f

Propagation of cardiac impulse

The Normal Conduction System

ECG machine

Generation of normal ECG complex

What is the heart rate? (300 / 6) = 50 bpm

What is the axis? Normal- QRS up in I and aVF

What is the diagnosis? Acute inferior MI with ST elevation in leads II, III, aVF Acute inferior MI with ST elevation in leads II, III, aVF

What is this rhythm? First degree AV block First degree AV block

What is this rhythm? Type 1 second degree block (Wenckebach)

What is this rhythm? Type 2 second degree AV block Dropped QRS

What is this rhythm? 3 rd degree heart block (complete)

14 ECTOPIC BEATS

15 ECTOPIC BEATS

16

ECG Leads Limb leads: I, II, III, aVR, aVL, aVF, Chest leads: V1-V6 Anterior surface: V1-4. Anterior surface: V1-4. Inferior surface: II, III and aVF. Inferior surface: II, III and aVF. Lateral surface: I, aVL and V5-6. Lateral surface: I, aVL and V5-6.

ECG Paper

Normal ECG

P-wave Normal values 1. Polarity. up in I&II and down in aVR. 2. Duration. < 2.5 mm. 3. Amplitude. < 2.5 mm. < 2.5 mm.Abnormalities 1. Inverted P-wave Junctional rhythm. Junctional rhythm. 2. Wide P-wave (P- mitrale) LAE LAE 3. Peaked P-wave (P-pulmonale) RAE RAE 4. Saw-tooth appearance Atrial flutter Atrial flutter 5. Absent P wave Atrial fibrillation Atrial fibrillation

P- mitrale P- pulmonale (LAE) (RAE)

PR interval Definition: the time interval between beginning of P-wave to beginning of QRS complex. Normal PR interval 3-5mm ( sec) Abnormalities 1. Short PR interval WPW syndrome WPW syndrome 2. Long PR interval First degree heart block First degree heart block

QRS complex Normal values Duration: < 3 mm. Duration: < 3 mm. Morphology: progression from Short R and deep S (rS) in V1 to tall R and short S in V6 with small Q in V5-6 (qRs). Morphology: progression from Short R and deep S (rS) in V1 to tall R and short S in V6 with small Q in V5-6 (qRs). Abnormalities : 1. Wide QRS complex Bundle branch block. Bundle branch block. Ventricular rhythm. Ventricular rhythm. 2. Tall R in V1 RVH. RVH. RBBB. RBBB. Posterior MI. Posterior MI. WPW syndrome. WPW syndrome. 3. abnormal Q wave [ > 25% of R wave] [ > 25% of R wave] MI. MI. Hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy. Normal variant. Normal variant.

Normal Q wave

Q wave in MI

Q wave in septal hypertrophy

ST- segment Normally it's isoelectric. [i.e. at same level of TP segment] [i.e. at same level of TP segment] Abnormalities: 1. ST elevation: Acute MI. Acute MI. Prinzmetal angina. Prinzmetal angina. Acute pericarditis. Acute pericarditis. Early repolarization. Early repolarization. 2. ST depression: Ischemia. Ischemia. Ventricular strain. Ventricular strain. BBB. BBB. Hypokalemia. Hypokalemia. Digoxin effect. Digoxin effect.

Abnormalities of ST- segment

T-wave Normal values. 1. Polarity: Always up in I,II,V4-6 Always up in I,II,V4-6 Always down in aVR. Always down in aVR. Variable in III, aVL, aVF, V1-3. Variable in III, aVL, aVF, V amplitude: < 10mm in the chest leads. Abnormalities: 1. Peaked T-wave: Hyper-acute MI. Hyper-acute MI. Hyperkalemia. Hyperkalemia. Normal variant. Normal variant. 2. T- inversion: Ischemia. Ischemia. Myocardial infarction. Myocardial infarction. Myocarditis Myocarditis Ventricular strain Ventricular strain BBB. BBB. Hypokalemia. Hypokalemia. Digoxin effect. Digoxin effect.

QT- interval QT- interval Definition: Time interval between beginning of QRS complex to the end of T wave. QRS complex to the end of T wave. Normally: At normal HR: QT ≤ 11mm (0.44 sec) (or ) QTc = QT/ √RR (or ) QTc = QT/ √RR Abnormalities: 1. Prolonged QT interval: hypocalcemia and congenital long QT syndrome. 2. Short QT interval: hypercalcemia.

INTERPRETATION OF ECG STANDARD? NAME? DATE? STANDARD? NAME? DATE? P(SR-nonSR ? rate? regular or irregular?) P(SR-nonSR ? rate? regular or irregular?) ORS(wide or narrow? LBBB OR RBBB? rate? regular or irregular?) ORS(wide or narrow? LBBB OR RBBB? rate? regular or irregular?) T(tall? invert? biphasic?) T(tall? invert? biphasic?) P-R(long? short? fixed or no? relation?) P-R(long? short? fixed or no? relation?) ST(elevate? Depressed? ) ST(elevate? Depressed? ) QT(long? short?) QT(long? short?) AXIS? AXIS?

Rate Rule of 300- Divide 300 by the number of boxes between each QRS = rate Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate

Rate HR of per minute is normal HR > 100 = tachycardia HR < 60 = bradycardia

Interpretation of ECG cont. 4. Axis (mean QRS axis): normally -30 to +100 LAD: LVH LAFB Inf. MI RAD: Normal RVH Lat. MI LPFB 5. Analysis of complete ECG complex in each lead.

Calculation of electrical axis depending on QRS polarity in leads I and aVF

WPW

Long QT syndrome

Bundle branch block

Left Bundle branch block (LBBB)

Right Bundle branch block (RBBB)

VT (with RBBB pattern)

VT (with LBBB pattern)

ECG changes in IHD ECG changes in IHD Signs of ischemia: Signs of ischemia: Reversible ST depression, ST elevation or T inversion. Reversible ST depression, ST elevation or T inversion. Signs of MI: Signs of MI: 1. Hyperacute T wave. 2. ST elevation (STEMI) ST depression(NSTEMI) ST depression(NSTEMI) 1. Q wave (Q or transmural infarction) 2. T inversion.

Evolution of ECG changes in MI Evolution of ECG changes in MI

Q wave infarction

Localization of MI 1. anterior MI

Localization of MI 2. lateral MI

Localization of MI 3. inferior MI

Hyperacute MI

Acute anteroseptal MI (STEMI)

Acute anterolateral MI (with hyperacute T)

Acute anterolateral MI Old inferior MI

Acute inferior MI

Right ventricular infarction

Old ant. MI

Old inf. MI

Criteria of ventricular enlargement LVH : 1. SV1 + (RV5 or RV6) ≥ 35 mm (or) RV5 or RV6 ≥ 25 mm 2. LV strain 3. LAE RVH : 1. Relatively tall R in V1 2. RV strain 3. RAD

LVH

LVH

RVH with RAE

RAE LAE

Acute pericarditis

SAH

Hyperkalemia

Sever hyperkalemia

PAC

PAC bigeminy

PVC

PVC

PVC. bigeminy

PVC. trigeminy PVC. trigeminy

VT

Multifocal PVC

PVC. Couplet

Sinus tachycardia

Paroxysmal supraventricular tachycardia [PSVT]

PSVT

Atrial fibrillation [fine]

Non-sustained VT

VT

Ventricular fibrillation

Sinus bradycardia

Junctional rhythm

Sinus arrest

First degree heart block

Second degree heart block Mobitz type I (Wenckebach block)

Complete heart block

Sinus rhythm (SR), rate 60, normal ECG.

SR rate 66, benign early repolarization (BER).

SR, rate 91, with first degree AV block.

Ectopic atrial rhythm, rate 82, otherwise normal ECG.

AV junctional rhythm, rate 50

Accelerated idioventricular rhythm (AIVR), rate 65

SR, rate 100, right bundle branch block (RBBB)

SR, rate 80, first degree AV block, left bundle branch block (LBBB),old inf MI

SR, rate 85, RBBB, left posterior fascicular block (LPFB)

rate 50, acute anterolateral myocardial infarction rate 50, acute anterolateral myocardial infarction

SR with second degree AV block type 1 (Mobitz I, Wenckebach), rate 50, left ventricular hypertrophy (LVH), RBBB.

Ventricular tachycardia (VT), rate 140

SR, rate 87, Wolff-Parkinson- White syndrome (WPW)

ST, rate 155

This ECG was recorded from a 25-year-old pregnant woman who complained of an irregular heart beat. Auscultation revealed a soft systolic murmur but her heart was otherwise normal. ^

ANSWER 1 The ECG shows: Sinus rhythm Ventricular extrasystoles Normal axis Normal QRS complexes and T waves Clinical interpretation The extrasystoles are fairly frequent but the ECG is otherwise normal. Ventricular extrasystoles are very common in pregnancy, and systolic murmurs are almost universal. Her heart is almost certainly normal. What to do Remember anaemia

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