulse” = “atrial beat rapidly but in uncoordinated and
ineffective manner , and ventricle activated irregularly at rate determined by conduction in AV
node.”
• The results are :
1- NO P wave
2- irregular QRS complex
3- baseline show irregular fibrillation waves
Atrial Fibrillation:
Ventricular tachyarrythmia
 Ventricular Tachycardia:
• After acute MI , chronic coronary disease or cardiomyopathy , a focus in the
ventricular muscle “ischemic tissue” depolarize with high frequency and rapidly
repeated extra-systole which end with “ventricular tachycardia”
• Excitation has to spread by an abnormal path through the ventricular muscle, and
the QRS complex is therefore wide and abnormal
• ECG ccc:
1-no p wave
2-broad , abnormal QRS complex , duration >0.2 sec.
3- no identifiable T wave
1-no p wave
2-broad , abnormal QRS complex , duration >0.2 sec.
3- no identifiable T wave
Miscellaneous
pulmonary embolism:
 Diffuse ST elevation in all leads except in :
Acute Pericarditis: .1- aVR , reciprocal ST depression
.V1 either ST depression or normal ST segment -2
Hyperkalemia:
Hyperkalemia:
Hello from the other side 
GOOD LUCK 

- Osama AL-Khawaja
- Ahmad Akram