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Normal
http://www.ecglibr
ary.com/norm.php
L Axis
Deviation
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/02/LAD.jpg
R Axis
Deviation
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/02/rightaxis.jpg
STEMI
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/07/ECGAnatomy-LITFL.jpg
Anterior http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/12/anteriorSTEMIevolving.jpg
Rate
Rhythm
Axis
P Waves
6080bpm
Sinus
Normal
(Leads I
and II
+ve)
Present
(height =
<2.5mm
in lead II)
QRS axis
between
-30o and
-90o
QRS Axis
between
+90o and
+180o
PR
Interval
0.12s-0.2s
(3-5 small
sq)
QRS
Complex
0.12s (3
small sq)
ST
Segment
T Wave
Same
direction
as R wave
aVR
always -ve
Leads I
and II
QRS
complexes
Leaving
Lead I
and aVL =
+ve QRS
Lead II
and aVF =
-ve QRS
Leads I
and II QRS
Reaching
Lead I
and aVL =
-ve QRS
Leads II
and aVF =
+ve QRS
Anterior
STE (V1V6) LAD
Septal
leads =
V1-V2
Lateral
STE (I,
aVL, V5
and V6)
LCx
Kishan Jethwa
Rate
Rhythm
Axis
P Waves
PR
Interval
QRS
Complex
Lateral http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/10/anterolater
al.jpg
ST
Segment
Inferior
STE (II, III
and aVF)
RCA
T Wave
Inferior http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/10/inf1.jpg
STE in
correspon
ding leads
STE
Days 1-2
STE
Days later
Normal
Weeks later
Normal
LBBB
(WiLliaM)
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/03/LBBB-Mand-W.jpg
RBBB
(MaRroW)
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/03/RBBB.png
Broad QRS
>0.12s (3
small sq)
RSRI
pattern in
V1
qRS
pattern in
T wave
inversion
T wave
inverted
Normal
Dominant
S wave in
V1
V1 V3 =
ST
depressio
n
Q wave
starts
Q wave
Smaller R
wave
Pathologic
al Q wave
(>1/3 of R
wave)
Broad
notched R
wave in
V6
V1-V3 = T
wave
inversion
Kishan Jethwa
Rate
Rhythm
L Anterior
Fasicular
Block/L
Anterior
Hemiblock
(Anterior
fascicle in L
bundle fails to
conduct)
Axis
L axis
deviation
P Waves
PR
Interval
QRS
Complex
V6
Fasicular Block
Leads I
and aVL Small Q
waves w/
tall R
waves
Leads II,
III and
aVF
small R
wave and
deep S
wave
V1 and
V6 - RBBB
pattern
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/02/LAFB4.jpg
Bifasicular
Block (RBBB
and L anterior
hemiblock)
L axis
deviation
http://www.learnth
eheart.com/ecgreview/ecgarchive/bifascicula
r-block-lafb-rbbbecg-1/
Trifasicular
Block
(Bifascicular
block + 3rd
Degree Heart
Block)
L axis
deviation
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/11/trifascicula
r-3.jpg
PR
interval
(>0.2s)
no relation
between P
wave and
QRS
V1 and
V6
RBBB
pattern
>60bpm
Sinus
ST
Segment
T Wave
Kishan Jethwa
Rate
Rhythm
Sinus
Arrhythmia
Sinus
Sinus Arrest
No impulse
generated
from SAN
Irregular
pause
following
normal
sinus beat
(>3secs)
http://www.google
.co.uk/url?
sa=i&rct=j&q=&es
rc=s&source=ima
ges&cd=&cad=rja
&uact=8&ved=0C
AcQjRw&url=http
%3A%2F
%2Fwww.unm.edu
%2F~lkravitz
%2FEKG
%2Fsablockarrest.
html&ei=g8R4VK6
FF8jnaIm3gOgM&
bvm=bv.80642063
,d.ZGU&psig=AFQj
CNHm3nsjv9YYZG
WUXHxTUXxaXjHI
pQ&ust=14172870
56917694
Sinus Block
Impulse
generated
from SAN but
not conducted
out the node
http://www.google
.co.uk/url?
sa=i&rct=j&q=&es
rc=s&source=ima
ges&cd=&cad=rja
&uact=8&ved=0C
AcQjRw&url=http
Irregular
pause
after
normal
sinus
Beat
following
pause =
sinus
Axis
P Waves
Normal
sinus P
waves
Irregular
P-P
intervals
If the
next beat
is a
junctional
escape
beat then
P wave
will be
absent
PR
Interval
Normal PR
Interval
QRS
Complex
Normal
Junctiona
l escape
beat
(w/out
preceding
P wave) if
next beat
comes
from the
AVN
AVN
escape
beat =
narrow
QRS
Ventricul
ar escape
beat (from
below
AVN) =
broad QRS
Normal
QRS
following
pause
ST
Segment
T Wave
Pause is
NOT
multiple of
2 R-R
intervals
Pause =
multiple of
2 normal
R-R
intervals
Kishan Jethwa
Rate
Rhythm
Brady
(>60bp
m)
Periods
of tachy
(<100bp
m)
Sinus
brady
Followed
by tachy
(usually
supraventr
icular i.e.
AF)
Axis
P Waves
PR
Interval
QRS
Complex
%3A%2F
%2Fwww.ilecture.com
%2Fsinusblock.ht
ml&ei=0Md4VMvb
H4_zaurjgtgI&bvm
=bv.80642063,d.Z
GU&psig=AFQjCNF
6berc16hVbpL5j4jpq0HPlxpiA&u
st=141728798703
3789
Sick Sinus
Syndrome
(Bradycardiatachycardia
syndrome)
http://www.google
.co.uk/url?
sa=i&rct=j&q=&es
rc=s&source=ima
ges&cd=&cad=rja
&uact=8&ved=0C
AcQjRw&url=http
%3A%2F
%2Fwww.aafp.org
%2Fafp
%2F2003%2F0415
%2Fp1725.html&e
i=Nst4VOW8IMPm
aua7gcAF&bvm=b
v.80642063,d.ZGU
&psig=AFQjCNGW
dby7ssH94spwfjy1
oRkNSoqsjw&ust=
141728888037754
6
1st Degree AV
Block
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/02/1st-
May be
sinus
block/arre
st
following
tachy
Sinus
May be
junctional
escape
beats
following
tachy,
which
would
have
absent P
waves
Present
AV Block
PR
Interval
(>0.2s /
>3-5
small sqs)
ST
Segment
T Wave
Kishan Jethwa
Rate
Rhythm
Axis
P Waves
degree-heartblock-on-call.jpg
Prolonged http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/02/severefirst-degree-p1.jpg
2nd Degree ,
Mobitz I
(Wenkebach)
Irregular
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/04/Wenckebac
h.jpg
2nd Degree,
Mobitz II
http://www.google
.co.uk/url?
sa=i&rct=j&q=&es
rc=s&source=ima
ges&cd=&cad=rja
&uact=8&ved=0C
AcQjRw&url=http
%3A%2F
%2Fwww.emedu.o
rg%2Fecg
Irregular
Constant
P-P
interval
P waves
at
constant
rate
One P
wave not
followed
by QRS
2:1
PR
Interval
NOTE: if
PR
Interval
>0.3s =
Prolonge
d 1st
Degree
AV Block
and P
waves
hidden in
T wave
Progressiv
ely PR
interval
until
dropped
QRS
Longest
directly
before
dropped
QRS
Shortest
directly
after
dropped
QRS
Constant
QRS
Complex
QRS
dropped
after
longest PR
interval
ST
Segment
T Wave
Kishan Jethwa
Rate
Rhythm
%2F2t2.htm&ei=T
tB4VNDRPMf1avb
qgLAO&psig=AFQj
CNHhgLgFNffu0W
14mHRtbkLSIsRAi
Q&ust=141729018
6481927
Axis
P Waves
PR
Interval
QRS
Complex
ST
Segment
Block
QRS rate
= P wave
rate x 2
(1 nonconductin
g P wave
following
a sinus
beat)
3:1
(Advance
d AV
Block)
3:1 = 2
nonconductin
g P waves
following
sinus
beat)
3rd Degree
No SAN
impulses
conducted to
ventricles
Irregular
Juntional/
ventricular
escape
rhythm
http://www.ecglibr
ary.com/chb4.html
Atrial
Fibrillation
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/af3.jpg
Fast
Ventricular
Ventricul
ar ~
100160bpm
Irregularly
irregular
P waves
at
constant
rate
PR
interval
QRS at
constant
rate
No
relation
between P
wave and
QRS
Supraventricular Tachycardias
Absent
Narrow
T Wave
Kishan Jethwa
Rate
Rhythm
Atrial
rate
~300bp
m
Vent.
Rate
depends
on block
2:1 =
150bpm
3:1 =
100bpm
Regular
(Unless,
Flutter
with
variable
block)
Usually
140280bpm
Regular
Rate
~200300bpm
Sinus
Axis
P Waves
PR
Interval
QRS
Complex
ST
Segment
T Wave
Rate http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/AF-rapidventricularresponse.jpg
Atrial Flutter
Caused by reentry circuit
within RA
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/Atrialflutter-with-2-1block.jpg
AVNRT
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/TypicalAVNRT1.jpg
Pseudo R wave
(V1 and V2)
Leads II,
III and
aVF Sawtooth
flutter
waves
Narrow
complex
tachy
(Narrow
complex
tachy,
~150bpm
suspect
Flutter)
V1
flutter
waves
may look
like P
waves
Absent
(Present P
waves =
inverted
in Leads
II, III and
aVF)
Narrow
(Unless
existing
BBB or
accessory
pathway)
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/Pseudo-Rwaves.jpg
AVRT (WolffParkinson
White)
Similar reentry circuit to
AVNRT but
PR
interval
(>0.12sec
/>3 small
Delta
wave
slurring at
start of
QRS
Possible
widesprea
d ST
depressio
n
Pseudo R
waves in
V1 and
V2 (small
upward
deflection
s at the
end of the
S
deflection)
WPW
can cause
RV
hypertrop
hy = Tall R
waves
Kishan Jethwa
Rate
circuit occurs
in an
accessory
bundle i.e.
Bundle of Kent
Type A http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/WPW-TypeA.jpg
Type B http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
010/05/WPW-ecg005.jpg
Rhythm
Axis
P Waves
PR
Interval
sqs)
QRS
Complex
AVRT w/
Orthodro
mic
Conducti
on
(antegrad
e
conductio
n down
AVN and
retrograde
conductio
n up
accessory
pathway)
Narrow
QRS
Antedromic
ECG
AVRT w/
antedro
mic
conducti
on
(antegrad
e
conductio
n down
accessory
pathway
and
retrograde
conductio
n down
AVN)
Wide
QRS
complex
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/AVRT-WPW-
Type B
WPW
Orthodromic
and
Antidromic
Conduction
Explanation
http://lifeinthefast
lane.com/ecglibrary/preexcitationsyndromes/
Orthodromic
ECG http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/Orthodromi
c-AVRT-1.jpg
ST
Segment
T Wave
Kishan Jethwa
Rate
Rhythm
>200bp
m
Irregular
>100bp
m
Regular
150500bpm
Irregularly
irregular
5yo-boy.jpg
AF w/ WPW
Accessory
pathway
allows impulse
conduction
directly to
ventricles,
instead of
going through
the AVN.
Rapid
ventricular
conduction can
lead to VT or
VF
Axis
P Waves
PR
Interval
QRS
Complex
dominant
S wave in
V1 and
V2
Wide
QRS
QRS
complexes
may
change
shape
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
010/05/WPW-ecg004.jpg
VT
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
012/01/VT6.jpg
VF
Rhythm strip http://cdn.lifeinthe
Ventricular Arrhythmias
Broad
QRS
(>0.16sec
s/>4 small
sq)
Uniform
QRS
complex
Absence
of RBBB or
LBBB
pattern
Not
Not
distinguis
distinguis
hable
hable
ST
Segment
T Wave
Kishan Jethwa
Rate
Rhythm
Axis
P Waves
PR
Interval
QRS
Complex
ST
Segment
T Wave
fastlane.com/wpcontent/uploads/2
011/12/VF3.png
Torsades de
Pointes
~200bp
m
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
011/11/ECG91103Torsades.jpg
Pericarditis
http://nl.ecgpedia.
org/images/e/ed/1
2leadpericarditis.p
ng
Brugada
Syndrome
(*Brugada
Sign)
http://cdn.lifeinthe
fastlane.com/wpcontent/uploads/2
009/09/Coved-STelevation.JPG
Sinus
tachycar
dia
(becaus
e of pain
and
pericardi
al
effusion)
QT
Interval
(QT
>0.6secs)
(QTc
>0.45secs
)
QRS
complexes
rotate
180o
around
isoelectric
baseline
(QRS
complexes
go from
being ve
deflection
s to +ve
deflection
s and
back)
PR
interval
depressio
n
Widesprea
d, saddle
shaped ST
elevation
(esepically
Leads I,
II, III,
aVL and
aVF)
*Sloped
ST
elevation
(>2mm
from
junction)
must be in
>1 of
leads V1-
*Sloped
ST
elevation
followed
by ve T
wave
Kishan Jethwa
Rate
Brugada ECG
Rhythm
Axis
P Waves
PR
Interval
QRS
Complex
ST
Segment
V3
T Wave
http://nl.ecgpedia.
org/images/9/9b/B
rugada_syndrome_
type1_example2.p
ng
References:
1. Lilly, LS. Pathophysiology of Heart Disease: a collaborative project of medical students and faculty. 5th Edition. Baltimore ; Lippincott Williams and
Wilkins. 2011
2. Kumar, P and Clark, M. Kumar and Clarks Clinical Medicine. 8th Edition. Edinburgh ; Saunders Elsevier. 2013
3. Hampton, JR. The ECG Made Easy. 8th Edition. Edinburgh ; Churchill Livingstone/Elsevier. 2013
4. http://lifeinthefastlane.com/ecg-library/ - Last accessed 28/11/14