ELECTROCARDIOGRAM

Electrocardiographic Cases Crisbert I. Cualteros, M.D.

Sinus Rhythm

SR frequent PVDs PRWP lat wall ischemia

ECG Indications
determine cardiac rate
define cardiac rhythm
diagnose old or new MI
identify intracardiac conduction disturbances
aid in the diagnosis of IHD, pericarditis, myocarditis, electrolyte abnormalities and pacemaker malfunction

V1 = 4th ICS, R sternal border
V2 = 4th ICS, L sternal border
V3 = halfway between V2 and V4
V4 = 5th ICS, L MCL
V5 = 5th ICS, anterior axillary line
V6 = 5th ICS, L mid-midaxillary line
V3R = halfway between V1 and V4R
V4R = 5th ICS, R MCL
Lead Locations

Correspondence Anteroseptal wall V1-V3 Lateral wall V5, V6 Anterior wall V3, V4 Septal wall V1, V2 High lateral wall I, aVL Inferior wall II, III, aVF Area Leads

Area Leads RV wall V3R and V4R Posterior LV wall Mirror image of V 1/2 Diffuse/global/massive Almost all leads Inferolateral wall V5, V6, II, III, aVF Anterolateral wall V3-V6, I, aVL

RRAHIM
Components of ECG interpretation
R ate
R hythm
A xis
H ypertrophy
I schemia and Infarction
M iscellaneous (normal variants)

Rate
Mnemonic: 300, 150, 100, 75, 60, 50
Formula: 1500 / # of small boxes
300 / # of big boxes
Bradycardia = <60 bpm
Normal Rate = 60-100 bpm
Tachycardia = >100 bpm

What is the rate? 1500/28 or 300/5.6 53 bpm

What is the rate? 1500/12 or 300/2.4 125 bpm

Rhythm
Identify the P wave
Check relation of P wave to QRS
Normal: P wave is before QRS
SVT, heart blocks: P wave after QRS or burried
Check PR interval ( 0.12 - 0.20s )
Shortened: WPW
Prolonged: 1 st and 2 nd degree AV block

Check QRS duration (< 0.10 s )
Widened: bundle branch blocks
Check relation of R-R and P-P int
PP < RR: complete heart block
PP > RR: AV dissociation

Common Rhythm Interpretations
Sinus rhythm
Supraventricular arrhythmias
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia (SVT)
Heart Blocks
First-degree AV block
Second-degree AV block
Mobitz Type I (Wenckebach)
Mobitz Type II

Third-degree AV block
Left or Right Bundle Branch Block
Complete
Incomplete
Ventricular Arrhythmias
Premature Ventricular Depolarization (PVD)
Ventricular Tachycardia (V-tach)
Sustained
Non-sustained
Ventricular fibrillation (V-fib)

Axis Determination
get the average QRS vector from the isoelectric baseline in Leads I and AVF
if the average QRS vector is above baseline -> (+) QRS deflection
if the average QRS vector is below baseline
-> (-) QRS deflection

Axis -- -- indeterminate + -- RAD -- + LAD + + Normal Axis AVF Lead 1

Normal (-30 to +90) RAD Indeterminate LAD

Axis
- 90 AVF
indeterminate LAD
± 180 0 I
RAD normal
(-30 to +90)
+ 90

What is the axis?

Axis Differentials WPW syndrome WPW syndrome LPFB LAFB Pulmonary embolism LBBB Lateral wall MI Inferior wall MI RVH (COPD, cor pul) LVH (HTN) N variant: thin, tall N variant: short, fat RAD LAD

Hypertrophy
Six Possibilities
No hypertrophy
LVH
RVH
LAE
RAE
combination

LVH criteria
3 Methods
1) S wave in V1 +
R wave in V5/6 > 35mm
2) R in AVL > 11mm
3) Romhilt and Estes Criteria (best)

SR, LVH with Strain Pattern, Old Anteroseptal Wall MI

RVH Criteria
RAD of ≥ +110, with any of the ff:
V1: R wave > S wave
COPD
RBBB
True posterior infarction
WPW
Deep S wave in V5-6
COPD
ST depression and T wave inversion in V1-3

LAE (p mitrale)
2 Methods
V1: wide terminal component of P wave ≥ 1 mm wide (0.04 s) and ≥ 1 mm deep
Any lead: P wave wider than 0.12s or with a ≥ 1 mm notch in the middle

ST, RAD, LAE, RVH

RAE (p pulmonale)
2 Methods
V1: tall initial component of P wave ≥ 2mm wide and ≥ 2 mm tall
Any Lead: P wave ≥ 2.5 mm tall

RRAHIM
Rate
Rhythm
Axis
Hypertrophy
Ischemia and Infarction
Miscellaneous (normal variants)

Myocardial Ischemia
1 mm ST-segment depression
Symmetrically/inverted T waves
Abnormally tall T waves
Normalization of abnormal T waves
Prolongation of QT interval
Arrhythmias, BBB, AV blocks or electrical alternans

SR, Anterolateral Wall Ischemia

Myocardial infarction
Criteria (any)
ST elevation
≥ 2 Chest leads: ≥ 2 mm elevation or
≥ 2 Limb leads: ≥ 1 mm elevation
Q waves ≥ 0.04s (1 small square)

Timing of MI/ECG 0-6 hours 6-24 h 24 -72 h 72 h – 6 weeks > 6 wk

Differentials for ST elevation
Acute pericarditis
Ventricular aneurysm
Severe LV wall hypokinesia
Early repolarization changes
Variant (prinzmetal) angina

Q waves
never significant in aVR
not significant in V1 unless with abnormalities in other precordial leads
not significant in III unless with abnormalities in II, aVF
more reliable if associated with ST changes
Not significant in V1-V3 if (+) LBBB , but significant if (+) RBBB

Criteria for Pathologic Q waves
≥ 0.04 sec in duration
≥ 25% of the R wave amplitude

Recent Anteroseptal Wall MI

SR, Acute Inferior Wall MI

RRAHIM
R ate
R hythm
A xis
H ypertrophy
I schemia and Infarction
M iscellaneous (normal variants)

Hypokalemia
V2, V3: u wave as tall or taller than T wave
Hyperkalemia
Chest leads: height of T wave > 10 mm
Limb leads: height of T wave > 5 mm
Hypocalcemia
Prolonged QT interval, longer than ½ the RR interval
Hypercalcemia
Shortened QT interval

Poor R wave Progression (PRWP)
Height of Rwave in V3 < 3 mm
Differentials
Old anteroseptal wall MI
LVH
Normal variant: heart rotated clockwise
LBBB
Early Repolarization Changes (ERP)
V2-V4: ST segment elevation of 2-3 mm
Normal variant, usually in males < 40y
Differentials
Acute anteroseptal wall MI
Acute pericarditis

SR, ERP

SR, PRWP

Hyperkalemia tall, peaked T waves usually >10 mm in the chest leads

Hypokalemia abnormally tall U waves most prominent in V2 and V3

Low-voltage QRS
QRS in all limb leads is < 5 mm
Artifacts
Irregular spikes or undulations on the ECG baseline not found in other segments
Causes
Patient movement (shivering)
Poor electrode contact

Atrial Fibrillation
Criteria
No P waves
Irregular fibrillatory waves
Irregularly irregular ventricular rhythm
Acute if < 48h

Top 5 causes of AF
(EVICT)
E thanol (Holiday Heart Syndrome)
V alvular heart disease (MS)
I HD
C ardiomyopathy
T hyrotoxicosis

AF with RVR PRWP NSSTTWC

AF with MVR, RBBB

AF with RVR, lateral wall ischemia

AV Nodal Blocks
First Degree AV Block
P-R interval > 0.21 sec
One-to-one AV conduction

Sinus Bradycardia with first degree AV block

AV Nodal Blocks
Second Degree AV Block
Sinus rhythm
Some P waves not followed by QRS complx
Mobitz I (Wenckebach)
Increasing PR interval -> dropped beat

Mobitz II
PR interval prolonged but constant
Third Degree AV Block or
Complete Heart Block
AV dissociation
P waves seen marching through the QRS
PP interval < RR interval
Idioventricular rhythm

SR with 2 nd degree AV block (Wenckebach)

3 rd degree AV block

Intraventricular Blocks
Complete RBBB
QRS duration ≥ 0.12 seconds
QRS in V1 has an rsR’ configuration or is a solitary R wave

Intraventricular Blocks
Complete LBBB
QRS duration ≥ 0.12 seconds
QRS is notched and splintered
QRS has a QS or rS deflection in V1

SR with cRBBB

ST with cRBBB

V-Tach
Criteria
≥ 3 consecutive QRS complexes…
of uniform configuration
of ventricular origin
> 100 bpm

Monomorphic
Sustained VT:
> 30 s
Hemodynamic compromise
Requires intervention for termination
Non-sustained
V-Tach Morphology

Polymorphic
beat to beat variation in QRS complexes
V-Tach Morphology

SupraV Tach
Criteria
regular succession of QRS complexes with normal duration and configuration
rate 150 – 250 bpm
P waves not identifiable (superimposed on QRS) or preceed / succeed the QRS complex

Sinus Rhythm

Second-degree AV block, type II

Third Degree AV Block

Acute Inferior Wall MI

AF with RVR

AF with SVR

Anteroseptal Wall MI

Atrial Flutter with 2:1 conduction

Digoxin Effect

First-Degree AV block, SB

Frequent PVCs in Bigeminy

Hyperkalemia

Left Bundle Branch Block

Right Bundle Branch Block

Ventricular Fibrillation

Ventricular Tachycardia

WPW Syndrome

SR LAE LVH with strain Pattern ERP vs Acute injury pattern in the anteroseptal wall

SR, LAH, LAE, IVCD, LVH, lateral wall ischemia and/or strain. NSSTTWC, inferior wall. ERP vs. acute injury, anteroseptal wall. 66 male (+) HTN (+) DM 5 pack years cc: fever, cough body malaise 150/80, 88, 20 trop I negative SR, LAE, with an acute injury pattern in the anteroseptal wall

D.R., 41 male (-) medical problem (-) smoker (-) alcoholic cc: 2 months productive cough low-grade fever 120/80, 104, 36 imp: PTB III meds: combivent ranitidine levofloxacin

Atrial flutter/atrial fibrillation with NSSTTWC

Thank You! http://crisbertcualteros.page.tl

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ELECTROCARDIOGRAM

by DJ CrissCross on Apr 15, 2009

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ELECTROCARDIOGRAM — Presentation Transcript