Cardiovascular System

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Cardiovascular system

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Cardiovascular System

  1. 1. Electrocardiogram <ul><li>Lilong Tang M.D., Ph.D </li></ul><ul><li>Department of Cardiology </li></ul><ul><li>The First Affiliated Hospital </li></ul><ul><li>Sun Yat-sen University </li></ul>
  2. 3. ECG ( EKG ) is Useful in the Diagnosis of <ul><li>Different kinds of arrhythmia; </li></ul><ul><li>Enlargement or hypertrophy of atria or ventricles; </li></ul><ul><li>Myocardial ischemia, injury, infarction; </li></ul><ul><li>Pericarditis; </li></ul><ul><li>Effects of some drugs ( Digitalis, Quinidine, Amiodarone, etc. ); </li></ul><ul><li>Disturbance of electrolyte metabolism ( hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, etc. ) </li></ul>
  3. 4. Dipole Theory
  4. 5. Electrode Records Upward or Downward Deflection
  5. 6. ECG Leads <ul><li>Standard limb leads: Ⅰ, Ⅱ, Ⅲ </li></ul><ul><li>( Augmented ) Unipolar limb leads: aVR, aVL, aVF </li></ul><ul><li>Chest ( precordial ) leads: V1~V6. </li></ul>
  6. 11. Precordial Leads
  7. 13. Sequence of Ventriclular Depolarization
  8. 14. Projection of a QRS Vector-loop onto Frontal and Horizontal Planes
  9. 15. Projection of a QRS Vector-loop onto Limb and Predordial Leads
  10. 16. Configuration of a QRS in Limb Leads
  11. 17. Configuration of a QRS in Precordial Leads
  12. 18. Measurements of an EKG
  13. 20. Mean QRS Vector
  14. 21. Mean QRS Axis <ul><li>The major direction of the depolariation forces in the ventricle expressed as degrees on the hexaxial system. </li></ul><ul><li>Normal QRS axis: -30 ° ~ +90 ° </li></ul><ul><li>Left axis deviation( LAD ): -30 ° ~ -90 ° </li></ul><ul><li>Right axis deviation( RAD ): +90 ~ +180 ° </li></ul><ul><li>Extreme RAD or Indeterminate axis: </li></ul><ul><li>+180 ° ~ -90 ° </li></ul>
  15. 22. QRS Axis Deviation
  16. 23. Normal QRS Axis
  17. 24. Left Axis Deviation
  18. 25. Right Axis Deviation
  19. 26. Determination of a QRS Axis by Calculation
  20. 27. Causes of LAD or RAD <ul><li>Causes of LAD: </li></ul><ul><li>Normal variant; LVH; Older age; COPD; LAFB ( left anterior fascicular block); </li></ul><ul><li>inferior MI; Preexcition syndrome </li></ul><ul><li>Causes of RAD: </li></ul><ul><li>Normal variant; RVH; Younger age; COPD; LPFB; Lateral MI; Preexcition syndrome </li></ul>
  21. 28. Sequence of Heart Activation
  22. 29. Measurements of an EKG
  23. 30. ECG Nomenclature <ul><li>P wave : depolarization of right and left atria </li></ul><ul><li>QRS complex : depolarization of right and left ventricles ( 0.06’’~0.10’’) </li></ul><ul><li>ST segment : beginning of repolarization of both ventricles </li></ul><ul><li>T wave : repolarization of both ventricles </li></ul><ul><li>U wave : late repolarization </li></ul>
  24. 31. ECG Nomenclature (Cont.) <ul><li>P-R interval : represents the time for an impulse to travel from SAN through specialized atrial conduction pathway… to Purkinjie cells. Includes depolarization of both atria and passage of the impulse to the point of ventricular muscle stimulation ( 0.12’’~0.20’’) </li></ul><ul><li>QT interval : the depolarization and repolarization of two ventricles ( 0.32’’~0.44’’) </li></ul>
  25. 32. Normal P wave <ul><li>Deflection : ↑ in Ⅱ, aVF, V3~V6; ↓ in aVR; ↑or ↓in V1~V2(varient) (Sinus P: + PR ≥ 0.12’’ ) </li></ul><ul><li>Amplitude : < 0.25mV in limb leads; < 0.2mV in precordial leads </li></ul><ul><li>Duration : < 0.11’’ </li></ul>
  26. 34. Normal QRS Complex R aVL < 1.2; R aVF < 2.0 qR, Rs or rS aVL, aVF < 0.5 QS, rS, rSr’ or Qr aVR 1.2~1.8, < 2.5 qR, qRs, Rs or R V5, V6 - RS (R/S1) V3, V4 < 1.0 rS V1, V2 Amplitude of R (mV) Deflection Leads
  27. 35. Progression of R in Precordial Leads
  28. 36. Low Voltage <ul><li>| R | + | S | or | Q | + | R | </li></ul><ul><li>< 0.5mV in every limb leads or </li></ul><ul><li>< 0.8 mV in every precordial leads </li></ul><ul><li>Clinical significance: pericardial effusion, pulmonary emphysema, obesity, etc. </li></ul>
  29. 37. Abnormal (Pathological) Q <ul><li>Amplitude: > 1/4R </li></ul><ul><li>Duration: > 0.04’’ </li></ul><ul><li>Clinical significance: myocadial infarction (MI), LBBB </li></ul>
  30. 38. T Wave <ul><li>Deflection: same as the main deflection of QRS in the same lead ( ( ↑ ) in Ⅰ , Ⅱ, and V4~V6; ( ↓ ) in aVR; ( ↑ ) or (+/-) or ( ↓ ) in Ⅲ, aVL, aVF, V1~V3 </li></ul><ul><li>Amplitude: > 1/10 R, 1.2~1.5mV in precordial leads( T V1 < 0.4mV) </li></ul>
  31. 39. S-T Segment <ul><li>↑ : < 0.3mV in V1~V3, < 0.1mV in V4~V5 and limb leads </li></ul><ul><li>↓ : < 0.05mV in any leads </li></ul>
  32. 40. Interpretation of an Electrocardiography <ul><li>1) Rhythm and rate: </li></ul><ul><li>P-R interval; P abnormalities; </li></ul><ul><li>abnormalities of rhythm </li></ul><ul><li>2) QRS: </li></ul><ul><li>Mean electrical axis; abnormalities of configuration </li></ul><ul><li>3) S-T and T </li></ul><ul><li>QRS-T angle; abnormalities( elevation or depression of ST, flat or inverted or sharp-peaked T ) </li></ul><ul><li>4) Q-T Interval: </li></ul><ul><li>Impression and Comment </li></ul>
  33. 41. A Normal EKG
  34. 42. Enlargement of Left Atrial
  35. 44. Left Atrial Enlargement <ul><li>Broad notched P </li></ul><ul><li>Duration: > 0.11’’, distance between peaks > 0.04’’ </li></ul><ul><li>P mitrale . </li></ul><ul><li>PtfV1: < -0.04mms </li></ul>
  36. 45. Right Atrial Enlargement
  37. 47. Right Atrial Enlargement <ul><li>Tall, peaked P. </li></ul><ul><li>Amp.: > 0.25mV in Ⅱ, aVL or aVF. </li></ul><ul><li>P pulmonale </li></ul>
  38. 48. Left Ventricular Hypertrophy
  39. 50. Left Ventricular Hypertrophy <ul><li>1) Increased mV of QRS: </li></ul><ul><li>R V5 > 2.5, R V5 +S V1 ≥ 3.5 (F), 4.0 (M); </li></ul><ul><li>R Ⅰ > 1.5, R aVL > 1.2, R Ⅰ +S Ⅲ > 2.5 or </li></ul><ul><li>R aVF > 2.0, R Ⅱ +R Ⅲ > 4.0 </li></ul><ul><li>2) LAD: usually < -30 ° </li></ul><ul><li>3) Delayed onset of intrinsicoid deflection: </li></ul><ul><li>VAT ( R peak time ) V5 > 0.05’’ </li></ul><ul><li>4) Repolarization changes: depressed ST and inverted T in V5, V6, ( Ⅰ, aVL) </li></ul>
  40. 51. Right Ventricular Hypertrophy
  41. 52. Right Ventricular Hypertrophy <ul><li>1) Increased mV of QRS: </li></ul><ul><li>R V 1 > 1.0, R V1 +S V5 >1.05( 1.2), R V1 /S V1 > 1 </li></ul><ul><li>S Ⅰ / R Ⅰ > 1, R aVR ↑ </li></ul><ul><li>2) RAD: usually -90 ° ~ -110 ° </li></ul><ul><li>3) Delayed onset of intrinsicoid deflection: VAT( R peak time ) V1 > 0.05’’ </li></ul><ul><li>4) Repolarization changes: depressed ST and inverted T in V1, V2 </li></ul>
  42. 54. AMI-99
  43. 58. Sinus Arrythmia <ul><li>Sinus P; </li></ul><ul><li>PRx-PRn ≥ 0.12’’ </li></ul><ul><li>Clinical Significance: None </li></ul>
  44. 59. Sinus Arrythmia
  45. 60. Sinus Tachycarcardia and Bradycardia <ul><li>Sinus Tachycarcardia: </li></ul><ul><li>1) Sinus P </li></ul><ul><li>2) Frequency of P > 100/min. </li></ul><ul><li>Clinical Significance: Fever, anemia, hyperthyrodism, myocarditis, heart failure, etc. </li></ul><ul><li>Sinus Bradycardia (Sinus P < 60 / min ): </li></ul><ul><li>Clinical Significance: Sports men, Inferior AMI, hypothyrodism, obstructive jaundice, ICP ↑, etc. </li></ul>
  46. 62. Atrial Premature Contraction (APC) <ul><li>Premature P’: differs from Sinus P ( bizarre or inverted). </li></ul><ul><li>PR ≥ 0.12’’ </li></ul><ul><li>QRS’ similar to sinus beat </li></ul><ul><li>Compensatory pause: Incomplete </li></ul><ul><li>Nonconducted or block APC </li></ul><ul><li>Clinical significance: </li></ul>
  47. 65. Ventricular Premature Contraction
  48. 66. Ventricular Premature Contraction (VPC) <ul><li>Premature an abnormal QRS without a preceded P : wide and bizarre; </li></ul><ul><li>Duration of QRS ≥ 0.12’’; </li></ul><ul><li>Deflection of T: opposite to main deflection of QRS; </li></ul><ul><li>Compensatory pause: complete </li></ul><ul><li>Interpolated VPC; Multiform VPCs; </li></ul><ul><li>Bigeminy; trigeminy; couplet; triplet (V. techycardia) </li></ul><ul><li>Clinical significance: </li></ul>
  49. 68. PVC
  50. 69. Junctional Premature Contraction
  51. 70. Junctional Premature Contraction (JPC) <ul><li>Premature QRS with or without a Retrograde P (P’) (preceding or following QRS); </li></ul><ul><li>P’-QRS < 0.12’’ or QRS-P’ < 0.20’’; </li></ul><ul><li>Compensatory pause: Completed or incompleted. </li></ul><ul><li>Clinical Significance: </li></ul>
  52. 71. Paroxymal Supraventricular Tachycardial ( PVST )
  53. 72. Supraventricular Paroxysmal Tachycardia <ul><li>Frequency of QRS > 140 (160)/min; </li></ul><ul><li>Rhythm: regularly; </li></ul><ul><li>Duration of QRS: ≤ 0.10’’. </li></ul><ul><li>Clinical significance: </li></ul>
  54. 73. Ventricular Paroxysmal Tachycardia
  55. 74. Ventricular Paroxysmal Tachycardia
  56. 75. Ventricular Paroxysmal Tachycardia <ul><li>≥ 3 rapid and continuous PVC; </li></ul><ul><li>Frequency: 140~200/min ( faster than P); </li></ul><ul><li>Shape of QRS: wide, bizarre, t ≥ 0.12’’; </li></ul><ul><li>Deflection of T: </li></ul><ul><li>Ventricular capture or Fusion. </li></ul><ul><li>Clinical significance: </li></ul>
  57. 76. Atrial Flutter
  58. 78. Atrial Flutter <ul><li>Disappearance of P, substituted by F waves; </li></ul><ul><li>Frequency of F: 250~350/min ( saw-tooth ); </li></ul><ul><li>Ratio of atrial to ventricular conduction: 2:1, 3:1, 4:1, etc. </li></ul><ul><li>Clinical significance: </li></ul>
  59. 79. Atrial Fibrillation <ul><li>Disappearance of P, substituted by irregular undulations of the baseline </li></ul><ul><li>( f waves ); </li></ul><ul><li>Frequency of f: 350~600/min; </li></ul><ul><li>Irregularly irregular R-R intervals. Clinical significance </li></ul>
  60. 80. Ventricular Flutter
  61. 81. Ventricular Flutter <ul><li>Undulating regular QRS waves; </li></ul><ul><li>Frequency: 180~250/min; </li></ul><ul><li>ST or T: Not identified. </li></ul><ul><li>Clinical Significance : Precursor of ventricular fibrillation. </li></ul>
  62. 82. Ventricular Fibrillation <ul><li>Bizarre, irregularly irregular fibrillatory waves; </li></ul><ul><li>Frequency: 250~500/min; </li></ul><ul><li>P, QRS, T: not identified </li></ul><ul><li>Clinical significance: </li></ul>
  63. 85. Ⅰ 0 Auriculo-Ventricular Block ( Ⅰ 0 AVB ) <ul><li>P-R > 0.20”; </li></ul><ul><li>There is a QRS followed each P. </li></ul><ul><li>Clinical significance: </li></ul>
  64. 86. 2nd Degree AV Block, Type I
  65. 87. Ⅱ 0 Degree AV Block ( 1. Mobitz Type Ⅰ ) ( Wenckebach) <ul><li>Group beating; </li></ul><ul><li>Progressive lengthening of P-R until a P is completely block ->An absent QRS; </li></ul><ul><li>Repeated cycle. </li></ul><ul><li>Clinical significance: </li></ul>
  66. 88. Mobitz II 2nd degree AV block
  67. 89. Ⅱ Degree AV Block ( 2. Mobitz Type Ⅱ ) <ul><li>Constant P-R; </li></ul><ul><li>Absent of a QRS periodically. </li></ul><ul><li>High degree or advanced AV block: </li></ul><ul><li>A / V ≥ 3:1 </li></ul><ul><li>Clinical significance: </li></ul>
  68. 90. Ⅲ Degree AV Block
  69. 91. Ⅲ Degree AV Block ( Complete AV Block ) <ul><li>The atria ( P waves ) beat independently of the ventricles ( QRS ) </li></ul><ul><li>Atrial rate is faster than ventricular rate ( escape rhythm ) </li></ul><ul><li>Clinical significance: Drugs ( digoxin… ), degeneration from aging, AMI, etc. </li></ul>
  70. 93. Right Bundle Branch Block
  71. 94. Right Bundle Branch Block (RBBB ) <ul><li>QRS duration ( ≥ 0.12’’- complete; </li></ul><ul><li>0.10~ 0.11- incomplete ); </li></ul><ul><li>RSR’ ( R’ > R ) in the “right ventricular leads” - V1, V2; </li></ul><ul><li>Wide or slurred S in the “left ventricular leads” - V5, V6 ( Ⅰ , aVL); </li></ul><ul><li>Ventricular repolarization changes ( downsloping ST and inverted T- opposite direction to R’) in V1, V2 </li></ul><ul><li>Late onset of intrinsicoid defletion ( R peak time ) in V1, V2 ( ≥ 0.04’’ ) </li></ul>
  72. 95. RBBB
  73. 96. Left Bundle Branch Block
  74. 97. Left Bundle Branch Block (LBBB ) <ul><li>QRS duration ( ≥ 0.12’’- complete; 0.10~ 0.11 - incomplete ); </li></ul><ul><li>Wide and notched R in the left ventricular leads”- </li></ul><ul><li>V5, V6 ( Ⅰ , aVL); </li></ul><ul><li>Wide or slurred S in the “Right ventricular leads”- </li></ul><ul><li>V1, V2; </li></ul><ul><li>Ventricular repolarization changes ( downsloping ST and inverted T- opposite direction to R) in V5, V6 </li></ul><ul><li>Late onset of intrinsicoid defletion ( R peak time ) in V5, V6 ( ≥ 0.06’’ ) </li></ul>
  75. 98. LBBB
  76. 99. Coronary Artery
  77. 100. Angina Pectoris
  78. 101. Classic Angina Pectoris ( Transient subendocardial ischemia ) <ul><li>Depression of ST; </li></ul><ul><li>( flat or inverted T ) </li></ul>
  79. 102. Classic Myocardial Infarction
  80. 103. Evolutionary Changes of EKG in AMI
  81. 104. Stages of MI <ul><li>Hyperacute; </li></ul><ul><li>Acute; </li></ul><ul><li>Subacute; </li></ul><ul><li>Old. </li></ul>
  82. 105. Location of MI
  83. 106. Hyperacute Inferior MI
  84. 107. Acute Inferior MI
  85. 108. Acute Extensive Anterior/ Anterolateral MI
  86. 109. Subacute Inferior MI ( Inferior and Anteroseptal )
  87. 110. Old Inferior MI, PVCs, and Af
  88. 111. Mechanism of WPW
  89. 113. Preexcitation Syndrome (WPW) ( Type A )
  90. 114. Preexcitation Syndrome (WPW) ( Type B )
  91. 115. Thank You !
  92. 118. Angina Variant ( Prinzmetal angina , Transient subepicardial ischemia ) <ul><li>Slope-elevation of ST; </li></ul><ul><li>Tall and widened T; </li></ul><ul><li>Increased VAT. </li></ul><ul><li>Clinical significance: </li></ul>
  93. 119. Precordial Leads
  94. 120. Sequence of Heart Activation

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