Postgraduate Education BS Physical Therapy, Silliman University, 1996 BS Zoology, MSU-Iligan Institute of Technology 1999 ...
Dr. Jill Irene Z. Capistrano, FPCP,DPCC INTERNAL MEDICINE-CARDIOLOGY
P Q R T QT interval   PR interval   ST interval   QRS interval   S ST segment PR segment
Normal Intervals <ul><li>Heart rate 60 - 100 beats/min </li></ul><ul><li>bradycardia < 60  </li></ul><ul><li>tachycardia >...
Normal P wave morphology
Normal QRS Complex Morphology
Normal T wave morphology
Guide in Reading ECG <ul><li>Standardization & technique </li></ul><ul><li>Rhythm </li></ul><ul><li>Rate: atrial & ventric...
Determination of Rhythm
RHYTHM   (Sinus? Regular? Irregular?) <ul><li>A.  </li></ul><ul><li>B.  </li></ul><ul><li>C. </li></ul><ul><li>D.  </li></ul>
RHYTHM   (Sinus? Regular? Irregular?) <ul><li>A.  </li></ul><ul><li>B.  </li></ul><ul><li>C. </li></ul><ul><li>D.  </li></ul>
 
 
Determination of Rate
v v Measurement of Rate
Measurement of Rate <ul><li>Formula 1 :  300 </li></ul><ul><li># big squares between R-R </li></ul><ul><li>Formula 2 :  15...
Normal rate? Bradycardia? Tachycardia?  <ul><li>A. </li></ul><ul><li>B. </li></ul><ul><li>C.  </li></ul>
 
 
 
Determination of Axis
Standard Locations of  Limb Leads III I II aVL aVR aVF
Determination of Axis Lead I Lead aVF
Determine the axis of the ff: <ul><li>A.  </li></ul><ul><li>B. </li></ul><ul><li>C.  </li></ul>
Chamber Enlargement
Standard Locations of Chest Leads
Atrial Enlargement
Atrial Enlargement II V1 B V1
 
Ventricular Enlargement
 
RIGHT VENTRICULAR HYPERTROPHY Sokolow-Lyon Criteria : R in V1 + S in V5-V6  > 11 mm R in V1  > 7mm R : S in V1  > 1 RAD  >...
 
 
A 55F hypertensive sought consult at the ER for a blood pressure of 150/100.  You requested for ancillary procedures, incl...
Sinus rhythm, normal axis, left ventricular hypertrophy 13 X 2 S in V1 + R in V5 or V6 > 35mm LEFT VENTRICULAR HYPERTROPHY...
A 24 year-old male with Atrial Septal Defect was admitted for shortness of breath.
Interval between QRS complex  < 3major divisions 1500/# small squares = 1500/12 =  125  beats/min SINUS TACHYCARDIA
P waves tall and pointed in II and aVF RIGHT ATRIAL ENLARGEMENT QRS downward in lead I and upright in lead aVF RIGHT AXIS ...
Sinus tachycardia, right axis deviation, right atrial abnormality, right ventricular hypertrophy QRS upright in  V1 RIGHT ...
 
LAE, RAE, RVH LAE P pulmonale RVH
Bundle Branch Block
 
 
 
 
 
 
 
 
A 24 year old female admitted for heart murmur.
Normal sinus rhythm, right bundle branch block QRS complex >120 msec Delayed intrinsicoid deflection time in V1 RIGHT BUND...
Normal sinus rhythm, right bundle branch block RSR’ in V1 Wide S waves in I, V6 RIGHT BUNDLE BRANCH BLOCK
A 50/M smoker diabetic admitted for pain.
Sinus rhythm, left bundle branch block Pseudoinfarct pattern in V1 Monophasic  R / notched R in V6 LEFT BUNDLE BRANCH BLOCK
 
 
 
 
Myocardial ischemia and infarction
 
Myocardial Injury <ul><li>Criteria: </li></ul><ul><li>1.  Elevation of the origin of ST segment at its junction (J point) ...
Myocardial Injury <ul><li>Criteria: </li></ul><ul><li>2. Depression of the origin of ST  segment at the J point  > 1.0 mm ...
Myocardial Infarction <ul><li>Criteria: </li></ul><ul><li>Development of new Q waves on areas overlying the infarct which ...
After 2days Several days or months First day First and second  day Normal ECG Onset and first several hours
Occlusion of left descending coronary artery
 
Occlusion of left circumflex coronary artery
Occlusion of right coronary artery
 
 
 
 
 
 
Exercise ECGs
 
 
 
 
 
 
 
 
 
 
 
Thank You!
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Ecg skills enhancement

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  • Sinus rhythm, normal axis 1.atrial rate 60 ventricular rate 60 PR interval 0.16 QRS interval 0.08 QT interval 0.36 Axis 45 °
  • Sinus rhythm, normal axis, left ventricular hypertrophy
  • Sinus tachycardia, right axis deviation, right atrial abnormality, right ventricular hypertrophy
  • Normal sinus rhythm, normal axis. right bundle branch block
  • Sinus rhythm,left axis deviation, left bundle branch block
  • Atrial fibrillation with rapid ventricular response, normal axis
  • Anteroseptal wall MI
  • Acute pericarditis. Note that there is widespread ST elevation that is upwardly deeply concave in the anterior, inferior, and lateral walls. In addition, there is no reciprocal depression and there are no Q waves.
  • Type 1, second degree AV block
  • 3 rd degree AV block
  • High grade AV block
  • Ecg skills enhancement

    1. 1. Postgraduate Education BS Physical Therapy, Silliman University, 1996 BS Zoology, MSU-Iligan Institute of Technology 1999 Doctor of Medicine, Mindanao State University-College of Medicine Post-graduate Internship University of the Philippines, Philippine General Hospital 2003-2004 Internal Medicine Residency University of the Philippines, Philippine General Hospital 2004-2007 Fellowship in Cardiology University of the Philippines, Philippine General Hospital 2008-2011 Affiliations Fellow, Philippine College of Physcians Fellow, Philippine Heart Association Diplomate, Philippine College of Cardiology JILL IRENE Z. CAPISTRANO MD, FPCP, DPCC
    2. 2. Dr. Jill Irene Z. Capistrano, FPCP,DPCC INTERNAL MEDICINE-CARDIOLOGY
    3. 3. P Q R T QT interval PR interval ST interval QRS interval S ST segment PR segment
    4. 4. Normal Intervals <ul><li>Heart rate 60 - 100 beats/min </li></ul><ul><li>bradycardia < 60 </li></ul><ul><li>tachycardia > 100 </li></ul><ul><li>PR interval 0.12 – 0.20 sec </li></ul><ul><li>QRS < 0.12 sec </li></ul><ul><li>QRS axis - 30º to + 110º </li></ul><ul><li>QTc < 0.45 sec </li></ul>
    5. 5. Normal P wave morphology
    6. 6. Normal QRS Complex Morphology
    7. 7. Normal T wave morphology
    8. 8. Guide in Reading ECG <ul><li>Standardization & technique </li></ul><ul><li>Rhythm </li></ul><ul><li>Rate: atrial & ventricular </li></ul><ul><li>P wave morphology & duration </li></ul><ul><li>P-R interval </li></ul><ul><li>QRS complex morphology & duration </li></ul><ul><li>ST segment </li></ul><ul><li>T-wave </li></ul><ul><li>U wave </li></ul><ul><li>Q-T interval </li></ul>
    9. 9. Determination of Rhythm
    10. 10. RHYTHM (Sinus? Regular? Irregular?) <ul><li>A. </li></ul><ul><li>B. </li></ul><ul><li>C. </li></ul><ul><li>D. </li></ul>
    11. 11. RHYTHM (Sinus? Regular? Irregular?) <ul><li>A. </li></ul><ul><li>B. </li></ul><ul><li>C. </li></ul><ul><li>D. </li></ul>
    12. 14. Determination of Rate
    13. 15. v v Measurement of Rate
    14. 16. Measurement of Rate <ul><li>Formula 1 : 300 </li></ul><ul><li># big squares between R-R </li></ul><ul><li>Formula 2 : 1500 </li></ul><ul><ul><ul><ul><li># small squares between R-R </li></ul></ul></ul></ul>
    15. 17. Normal rate? Bradycardia? Tachycardia? <ul><li>A. </li></ul><ul><li>B. </li></ul><ul><li>C. </li></ul>
    16. 21. Determination of Axis
    17. 22. Standard Locations of Limb Leads III I II aVL aVR aVF
    18. 23. Determination of Axis Lead I Lead aVF
    19. 24. Determine the axis of the ff: <ul><li>A. </li></ul><ul><li>B. </li></ul><ul><li>C. </li></ul>
    20. 25. Chamber Enlargement
    21. 26. Standard Locations of Chest Leads
    22. 27. Atrial Enlargement
    23. 28. Atrial Enlargement II V1 B V1
    24. 30. Ventricular Enlargement
    25. 32. RIGHT VENTRICULAR HYPERTROPHY Sokolow-Lyon Criteria : R in V1 + S in V5-V6 > 11 mm R in V1 > 7mm R : S in V1 > 1 RAD > +90 degrees <ul><li>Additional Criteria : </li></ul><ul><ul><li>QR in V1 </li></ul></ul><ul><ul><li>S1 Q3 pattern </li></ul></ul><ul><ul><li>S1 S2 S3 pattern </li></ul></ul><ul><ul><li>p pulmonale </li></ul></ul>
    26. 35. A 55F hypertensive sought consult at the ER for a blood pressure of 150/100. You requested for ancillary procedures, including an ECG.
    27. 36. Sinus rhythm, normal axis, left ventricular hypertrophy 13 X 2 S in V1 + R in V5 or V6 > 35mm LEFT VENTRICULAR HYPERTROPHY 20 X 2
    28. 37. A 24 year-old male with Atrial Septal Defect was admitted for shortness of breath.
    29. 38. Interval between QRS complex < 3major divisions 1500/# small squares = 1500/12 = 125 beats/min SINUS TACHYCARDIA
    30. 39. P waves tall and pointed in II and aVF RIGHT ATRIAL ENLARGEMENT QRS downward in lead I and upright in lead aVF RIGHT AXIS DEVIATION
    31. 40. Sinus tachycardia, right axis deviation, right atrial abnormality, right ventricular hypertrophy QRS upright in V1 RIGHT VENTRICULAR HYPERTROPHY Prominent S waves across precordial leads
    32. 42. LAE, RAE, RVH LAE P pulmonale RVH
    33. 43. Bundle Branch Block
    34. 52. A 24 year old female admitted for heart murmur.
    35. 53. Normal sinus rhythm, right bundle branch block QRS complex >120 msec Delayed intrinsicoid deflection time in V1 RIGHT BUNDLE BRANCH BLOCK Intrinsicoid deflection time
    36. 54. Normal sinus rhythm, right bundle branch block RSR’ in V1 Wide S waves in I, V6 RIGHT BUNDLE BRANCH BLOCK
    37. 55. A 50/M smoker diabetic admitted for pain.
    38. 56. Sinus rhythm, left bundle branch block Pseudoinfarct pattern in V1 Monophasic R / notched R in V6 LEFT BUNDLE BRANCH BLOCK
    39. 61. Myocardial ischemia and infarction
    40. 63. Myocardial Injury <ul><li>Criteria: </li></ul><ul><li>1. Elevation of the origin of ST segment at its junction (J point) with the QRS of: </li></ul><ul><li>a. > 1.0 mm (0.10 mV) in > 2 limb leads lasting at least 80 msecs </li></ul><ul><li>or </li></ul><ul><li>b. > 2.0 mm (0.20 mV) in > 2 precordial leads </li></ul>
    41. 64. Myocardial Injury <ul><li>Criteria: </li></ul><ul><li>2. Depression of the origin of ST segment at the J point > 1.0 mm (0.20 mV) in at least 2 leads </li></ul><ul><li>*ST segment deviation typically either horizontal or slope toward the direction of T waves </li></ul>
    42. 65. Myocardial Infarction <ul><li>Criteria: </li></ul><ul><li>Development of new Q waves on areas overlying the infarct which is: </li></ul><ul><li>a. > 0.04. secs duration </li></ul><ul><li> b. >25% of the height of associated R wave </li></ul>
    43. 66. After 2days Several days or months First day First and second day Normal ECG Onset and first several hours
    44. 67. Occlusion of left descending coronary artery
    45. 69. Occlusion of left circumflex coronary artery
    46. 70. Occlusion of right coronary artery
    47. 77. Exercise ECGs
    48. 89. Thank You!

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