2. Dr Samira Arami General Cardiologist

3. Conductive system

4. LEAD TYPEPOSITIVE INPUTNEGATIVE INPUT Standard Limb Leads Lead ILeft armRight arm Lead IILeft legRight arm Lead IIILeft legLeft arm Augmented Limb Leads aVRRight armLeft arm plus left leg aVLLeft armRight arm plus left leg aVFLeft legLeft arm plus right arm

5. Precordial Leads* V1V1 Right sternal margin, fourth intercostal space Wilson central terminal V2V2 Left sternal margin, fourth intercostal space Wilson central terminal V3V3 Midway between V 2 and V 4 Wilson central terminal V4V4 Left midclavicular line, 5th intercostal space Wilson central terminal V5V5 Left anterior axillary line [†] Wilson central terminal V6V6 Left midaxillary line [†] Wilson central terminal V7V7 Posterior axillary line [†] Wilson central terminal V8V8 Posterior scapular line [†] Wilson central terminal V9V9 Left border of spine [†] Wilson central terminal

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

7. ECG Paper

8. ECG Complex

9. WAVE OR INTERVAL DURATION (msec) P wave duration<120 PR interval120-200(3-5mm) QRS duration<110-120(2.5-3mm) QT interval (corrected) ≤440-450*

10. ECG Interpretation  Rhythm  Rate  Axis  P, QRS,Intervals  ST & T changes  Other abnormalities

11. Normal Sinus Rythm  Positive P in I,II  HR=60-100  Regular RR intervals  PR>120msec

12.  Heart Rates= 300/RR interval(large squares) or 1500/RR interval(small squares)  Bazzet`s formula : QTc = QT/ √RR(sec)

14. Axis (mean QRS axis): normally -30 to +90 LAD: LVH LAFB Inf. MI RAD: Normal RVH Lat. MI LPFB

15. Normal ECG

17. P-wave Normal values 1. Polarity. up in all leads except aVR. 2. Duration. < 2.5 mm. 3. Amplitude. < 2.5 mm. Abnormalities 1. Inverted P-wave  Junctional rhythm. 2. Wide P-wave (P- mitrale)  LAE 3. Peaked P-wave (P-pulmonale)  RAE 4. Saw-tooth appearance  Atrial flutter 5. Absent P wave  Atrial fibrillation

18. QRS complex Normal values  Duration: < 2.5 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). Abnormalities : 1. Wide QRS complex  Bundle branch block.  Ventricular rhythm. 2. Tall R in V1  RVH.  RBBB.  Posterior MI.  WPW syndrome. 3. abnormal Q wave [ > 25% of R wave]  MI.  Hypertrophic cardiomyopathy.  Normal variant.

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

20. T-wave Normal values. 1. Polarity:  Always up in I,II,V4-5  Always down in aVR.  Variable in III, aVL, aVF, V1- 3. 2. amplitude: < 10mm in the chest leads. Abnormalities: 1. Peaked T-wave:  Hyper-acute MI.  Hyperkalemia.  Normal variant. 2. T- inversion:  Ischemia.  Myocardial infarction.  Myocarditis  Ventricular strain  BBB.  Hypokalemia.  Digoxin effect.

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

23. Mitral P Pulmonar P

24. 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

25. LVH

27. RVH with RAE

29. Bundle system and sites of block

30. Complete Left Bundle Branch Block QRS duration ≥ 120 msec Broad, notched, or slurred R waves in leads I, aVL, V 5 and V 6 Small or absent initial r waves in right precordial leads (V 1 and V 2 ) followed by deep S waves Absent septal q waves in leads I, V 5, and V 6 Prolonged time to peak R wave (>60 msec) in V 5 and V 6

31. Complete Right Bundle Branch Block QRS duration ≥ 120 msec rsr ′, rsR ′,, or rSR ′, patterns in leads V 1 and V 2 S waves in leads I and V 6 ≥ 40 msec wide Normal time to peak R wave in leads V 5 and V 6 but >50 msec in V 1

32. Left Bundle branch block (LBBB)

33. Right Bundle branch block (RBBB)

34. Incomplete RBBB

35. Left anterior fascicular block (LAFB)

36. Bifascicular block (RBBB+LAFB)

37. Trifascicular block 1

39. ST segment and T wave changes in ischemia and MI

40. Lateral ischemia

41. Inferolateral ischemia

42. SVT with ischemia

43. NSTEMI

44. Evolution of ECG changes in MI

45. Hyperacute MI

46. Acute anteroseptal MI (STEMI)

47. Acute anterolateral MI (with hyperacute T)

48. Acute anterolateral MI

49. Acute inferoposterior MI

50. Right ventricular infarction

52. SAH

53. Hyperkalemia

54. Sever hyperkalemia

56. Atrial ectopic

57. Atrial bigeminy

58. Junctional ectopic

59. Ventricular ectopic with compensatory pause

60. Ventricular ectopic without compensatory pause

61. V. bigeminy

62. V. trigeminy

63. R on T event

64. R on T phenomena

65. Multifocal V. ectopics

66. V. Couplet

68. Tachycardia  Wide or Narrow  Regularity  P wave  P and QRS Rate and Association  Axis  Abnormalities

69. Sinus tachycardia

70. Sinus arrhythmia

71. Paroxysmal supraventricular tachycardia [PSVT]

72. SVT

73. SVT with retrograde P- wave

74. Atrial fibrillation [fine]

75. Atrial fibrillation [coarse]

76. AF + LBBB

77. Atrial flutter

79. Multifocal atrial tachycardia

80. Accelerated junctional rhythm

83. SUPPORTS SVTSUPPORTS VT Slowing or termination by vagal toneFusion beats Onset with premature P waveCapture beats RP interval ≤100 msecAV dissociation P and QRS rate and rhythm linked to suggest that ventricular activation depends on atrial discharge, e.g., 2 : 1 AV block rSR ′ V 1 P and QRS rate and rhythm linked to suggest that atrial activation depends on ventricular discharge, e.g., 2 : 1 VA block Long-short cycle sequence “Compensatory” pause Left-axis deviation; QRS duration >140 msec Specific QRS contours (see text) Major Features in the Differential Diagnosis of Wide QRS Beats Versus Tachycardia

84. Non-sustained VT

85. Ventricular tachycardia (VT)

86. VT

87. VT (with RBBB pattern)

88. VT (with LBBB pattern)

89. VT with capture beat

90. VT with fusion beat

91. Twisting VT (Torsades de pointes)

92. Ventricular fibrillation

94. Sinus bradycardia

95. Sinus arrhythmia

96. Junctional rhythm

97. Sinus arrest

99. Sino-atrial exit block

100. SA exit block

101. Sick sinus syndrome

102. First degree heart block

103. Second degree heart block Mobitz type I (Wenckebach block)

104. Second degree heart block Mobitz type II

106. Complete heart block

109. High degree AV block

110. Thanks for Attention