ECG for residents
Yitagesu Getachew
(MD, MPH)
AAU, CHS, SOM, Department of Internal Medicine
Division of Cardiology
January, 2022
Outline
• Basics of ECG ( selected)
• Examples
• Exercise on ECG, CXR and echo imaging
• Number of slides are 89
Fundamental principles
• The ECG is the outcome of a complex series of physiologic and
technologic processes
• Trans-membrane ionic currents are generated by ion fluxes across
cell membranes and between adjacent cells
• Currents are synchronized during cardiac activation and recovery
sequences
• Generates a physiologically meaningful, time- varying electrical field
in and around the heart.
Principle…
• Electrodes placed in specific locations on the extremities and
torso detect the currents reaching the skin
• Electrodes are configured to produce leads
• The outputs of leads are then amplified, filtered, digitized, and
displayed to produce an ECG recording
• Signals are analyzed by signal processing and pattern recognition
software to provide a preliminary interpretation which is subject
to careful clinician review.
Location of Electrodes and Lead Connections for
the Standard 12- Lead Electrocardiogram and Additional Leads
Location of Electrodes and Lead Connections for
the Standard 12- Lead…………
The waves and intervals of a normal electrocardiogram
Normal Upper Limits for Durations of
Electrocardiogram Waves and Intervals
The abnormal ECG
Chamber enlargement and hypertrophy
• Atrial abnormality
• P wave abnormalities reflecting changes in:
(1) the origin of the initiating sinus node impulse
(2) conduction within the atria and from the RA to the LA
(3) the size and shape of the atria
• May result in abnormal patterns of inter-atrial block, left atrial
abnormalities, and right atrial abnormalities
Chamber enlargement…..
• Left Atrial Abnormality
• Anatomic abnormalities of the LA that alter the P waves include:
Atrial dilation
Elevated intra- atrial pressures
Conduction slowing
• These pathophysiologic abnormalities often coexist and produce similar ECG
effects
• The resulting patterns are often referred as left atrial abnormality.
Common Diagnostic Criteria for Left and Right
Atrial Abnormalities
Left Ventricular Hypertrophy (LVH)
• QRS changes include greater than normal amplitudes of R waves in leads
facing the LV (leads I, aVL, V5, and V6), and deeper than normal S waves
in leads overlying the opposite side of the heart (V1 and V2).
• These changes are often associated with left axis deviation, notching or
slurring of R waves, and patterns suggesting intraventricular conduction
defects
• Commonly the ST segment is depressed and followed by an inverted T
wave
• In leads I, II, aVL, and V5–V6. The depressed ST segment is typically either
flat or sloped downward from a depressed J point followed by an
asymmetrically inverted T wave (strain pattern)
LVH…….
Common Diagnostic Criteria for LVH
Right Ventricular Hypertrophy (RVH)
• RVH changes fundamental aspects of the QRS complex
• Most often it include abnormally tall R waves in anteriorly and
rightward- directed leads (aVR, V1, V2)
• Abnormally deep S waves and Small r waves in leftward-
directed leads ( I, aVL, and lateral precordial leads)
• The normal R wave progression in the precordial leads is
reversed, the frontal plane QRS axis is shifted to the right, and
S waves in leads I, II, and III are common (the SISIISIII pattern)
Common Diagnostic Criteria for RVH
Right ventricular hypertrophy pattern consistent with severe
pressure overload of the RV.
(1) a tall R wave in V1,
(2) right axis deviation
(3) ST- segment depression and T wave inversion in V1 through V3
(4) delayed precordial transition zone (rS in V6)
(5) right atrial abnormality, and (6) an S1Q3T3 pattern
Acute Cor-pulmonale secondary to acute pulmonary
embolism simulating inferior and anterior infarction.
Tracing shows an S1Q3T3 pattern, a QS in lead V1
with slow R wave progression in the right precordial leads
and right precordial to midprecordial ST elevation and T
wave inversion (V1 to V4)
Common Diagnostic Criteria for Fascicular Blocks
Left Bundle Branch Block (LBBB)
• ECG changes include a widened QRS complex with characteristic
changes in its shape and the ST- T wave
• Basic requirements include QRS duration of 120 msec or more
• Broad and, typically, notched R waves in leads I, aVL, and the left
precordial leads; narrow r waves followed by broad and deep S
waves in the right precordial leads; and, usually, the absence of
septal q waves
• The mean QRS axis may be normal, deviated to the left or, rarely, to
the right
LBBB…….
• The ST segment and T wave are discordant with the QRS
complex in most cases.
• The ST segments are depressed, and T waves are inverted in
leads with positive QRS waves (e.g., leads I, aVL, V5, V6).
• ST segments are elevated and T waves are typically upright in
leads with predominantly negative QRS complexes (e.g.,
leads V1, V2).
Right Bundle Branch Block (RBBB)
• The ST- T waves are discordant with the QRS complex
• T waves are inverted in the right precordial leads and
upright in the left precordial leads and in leads I and aVL.
• The mean QRS axis is not altered by RBBB
• Axis shifts can occur, however, as a result of the
simultaneous occurrence of fascicular blocks along with
RBBB
Common Diagnostic Criteria for Bundle Branch
Blocks
Myocardial Ischemia and Infarction
The waveform findings vary considerably depending on at least five major
factors:
• (1) the duration of the ischemic process (acute versus evolving versus
chronic)
• (2) its severity (ischemia with or without infarction)
• (3) its extent (size and degree of transmural involvement)
• (4) its topography (anterior versus inferior- posterior- lateral or right
ventricular)
• (5) the presence of other underlying abnormalities (e.g., prior infarction,
LBBB, WPW syndrome, or pace-maker patterns) that can alter or mask the
classic patterns
MI………
• Ischemic ST- segment elevation and hyper-acute T wave changes
may occur as the earliest ECG manifestations of STEMI
• Followed by hours to days by evolving T wave inversion and
sometimes Q waves in the same lead distribution
• T wave inversion from evolving or chronic ischemia correlates
with increased ventricular action potential duration, and these
changes are associated with QT prolongation
Localization of myocardial infarction
based on ECG changes (AHA)
ECG changes and criteria to consider/exercise
• PSVTs ( AVNRT)
• Atrial fibrillation and flutter, MAT, Atrial tachycardia
• AV Blocks, PVCs
• Ventricular tachycardia and fibrillation, TDP
• Syndromes ( Brugada, WPW, long QT)
• HCM
• Pericarditis
• Drugs
• Electrolytes
• Hypothermia, pacemaker ECG
• Artifacts and lead reversal
• And more……
Selected ECG, CXR and Echo images exercise
For each ECG perform a systematic reading
• Consider the rhythm, rate, axis, and intervals and whether atrio-
ventricular conduction disturbances are present
• Determine if criteria are met for atrial or ventricular hypertrophy,
intraventricular conduction disturbances, or prior myocardial
infarction
• Continue by noting abnormalities of the ST segment and T waves
• Conclude by suggesting a clinical diagnosis compatible with each
tracing
A 55-year-old man with long-standing hypertension
A 23-year-old woman referred to the cardiology clinic
because of a murmur and abnormal ECG
A 72-year-old man with palpitations after coronary
artery bypass surgery
A 70-year-old woman presents to the emergency
department with severe chest pain and dyspnea
A 66-year-old man with a history of cigarette smoking,
presents to his new primary care physician for a routine
examination
A 28-year-old man with a lifelong heart murmur
A 47-year-old man with episodes of syncope
A 63-year-old man with tachycardia
A 78-year-old woman with a history of a heart murmur
presents with intermittent dyspnea and lightheadedness
A 21-year-old woman with palpitations and presyncope
A 48-year-old woman with nausea
A 61-year-old man admitted with frequent dizziness
A 65-year-old man who underwent coronary artery
bypass graft surgery 24 hours ago
A 74-year-old man with an irregular pulse
A 66-year-old woman with renal failure, palpitations,
and lightheadedness
A 54-year-old man with sudden lightheadedness
A 64-year-old woman with profound nausea and
diaphoresis
A 51-year-old woman with discrete episodes of
presyncope
An elderly nursing home resident with fatigue
Routine preoperative
evaluation of an asymptomatic 45-year-old man scheduled
to undergo wrist surgery
A 62-year-old man is brought to ER because of severe headache and
dizziness. His blood pressure is 186/98 mm Hg
A 56-year-old woman with sudden onset of pleuritic
chest discomfort and dyspnea
A 36-year-old man with sharp inspiratory precordial chest
discomfort that radiates to the left shoulder
A 71-year-old alcoholic man with epigastric discomfort after 18
hours of intermittent vomiting
A 19-year-old male with exertional
lightheadedness and a harsh systolic murmur
A 59-year-old man with severe lightheadedness
A 46‐Year‐Old Man with Heart Failure and New Onset
Palpitations
A 43‐Year‐Old Man with Chest Pain and an Episode
of Syncope
A 50‐Year‐Old Man with Worsening Cough and Dyspnea
A 25 year old Japanese without any past
medical history collapsed suddenly while in a
meeting, ECG after cardioversion
A 31‐Year‐Old Woman with Palpitations While at Work
An 80-year-old man who complained of breathlessness and
ankle swelling
A 40-year-old man who was admitted to emergency, with the
sudden onset of the symptoms heart failure
A 48-year-old man
who had severe chest pain for 1 h
A 20-year-old student complains of palpitations.
Attacks occur about once per year
A 60-year-old man complained of severe chest pain, and a few
minutes later became extremely breathless and collapsed
Asymptomatic 45-year-old man at a ‘health screening’
examination
A 70-year-old woman
who had complained of attacks of dizziness for about a year
An 80-year-old man is found at routine examination
to have a slow heart rate
An elderly man was admitted unconscious after a
stroke, and this was his ECG
A 35-year-old woman, who had had palpitations for
many years without any diagnosis being made, blood pressure is
normal
Thank you!
