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BASIC ECG

Noel R. Lamorena,MD,FPCP,FPCC,FPSCCM
Internal Medicine
Cardiology
Critical Care Specialist

The ECG is one of the most frequently performed


tests in all of clinical medicine.
Proper interpretation is therefore of great
importance.

Objective
to provide a thorough understanding of both
the fundamental principles of clinical
electrocardiography, and building upon these,
more advanced concepts of interpretation.

LAYERS OF THE HEART WALL


Epicardium
Coronary arteries are
found in this layer

Myocardium
Responsible for
contraction of the heart

Endocardium
Lines the inside of the
myocardium
Covers the heart valves

MYOCARDIAL CELL TYPES

Kinds of
Cardiac Cells

Where
Found

Primary
Function

Primary
Property

Myocardial cells

Myocardium

Contraction and
Relaxation

Contractility

Specialized cells
of the electrical
conduction
system

Electrical
conduction
system

Generation and
conduction of
electrical
impulses

Automaticity
Conductivity

CONDUCTION SYSTEM OF THE HEART

SA Node

Atrial Muscle
AV Node
Bundle of His
Bundle Branches
Purkinje Fibers
Ventricular Muscle

ELECTROCARDIOGRAM

The electrocardiogram (ECG) is a graphic


recording of the electrical potentials produced
by the cardiac tissue.
Electrical impulse formation occurs within the
conduction system of the heart.
Excitation of the muscle fibers throughout the
myocardium results in cardiac contraction.

The ECG is recorded by applying electrodes to


various locations on the body surface and
connecting them to a recording apparatus.

ELECTROCARDIOGRAM

Clinical Value of the ECG

Atrial and ventricular hypertrophy


Myocardial ischemia and infarction
Systemic diseases that affect the heart
Determination of the effect of cardiac drugs
Disturbances in electrolyte balance
Evaluation of function of cardiac pacemakers

ELECTROPHYSIOLOGY OF THE HEART

Four Electrophysiologic Events Involved in the


Genesis of the ECG

Impulse formation
Transmission of the impulse
Depolarization
Repolarization

12 LEAD ECG

Limb Leads
RA
LA
LL
RL

Red
Yellow
Green
Black

Right arm
Left arm
Left leg
Right

Chest Leads
V1
V2
V3
V4
V5
V6

Red
Yellow
Green
Brown
Black
Violet

12 LEAD ECG

4th ICS RPSB


4th ICS LPSB
Midway between V2 and V4
5th ICS LMCL
LAAL Lateral & horizontal to V4
LMAL Lateral & horizontal to V4

ECG PAPER

TERMINOLOGY
Definition of Terms
Waveform
Movement away from the baseline
in either a positive or negative
direction

TERMINOLOGY
Definition of Terms
Segment
A line between wave forms

TERMINOLOGY
Definition of Terms
Interval
A waveform + segment

THE NORMAL ELECTROCARDIOGRAM

P wave
Generated by activation of the atria

PR segment
Represents the duration of atrioventricular (AV)
conduction

QRS complex
Produced by activation of both ventricles

ST-T wave
Reflects ventricular recovery

STANDARD 12 LEAD ECG

The P wave
Atrial activation
Height < 2 mm
Duration < 0.12 sec

STANDARD 12 LEAD ECG

P-R Interval
Intraatrial, internodal, His purkinje conduction
Duration 0.12 to 0.20 sec

STANDARD 12 LEAD ECG

The QRS Complex


Ventricular activation
Duration of <0.10 sec

STANDARD 12 LEAD ECG

The ST-segment
Isoelectric in normal subjects

STANDARD 12 LEAD ECG

The T wave
Ventricular relaxation
- Normally upright

The QT Interval
From beginning of QRS to end of T wave
Reflects the duration of depolarization and
repolarization
Bezett: Q-Tc Interval = Q-T/ R-R (NV=0.350.44sec)

ANALYZING ECG

I. Rate
II. Rhythm
III. Axis
IV. Hypertrophy
V. Ischemia and Infarction
VI. Miscellaneous
Mnemonic: RRAHIM

ANALYZING ECG

I. RATE

ANALYZING A RHYTHM STRIP

I. RATE
a) 3 Possibilities:
Bradycardia (<60 beats/minute)
Normal Rate (60-100 beats/minute)
Tachycardia (>100 beats/minute)

ANALYZING A RHYTHM STRIP


I.

RATE
b)Rate Analysis
1. Mnemonic using # of big squares between RR intervals
300, 150, 100, 75, 60, 50, 40, 30
2. Formula
HR = 1500/# of small boxes between the R-R
interval
or
HR = 300/# of big boxes between the R-R
interval

What Is The Rate?

I. Rate
1500/#Small squares (R-R Interval)
300/#Big squares (R-R Interval)

ANALYZING ECG

II. RHYTHM

ANALYZING A RHYTHM STRIP

II. Rhythm
Tips
- Identify the P wave
- Identify the relationship of P wave to the
QRS
- Check the PR interval
- Check QRS duration
- Check the R-R interval and P-P interval

II. Rhythm Interpretations


Sinus rhythm

II. Rhythm Interpretations


Sinus Bradycardia

II. Rhythm Interpretations


Sinus Tachycardia

II. Rhythm Interpretations


Atrial fibrillation
- HR = # of QRS in a 6 sec. Strip X 10
R

Atrial Fribrillation
Rate
Rhythm

P waves

PR interval
QRS

Atrial rate usually greater than 350-400 beats per


minute; ventricular rate variable
Ventricular rhythms usually very irregular

No identifiable P waves; fibrillatory waves present.


Erratic wavy baseline.
Not measurable
Usually less than 0.10 second but may be
widened if an intraventricular conduction defect
exists.

II. Rhythm Interpretations


Atrial Flutter

Sawtooth appearance
R

Atrial Rhythms
Atrial Flutter
Rate

Rhythm

P waves
PR interval
QRS

Atrial rate 250-350 beats per minute; ventricular


rate variable determined by AV blockade. The
ventricular rate will usually not exceed 180 beats
per minute due to the intrinsic conduction rate of
the AV junction.
Atrial regular
Ventricular may be regular or irregular
No identifiable P waves; saw-toothed flutter
waves
Not measurable
Usually less than 0.10 second but may be
widened if flutter waves are buried in the QRS
complex or if an intraventricular conduction
defect exists.

II. Rhythm Interpretations

Supraventricular Tachycardia

Atrial Rhythms
Supraventricular Tachycardia
Rate
Rhythm
P waves

PR interval

QRS

150-250 beats per minute


Regular
Atrial P waves may be seen which differ from sinus P
waves (may be flattened, notched, pointed, or
biphasic). P waves are usually identifiable at the
lower end of the rate range but are seldom identifiable
at rates above 200. May be lost in the preceding T
wave.
Usually not measurable because the P wave is difficult
to distinguish from the preceding T wave. If P waves
are seen, the RR interval will usually measure 0.120.20 second.
Less than 0.10 second unless an intraventricular
conduction defect exists.

Atrial Rhythms
ELECTRICAL THERAPY Synchronized Countershock
Description and Purpose
Synchronized countershock reduces the potential for delivery of
energy during the vulnerable period of the T wave (relative
refractory period). A synchronizing circuit allows the delivery of
a countershock to be programmed. The machine searches
for the peak of the QRS complex (R wave deflection) and
delivers the shock a few milliseconds after the highest part of
the R wave.
Indications:

Supraventricular tachycardia

Atrial fibrillation

Atrial flutter

Unstable ventricular tachycardia with pulse

ANALYZING A RHYTHM STRIP

II. Rhythm Interpretation

HEART BLOCKS

1st Degree AV-Block


P-R interval>0.2sec (5 small squares)

Atrioventricular Blocks
First Degree AV Block
Rate
Rhythm
P waves
PR interval
QRS

Atrial and ventricular rates the same; dependent


upon underlying rhythm.
Atrial and ventricular regular
Normal in size and shape
Only one P wave before each QRS
Prolonged (greater than 0.20 second) but constant
Usually 0.10 second or less unless an
intraventricular conduction exists

2nd Degree AV-Block


Mobitz Type I
Absent QRS

Atrioventricular Blocks
Second-Degree AV Block, Type I (Wenckebach)
Rate
Rhythm
P waves

PR interval

QRS

Atrial rate is greater than the ventricular rate. Both


are often within normal limits.
Atrial regular (Ps plot through)
Ventricular irregular.
Normal in size and shape. Some P waves are not
followed by a QRS complex (more Ps than
QRSs).
Lengthens with each cycle (although lengthening
may be very slight), until a P wave appears
without a QRS complex. The PRI after the
nonconducted beat.
Usually 0.10 second or less but is periodically
dropped.

2nd Degree AV-Block


Mobitz Type II

Absent QRS

Atrioventricular Blocks
Second-Degree AV Block, Type II (Mobitz)
Rate
Rhythm
P waves

PR interval

QRS

Atrial rate is greater than the ventricular rate.


Ventricular rate is often slow.
Atrial regular (Ps plot through)
Ventricular irregular.
Normal in size and shape. Some P waves are not
followed by a QRS complex (more Ps than
QRSs).
Within normal limits or prolonged but always
constant for the conducted beats. There may be
some shortening of the PRI that follows a
nonconducted P wave.
Usually 0.10 second or greater, periodically absent
after P waves.

3rd Degree AV Block or Complete


Heart Block
P

Atrioventricular Blocks
Complete (Third-Degree) AV Block
Rate

Rhythm
P waves
PR interval
QRS

Atrial rate is greater than the ventricular rate. The


ventricular rate is determined by the origin of the
escape rhythm.
Atrial irrregular . Ventricular regular. There is no
relationship between the atrial and ventricular
rhythm.
Normal in size and shape.
None the atria and ventricles beat independently
of each other, thus there is no true PR interval.
Narrow or broad depending on the location of the
escape pacemaker and the condition of the
intraventricular conduction system.
Narrow = junctional pacemaker; wide = ventricular
pacemaker.

ANALYZING A RHYTHM STRIP

II. Rhythm Interpretation

Bundle Branch Blocks (BBB)

QRS Width

Right Bundle Branch


Block (RBBB)
Left Bundle Branch Block
(LBBB)

RBBB vs LBBB

ANALYZING A RHYTHM STRIP

Rhythm Interpretation
2 Types of BBB
- complete if QRS is > 0.12sec
- incomplete if QRS is < 0.12sec

ANALYZING A RHYTHM STRIP

Rhythm Interpretation

Ventricular Arrhythmias

Ventricular Rhythms
Premature Ventricular Complexes (PVC)
Rate
Rhythm

P waves
PR interval
QRS

Usually normal but depends on the underlying


rhythm
Essentially regular with premature beats. If the
PVC is an interpolated PVC, the rhythm will be
regular.
There is no P wave associated with the PVC
None with the PVCs because the ectopic beat
originates in the ventricle
Greater than 0.12 second.
Wide and bizarre.
T wave frequently in opposite direction of the QRS
complex.

Ventricular Rhythms
Patterns of PVCs
1.
2.
3.
4.
5.
6.
7.

Isolated PVC - < 1/min


Multifocal PVCs PVCs with different morphologies
Bigeminal PVCs every other beat is a PVC
Trigeminal PVCs every third beat is a PVC
Quadrigeminal PVCs every fourth beat is a PVC
Pairs (couplets) two sequential PVCs
Runs or bursts (salvos) three or more sequential PVCs

Isolated PVC

Multifocal PVC

PVC in Bigeminy
2

PVC in Quadrigeminy
4
3
1
2

4
1

PVC in Couplets

PVC in Runs or Bursts


(salvos)

Ventricular Rhythms
Common Causes of PVCs

Normal variant
Anxiety
Exercise
Hypoxia
Digitalis toxicity
Acid-base imbalance
Myocardial ischemia
Electrolyte imbalance (hypokalemia, hypocalcemia,
hypercalcemia, hypomagnesemia)
Congestive heart failure
Increased sympathetic tone
Acute myocardial infarction
Stimulants (alcohol, caffeine, tobacco)
Drugs (sympathomimetics, cyclic antidepressants,
phenothiazines)

Ventricular Rhythms
Warning Dysrhythmias

Six or more PVCs per minute


PVCs that occurred in pairs (couplets) or in runs or
three or more (ventricular tachycardia)
PVCs that fell on the T wave of the preceding beat
(R-on T phenomenon)
PVCs that differed in shape (multiformed PVCs)

Ventricular Tachycardia (VT)

Ventricular Rhythms
Ventricular Tachycardia (VT)
Rate
Rhythm
P waves

PR interval
QRS

Atrial rate not discernible, ventricular rate 100-250


beats per minute
Atrial rhythm not discernible
Ventricular rhythm is essentially regular
May be present or absent; if present they have no
set relationship to the QRS complexes
appearing between the QRSs at a rate different
from that of the VT.
None
Greater than 0.12 second.
Often difficult to differentiate between the QRS
and the T wave.

Torsade de pointes

Ventricular Rhythms
Torsades de Pointes (TdP)
Rate
Rhythm
P waves
PR interval
QRS

Atrial rate not discernible, ventricular rate 150-250


beats per minute
Atrial not discernible
Ventricular may be regular or irregular
None
None
Greater than 0.12 second.
Gradual alteration in the amplitude and direction of
the QRS

Ventricular Fibrillation

Ventricular Rhythms
Ventricular Fibrillation
Rate
Rhythm
P waves
PR interval
QRS

Cannot be determined since there are no


discernible waves or complexes to measure
Rapid and chaotic with no pattern or regularity
Not discernible
Not discernible
Not discernible

Ventricular Rhythms
Defibrillation (Unsynchronized Countershock)
Description and Purpose:
The purpose of defibrillation is to produce momentary asystole. The
shock attempts to completely depolarize the myocardium and
provide an opportunity for the natural pacemaker centers of the
heart to resume normal activity. Defibrillation is a random
delivery of energy there is no relation of the discharge of
energy to the cardiac cycle.
Indications:
Pulseless ventricular tachycardia
Ventricular fibrillation
Sustained Torsade de pointes

Idioventricular Rhythm

Ventricular Rhythms
Idioventricular (Ventricular Escape) Rhythm
Rate
Rhythm
P waves
PR interval
QRS

Atrial not discernible, ventricular 20-40 beats per


minute
Atrial not discernible
Ventricular essentially regular
Absent
None
Greater than 0.12 second.
T wave deflection is in the opposite direction of the
QRS.

Asystole

Ventricular Rhythms
Asystole
Rate
Rhythm
P waves
PR interval
QRS

Ventricular usually indiscernible but may see some


atrial activity.
Atrial may be discernible.
Ventricular indiscernible.
Usually not discernible
Not measurable
Absent

ANALYZING ECG

AXIS

ANALYZING A RHYTHM STRIP

What Is The Axis?

Normal
0 (+90)

Left axis
0 (-90)

Right axis
(+90) (+180)

AVL

Extreme axis

AVR

(-90) (-180)
AVF

What Is The Axis?

10
AVL

Lead I

AVR

10

AVF

AVF

ANALYZING A RHYTHM STRIP

Lead I
Normal axis
+
Left Axis Deviation +
Right Axis Deviation Indeterminate Axis -

Lead AVF
+
+
-

ANALYZING ECG

HYPERTROPHY
OR
CHAMBER
ENLARGEMENT

ANALYZING ECG

IV. Hypertrophy
6 Possibilities:
- No hypertrophy
- Left ventricular hypertrophy (LVH)
- Right ventricular hypertrophy (RVH)
- Left atrial enlargement (LAE)
- Right atrial enlargement (RAE)
- Combination of the above

Right Atrial Enlargement


Tall peaked P wave >2.5 mm and normal width in lead II, III, or AVF
Increased in the initial positive P wave in V1
Frontal P wave axis >+75
qR in V1-V2

Left Atrial Enlargement

Features:
Width of the P wave > 0.12
sec in lead II
Notched P wave
P terminal force is > 0.04
sec & >1mm tall
Lead V1 shows large
biphasic P wave with
wide terminal component
Leftward shift of P axis to
+45 and -30

Bi-atrial Enlargement
Features:
Tall and broad P wave in lead II, III or AVF
Large biphasic P wave in V1 with wide terminal
component

Right Ventricular Hypertrophy


Sokolow-Lyon
R in V1 + S in V5 or V6 >11 mm
R in V1 > 7mm
R:S ratio in V1 >1
RAD >+90 degrees

RVH
s
R

R=12mm + S=13 = 23mm

Left Ventricular Hypertrophy


Sokolow-Lyon
R in V5 or R in V6 + SV1 = 35 mm or greater
(Sokolow index) most widely used
R in aVL > 12 mm
R in aVF > 20 mm
R in I + S in III > 25 mm
S in V1 > 24 mm

Left Ventricular Hypertrophy

S
R

S=15mm + R=25mm = 40mm

RA abnormality and RV enlargement

ANALYZING ECG

ISCHEMIA AND
INFARCTION

Atherosclerosis Timeline
Normal Anatomy
Foam
Cells

Fatty Intermediate Atheroma


Streak
Lesion

Fibrous
Plaque

Complicated
Lesion/
Rupture

Endothelial Dysfunction
From First
Decade

From Third
Decade

From Fourth
Decade

Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).

Coronary Heart Disease

ANALYZING RHYTHM STRIP

Localization
I, AVL
High lateral wall

II, III, AVF


Inferior wall

AVL

AVR

AVF

ANALYZING THE RHYTHM STRIP


Localization
V1,V2
Septal wall

V3,V4
Anterior wall

V5,V6
Lateral wall

V1-V3 or V4
Anteroseptal wall

V3 or V4-V6
Anterolateral wall

V1-V6 - anterolateral wall MI


I,AVL,V5,V6 Lateral wall

ST T WAVE CHANGES
ST elevation
-Myocardial infarction
ST depression
-Myocardial ischemia
T wave inversion (symmetrical)

-Myocardial ischemia
Q waves
-old myocardial infarction

ST T WAVE CHANGES
ST ELEVATION

- > 2mm in 2 or more contiguous


chest leads and > 1mm in 2 or
more limb leads

ST T WAVE CHANGES
ST DEPRESSON

-At least 1mm ST depression


horizontal or downsloping

ST T WAVE CHANGES
T WAVE INVERSION

-Symmetrically or deeply inverted


T wave

Q WAVE CHANGES
>0.04.

sec duration
OR
>25% of the height of associated
R wave

ST and T wave Changes in Infarction


Development of new Q
waves on areas
overlying the infarct
which
>0.04. secs
duration
>25% of the height
of associated R
wave

ANALYZING ECG

VI. Miscellaneous

ANALYZING ECG

Electrical Alternans

ANALYZING ECG

Hypokalemia presence of U waves


Hyperkalemia peaked T waves, >5mm
in most leads
Hypocalcemia prolonged QT-interval
Hypercalcemia shortened QT-interval

Practice Tracings

Normal ecg tracing

What Is The Rhythm and Rate?

Atrial Fibrillation:QRS cmplex in 6-sec strip X 10

Supraventricular Tachycardia

1st degree AV Block

2nd degree AV block Mobitz Type I (Wenkebach)

2nd degree AV block Mobitz Type II

3rd Degree AV block (Complete Heart Block)

Isolated PVC, LAD,LVH with strain pattern

Ventricular Tachycardia

Ventricular Fibrillation

Normal sinus rhythm, RAE, Acute anterolateral wall MI,


inferior wall ischemia

1st degree AV block, acute inferior wall MI,


anteroseptal wall ischemia

Practice makes
perfect!
Thank You