1. ELECTROCARDIOGRAM (ECG)
بسم الله الرحمن الرحيم
Cardiovascular System
ANALYSIS
Dr.Mohammed Sharique Ahmed Quadri
Asst. Professor Physiology
Almaarefa College
ELECTROCARDIOGRAM (ECG)

2. The 12-Leads The 12-leads include: 3 Limb leads (I, II, III)
3 Augmented leads (aVR, aVL, aVF)
6 Precordial leads (V1- V6)

3. Views of the Heart Left Lateral portion of the heart( I , Avl, v5,v6)
Some leads get a good view of the:
Anterior portion of the heart
(V1,V2,- setum
V3,V4-)- anterior
Inferior portion of the heart
II, III, aVF

4. Basic components

5. The “PQRST” P wave - Atrial depolarization
QRS - Ventricular depolarization
T wave - Ventricular repolarization

6. Atrial depolarization
The PR Interval
Atrial depolarization +
delay in AV junction
(AV node/Bundle of His)
(delay allows time for the atria to contract before the ventricles contract)

7. Segments & intervals PR interval: 0.12 – 0.20 sec
QRS interval : 0.08 – 0.10sec
QT interval : sec
ST interval : sec

8. How to read the ecg Rhythm analysis
Analyzing individual wave & segments
Determine the mean electrical axis

9. Rhythm Analysis Step 1: Determine regularity. Step 2: Calculate rate.
Step 3: Assess the P waves.
Step 4: Determine PR interval.
Step 5: Determine QRS duration.

10. 1-Determine regularity
Look at the R-R distances (using a caliper or markings with a pen on paper).
Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular? Irregularly irregular?
Interpretation? R R
Regular

11. 2-Calculating heart rate
H.R = NO OF SMALL SQURES BETWEEN R-R WAVES OR
H.R = NO OF BIG SQURES BETWEEN R-R WAVES

12. Calculate Rate Option 2 R wave
Find a R wave that lands on a bold line.
Count the # of large boxes to the next R wave. If the second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes - 100, 4 boxes - 75, etc. (cont)
R wave

13. 3-Assess the P waves Are there P waves? Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation?
Normal P waves with 1 P wave for every QRS

14. 4-Determine PR interval
Normal: seconds.
(3 - 5 boxes)
Interpretation?
0.12 seconds

15. 5-QRS duration Normal: 0.04 - 0.12 seconds. (1 - 3 boxes)
Interpretation?
0.08 seconds

16. Rhythm Summary Normal Sinus Rhythm Regularity regular Rate 90-95 bpm
P waves normal
PR interval s
QRS duration s
Interpretation?
Normal Sinus Rhythm

17. Calculate Heart Rate.
What is Axis ?
Normal ECG

18. Variations in Sinus Rhythm
Rate?
35 bpm
Regularity?
regular
P waves?
normal
PR interval?
0.12 s
QRS duration?
0.10 s
Interpretation?
Sinus Bradycardia

19. Variations in Sinus Rhythm
Rate?
130 bpm
Regularity?
regular
P waves?
normal
PR interval?
0.16 s
QRS duration?
0.08 s
Interpretation?
Sinus Tachycardia

20. SINUS ARHYTHMIA INTERPRETE THE ECG ?
Observe Variation in Heart Rate during Inspiration and Expiration.
[Increased Heart Rate during Inspiration]

21. Atrial Fibrillation Deviation from NSR
No organized atrial depolarization, so no normal P waves (impulses are not originating from the sinus node).
The atrial rate is usually above 350 beats per minute
Atrial activity is chaotic (resulting in an irregularly irregular rate).
Common, affects 2-4%, up to 5-10% if > 80 years old

22. Atrial Flutter Rate? 70 bpm Regularity? regular P waves? flutter waves
PR interval?
none
QRS duration?
0.06 s
Interpretation?
Atrial Flutter

23. AV Nodal Blocks
1st Degree AV Block
2nd Degree AV Block, MobitzType I
2nd Degree AV Block,MobitzType II
3rd Degree AV Block

24. Rate? 60 bpm Regularity? regular P waves? normal PR interval? 0.36 s
Take a look at this ECG. What do you notice
Rate?
60 bpm
Regularity?
regular
P waves?
normal
PR interval?
0.36 s
QRS duration?
0.08 s
Interpretation?
1st Degree AV Block
PR Interval > 0.20 s
Etiology: Prolonged conduction delay in the AV node or Bundle of His.

25. 2nd Degree AV Block, Type I
Take a look at this ECG. What do you notice
Rate?
50 bpm
Regularity?
regularly irregular
P waves?
normal, but 4th no QRS
PR interval?
lengthens
QRS duration?
0.08 s
Interpretation?
2nd Degree AV Block, Type I
PR interval progressively lengthens, then the impulse is completely blocked (P wave not followed by QRS).
Etiology: Each successive atrial impulse encounters a longer and longer delay in the AV node until one impulse (usually the 3rd or 4th) fails to make it through the AV node.

26. 2nd Degree AV Block, Type II
Take a look at this ECG. What do you notice
Rate?
40 bpm
Regularity?
regular
P waves?
normal, 2 & 3 no QRS
PR interval?
0.14 s
QRS duration?
0.08 s
Interpretation?
2nd Degree AV Block, Type II
Occasional P waves are completely blocked (P wave not followed by QRS).
Etiology: Conduction is all or nothing (no prolongation of PR interval); typically block occurs in the Bundle of His.

27. Interpretation? 3rd Degree AV Block Rate? 40 bpm Regularity? regular
Take a look at this ECG. What do you notice
Rate?
40 bpm
Regularity?
regular
P waves?
no relation to QRS
PR interval?
none
QRS duration?
wide (> 0.12 s)
Interpretation?
3rd Degree AV Block
Etiology: There is complete block of conduction in the AV junction, so the atria and ventricles form impulses independently of each other. Without impulses from the atria, the ventricles own intrinsic pacemaker kicks in at around beats/minute.

28. Remember
When an impulse originates in a ventricle, conduction through the ventricles will be inefficient and the QRS will be wide and bizarre.

29. Determination of Mean Electrical Axis
Axis refers to the mean QRS axis (or vector) during ventricular depolarization. As you recall when the ventricles depolarize (in a normal heart) the direction of current flows leftward and downward because most of the ventricular mass is in the left ventricle. We like to know the QRS axis because an abnormal axis can suggest disease such as pulmonary hypertension from a pulmonary embolism.

30. When a vector is exactly horizontal and directed toward the person’s left side,the vector is said to extend in the direction of 0 degrees
From this zero reference point, the scale of
vectors rotates clockwise:

31. FORMATION OF HEXAAXIAL SYSTEM
I III II

32. FORMATION OF HEXAAXIAL SYSTEM
aVR aVL
aVF

33. FORMATION OF HEXAAXIAL SYSTEM
-90
aVR aVL I
III II
+90
aVF

34. Determination of Mean Electrical Axis
The QRS axis is determined by overlying a circle, in the frontal plane. By convention, the degrees of the circle are as shown.
The normal QRS axis lies between -30o and +110o.
A QRS axis that falls between -30o and -90o is abnormal and called left axis deviation. 0o
30o
-30o
60o
-60o
-90o
-120o
90o
120o
150o
180o
-150o
A QRS axis that falls between +110o and +180o is abnormal and called right axis deviation.
A QRS axis that falls between +180o and -90o is abnormal and called Indeterminant (extende rt axis ) .

35. How to calculate the qrs axis
Leads & there isoelectric partners

37. How to calculate the QRS axis
… if the QRS is negative in lead I and negative in lead II what is the QRS axis? (normal, left, right or right superior axis deviation)
QRS Complexes
I aVF
Axis
normal
left axis deviation
right axis deviation
right superior axis deviation/ indeterminant