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ECGDr. Sumit Kr. GhoshAsst. ProfessorDepartment of MedicineMedical College & Hospital,
INTRODUCTIONGraphic representation of electrical activities of heartResting ECGExercise ECG / TMT24-hr ECG / Holter
READING ECG• Rate• Rhythm• Axis• Lie & Rotation• Voltage• Waves & Intervals• Abnormalities
ECG PAPER
STANDARDISATION• 1mv will produce deflection of 10 mm / 1cm• Stylus should have an appropriate pressure
WAVES & INTERVALP Q R S T > 5mmq r s < 5mmPQRSTUJ-pointJδPRQRSSTQTTPPP & RR
LEADSLead = paired electrode12 leadsLimb leads Precordial leadsFrontal or Coronal plane leads Horizontal plane leadsBipola...
Resultant vector• Towards lead : positive / upward deflection• Away from lead : negative / downward deflection• Perpendicu...
RATEVentricular rate vs Atrial rateRate = 1500/ no of small square = 300/no oflarge squareDepends on speed of ECG paperUsu...
RHYTHM• Regular :~ Sinus~ Nodal~ Idioventricular• Irregular :~ Regularly irregular~ Irregularly irregular
AXIS• Normal axis : 0 to +90 degree (most cases +40 to +60 degree)• LAD : 0 to -90 degree (slight LAD : 0 to -30 degreemar...
AXIS DETERMINATION• Lead I,II & III• Pairs of perpendicular leads• Perpendicular to the lead where R=S• In degreeI II III↑...
++__ IaVF0± 180- 90+ 90NORMAL AXIS RAD LAD INDETERMINATE AXIS
EASY TO REMEMBERI (left) aVF (right)↑ ↑ Normal↑ ↓ LAD↓ ↑ RAD↓ ↓ Indeterminate
LAD• LAHB• LBBB• Inf wall MI• Pacing from apex of RV/LV• WPWIsolated LVH does not causeLADRAD• RV dominance- acq. Rt heart...
LIE & ROTATION• LIE : in frontal plane [ vertical (90 degree) to horizontal (0 degree )• Rotation : in horizontal plane~ C...
P - WAVE• Atrial activity (RA earliar than LA)• Best seen in lead II & v1• Normal duration : 0.08 s – 0.1 s (not > 0.11 s)...
QRS COMPLEX• Ventricular depolarisationQ-wave : initial negative deflectionseptal depolarisation :: from left to rightR-wa...
QRS COMPLEXQRS in precordial leads
T-WAVE• Ventricular repolarisation• Blunt apex with 2 asymerical limbs :proximal limb shallower than distal• Tall –peaked ...
U-WAVE• Positive deflection after T & before P ofnext cycle• Slow repolarisation of Purkinje’s fibres,septum, papillary mu...
P-R INTERVAL• Beginning of P-wave to beginning of QRScomplex• Intra-atial, AV nodal & His-Purkinje coduction• Normal durat...
QRS INTERVAL• Total ventricular depolarisation• Beginning of Q-wave ( beginning of P-wave,if no Q-wave present) to termina...
ST SEGMENT• End of QRS complex to beginning of T• Normal ST segment merges smoothly & imperceptibly withproximal limb of T...
QT INTERVAL• Beginning of Q to end of T• Ventricular depolarisation + repolarisation• Corrected QT or QTc : as QT changes ...
PP & RR INTERVAL• PP interval : distance between 2 successive P waves- reflects atrial rate• RR interval : distance betwee...
Atrial hypertrophy :LAH : P-mitraleRAH : P- pulmonaleBi-atrial hypertrophyVentricular hypertrophy :LVHRVHBi-ventricular hy...
LVH• Voltage criteria :~ Sv1 + Rv6 > 35~ Sv1 / Rv6 ≥ 20~ Rv6 ≥ Rv5~ RI ≥ 15~ RaVL ≥ 11~ Rall(12) > 175• Horizontal heart• ...
RVH• Voltage criteria :~ R > S~ Rv1 > 5 mm~ persistent Sv5 / Sv6• Usually RAD (most common & at times only manifestation);...
BIVENTRICULAR HYPERTROPHY• LVH + RAD• LVH + Clockwise rotation• Tall Rv6 + tall Rv1 ( R > S)
CORONARY INSUFFICIENCY• Impaired coronary blood flow : present all the time :absolute• Increased demand : present time to ...
MYOCARDIAL INFARCTION
ECG CHANGES• Hyperacute phase~ increased amplitude of R wave~ increased VAT~ slope elevation of ST segment~ tall & wide T•...
AMILV RVv1 & v4RAnterior wallExtensive anterior wallI, aVL, v1 to v6Anterolateral wallI, aVL, v4 to v6Anteroseptal walv1 t...
PATHOLOGICAL Q• Present in indicative leads• 0.04s in duration• >4 mm deep• >1/4thof R wave magnitudePhysiological Q• Sept...
• Sinus rhythm : 60-100 beats/min• Sinus arrythmia (sinus node rate can change withinspiration/expiration, especially in y...
Similarities :PrematureEctopicEtiologyDissimilarities :SVPB VPBFocus in Atrium ( other than SAnode)VentricleQRS complex Mo...
SUPRAVENTRICULARTACHYARRYTHMIASVTs from a sinoatrial source:• Inappropriate sinus tachycardia• Sinoatrial node reentrant t...
PAT / PSVT / AVNRT• A run of rapidly repeated SVPBs ( usually ≥ 3 )• Narrow QRS• Rate around 160-220/ min• Usually 1:1 con...
Atrial fibrillation• Chaotic atrial excitation & contraction• Atrial rate 350-600 / min• No definite P; replaced by ‘f’ wa...
Atrial flutter• Regular atrial contraction• Atrial rate 220-350 / min• Ventricular rate ½ - ¼ th of atrial rate; may beirr...
VENTRICULARTACHYARRYTHMIAVTVFlVFVPCBigeminy : alternate sinus beat & VPCTrigeminy : 2 sinus beat followed by VPCCouplets /...
VTSustained VT : >30s in duration & symptomatic :generally requires termination by anti-tachycardiapacing techniquesNon-su...
VFl• High frequency (250- 350/min) beats• The ECG signal looks like sinusoidal or ‘sine-like wave’ form• High rate of cont...
VF• Most dangerous arrythmia• Ventricular rate 350-450/min• Totally uncoordinated : no discriminate waves :totally irregul...
ATRIOVENTRICULARCONDUCTION DEFECTS• 1stdegree• 2nddegree~ Mobitz type I~ Mobitz type II~ Constant / fixed AV block• 3rddeg...
1stdegreeProlonged PR interval (>0.2 s)2nddegreeMobitz type IMobitz type IIConstant / fixed AV block3rddegree / Complete b...
INTERVENTRICULARCONDUCTION DEFECTS• Unilateral bundle branch block ( LBBB,RBBB)• Peripheral block ( LAHB, LPHB, Septalbloc...
BBB
LBBB• M pattern or M-shaped complexes in lead I, aVL, v5, v6• Absent Q• ST depression with T inversion• QRS interval more ...
RBBB• RSR’ pattern in v1, v2, aVR, v3R• ST depression with T inversion• Wide & slurred S in I, aVL, v5, v6• QRS interval m...
LAHB• LAD• qR in I, aVL & rS in II, III, aVFLPHB• RAD• qR in II, III, aVF
Bifascicular block• RBBB + LAHB• RBBB + LPHB• LAHB + LPHBTrifascicular block• LAD + RBBB + Prolonged PR
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata
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ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata

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ECG
Proff.Sumit Kr Ghosh
Dept of Internal Medicine
Medical College
88 College Street Kolkata

Published in: Health & Medicine
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ECG Final Proff.Sumit Kr Ghosh Dept of Internal Medicine Medical College 88 College Street Kolkata

  1. 1. ECGDr. Sumit Kr. GhoshAsst. ProfessorDepartment of MedicineMedical College & Hospital,
  2. 2. INTRODUCTIONGraphic representation of electrical activities of heartResting ECGExercise ECG / TMT24-hr ECG / Holter
  3. 3. READING ECG• Rate• Rhythm• Axis• Lie & Rotation• Voltage• Waves & Intervals• Abnormalities
  4. 4. ECG PAPER
  5. 5. STANDARDISATION• 1mv will produce deflection of 10 mm / 1cm• Stylus should have an appropriate pressure
  6. 6. WAVES & INTERVALP Q R S T > 5mmq r s < 5mmPQRSTUJ-pointJδPRQRSSTQTTPPP & RR
  7. 7. LEADSLead = paired electrode12 leadsLimb leads Precordial leadsFrontal or Coronal plane leads Horizontal plane leadsBipolar unipolar (low EP) unipolarI, II, III aVR, aVL, aVF v1, v2, v3, v4, v5, v6rt side septum lt sideI, avL, v5, v6 : lateral wallII, III Avf : inferior wallLong leadsV7, v8, v9V1r – v9r3v1 – 3v9Esophageal leads
  8. 8. Resultant vector• Towards lead : positive / upward deflection• Away from lead : negative / downward deflection• Perpendicular to lead : equiphasic deflection
  9. 9. RATEVentricular rate vs Atrial rateRate = 1500/ no of small square = 300/no oflarge squareDepends on speed of ECG paperUsual speed = 90m/hr =1.5m/minNo of QRS complex in 1 min = HR
  10. 10. RHYTHM• Regular :~ Sinus~ Nodal~ Idioventricular• Irregular :~ Regularly irregular~ Irregularly irregular
  11. 11. AXIS• Normal axis : 0 to +90 degree (most cases +40 to +60 degree)• LAD : 0 to -90 degree (slight LAD : 0 to -30 degreemarked LAD : -30 to -90 degree )• RAD : +90 to ± 180 degree• Inderminate / NW axis : -90 to ± 180 degreean expression of :- marked RAD- marked LAD- discharge of ectopicventricular pacemaker
  12. 12. AXIS DETERMINATION• Lead I,II & III• Pairs of perpendicular leads• Perpendicular to the lead where R=S• In degreeI II III↑ ↑ ↑ Normal↑ ↑ ↓ ↓ LAD↓ ↑ ↑ RAD
  13. 13. ++__ IaVF0± 180- 90+ 90NORMAL AXIS RAD LAD INDETERMINATE AXIS
  14. 14. EASY TO REMEMBERI (left) aVF (right)↑ ↑ Normal↑ ↓ LAD↓ ↑ RAD↓ ↓ Indeterminate
  15. 15. LAD• LAHB• LBBB• Inf wall MI• Pacing from apex of RV/LV• WPWIsolated LVH does not causeLADRAD• RV dominance- acq. Rt heart disease :pulm embolismchr. Cor pulmonale- cong. heart disease :TOF• Anterolateral MI• LPHB• WPW
  16. 16. LIE & ROTATION• LIE : in frontal plane [ vertical (90 degree) to horizontal (0 degree )• Rotation : in horizontal plane~ Clockwise – persistent S waves in v5, v6~ Anti-clockwise – R waves in v2
  17. 17. P - WAVE• Atrial activity (RA earliar than LA)• Best seen in lead II & v1• Normal duration : 0.08 s – 0.1 s (not > 0.11 s)• Normal amplitude : not > 2 mm ( max – 2.5 mm)• Diphasic in v1• Inverted in aVR (normally), wrong electrode placement,dextrocardia, retrograde atrial activation• Absent : Atrial fibrillation, nodal rhythm, hyperkalemia• P-pulmonale : tall & peaked (amplitude > 2.5 mm) » » RAH• P-mitrale : wide & notched (duration > 0.11 s) » » LAH• P-tricuspidale
  18. 18. QRS COMPLEX• Ventricular depolarisationQ-wave : initial negative deflectionseptal depolarisation :: from left to rightR-wave : depolarisation of venticular muscle massS-wave : depolarisation of postero-basal part of leftventricle, superiormost part of ventricular septum• High amplitude : RVH / LVH• Low amplitude : Low voltage complex(< 5 mm in limb leads & < 10 mm in precordial leads)Standardisation is important• Taller in v5 than v6
  19. 19. QRS COMPLEXQRS in precordial leads
  20. 20. T-WAVE• Ventricular repolarisation• Blunt apex with 2 asymerical limbs :proximal limb shallower than distal• Tall –peaked : hyperkalemia• Tall- wide : hyperacute stage of MI• Inverted : IHD, Ventricular strain, CVA• Flat : thick chest wall, emphysema,pericardial effusion, hypokalemia
  21. 21. U-WAVE• Positive deflection after T & before P ofnext cycle• Slow repolarisation of Purkinje’s fibres,septum, papillary muscles but uncertain• Mid-precordial leads – v2 to v4• Prominent : hypokalemia• Inverted / absent : diastolic overload /myocardial dysfunction
  22. 22. P-R INTERVAL• Beginning of P-wave to beginning of QRScomplex• Intra-atial, AV nodal & His-Purkinje coduction• Normal duration : 0.12 – 0.20 s• Prolonged : Acute rheumatic fever, 1stdegreeAV block• Progressive prolongation : Mobitz type-I (2nddegree AV block) » » Wenckebach phenomenon• Shortened : WPW syndrome, AV nodal rhythm
  23. 23. QRS INTERVAL• Total ventricular depolarisation• Beginning of Q-wave ( beginning of P-wave,if no Q-wave present) to termination of S-wave• Normal duration : usually not > 0.09 sec(range 0.05-0.11 s)• Prolonged : Intaventricular conduction defector BBB≥ 0.12 sec » » complete BBB• Intrinsicoid deflection / ventricular activationtime : time taken for an impulse to traversemyocardiumVAT normally not > 0.02 s in v1, v2& not > 0.04 s in v5, v6
  24. 24. ST SEGMENT• End of QRS complex to beginning of T• Normal ST segment merges smoothly & imperceptibly withproximal limb of T : difficult to separate• Time interval between ventricular depolarisation &repolarisation• Isoelectric to TP segment• Elevated :~ with upward convexity : AMI, coronary spasm, LVAneurysm~ with upward concavity : acute pericarditis• Depressed :~ oblique/plane/sagging : CAD~ mirror image of correction mark : digitalis effect~ upward convexity : strain pattern• End of QRS complex & beginning of ST segment : J point
  25. 25. QT INTERVAL• Beginning of Q to end of T• Ventricular depolarisation + repolarisation• Corrected QT or QTc : as QT changes with heart rate• Bazett’s formula :QT interval√RR intervalIt should be ≤ 0.44 sProlonged : acute rheumatic carditis, hypokalemia,hypocalcemia, drugsShortened : hypercalcemia, digitalis, hyperthermiaQTc =
  26. 26. PP & RR INTERVAL• PP interval : distance between 2 successive P waves- reflects atrial rate• RR interval : distance between 2 successive R waves- reflects ventricular rate• Normally PP = RR
  27. 27. Atrial hypertrophy :LAH : P-mitraleRAH : P- pulmonaleBi-atrial hypertrophyVentricular hypertrophy :LVHRVHBi-ventricular hypertrophy
  28. 28. LVH• Voltage criteria :~ Sv1 + Rv6 > 35~ Sv1 / Rv6 ≥ 20~ Rv6 ≥ Rv5~ RI ≥ 15~ RaVL ≥ 11~ Rall(12) > 175• Horizontal heart• VAT in v5/v6 > 0.04 s• Strain pattern in I, aVL, v5, v6LAD is not a criteria for isolated LVH• Pressure overload LVH• Volume overload LVH
  29. 29. RVH• Voltage criteria :~ R > S~ Rv1 > 5 mm~ persistent Sv5 / Sv6• Usually RAD (most common & at times only manifestation); but axismay be normal• Vertical heart• VAT in v1 > 0.02 s• Strain pattern in v1, Avr• Associated P-pulmonale may be there
  30. 30. BIVENTRICULAR HYPERTROPHY• LVH + RAD• LVH + Clockwise rotation• Tall Rv6 + tall Rv1 ( R > S)
  31. 31. CORONARY INSUFFICIENCY• Impaired coronary blood flow : present all the time :absolute• Increased demand : present time to time : relative• ST depression : horizontality, upward sloping, plane,downward sloping• ST elevation : coronary vasospasmmore severe than ST depression• T wave :~ symmetrical limbs with sharp vertex : coronaryinsufficiency~ asymmetrical limbs with blunt vertex : strain, digitaliseffect• Inverted U
  32. 32. MYOCARDIAL INFARCTION
  33. 33. ECG CHANGES• Hyperacute phase~ increased amplitude of R wave~ increased VAT~ slope elevation of ST segment~ tall & wide T• Fully evolved phase~ pathological Q~ ST elevation with upward convexity~ symmetrical T inversion• Chronic stabilized phase~ pathological Q~ ST segment & T may be normal orpoint towards coronary insuffiencyIndicative & reciprocal changes
  34. 34. AMILV RVv1 & v4RAnterior wallExtensive anterior wallI, aVL, v1 to v6Anterolateral wallI, aVL, v4 to v6Anteroseptal walv1 to v4Apical wallV5,V6Inferior wallII, III, aVFPosterior wallmirror-image changein v1 to v3, esp v2
  35. 35. PATHOLOGICAL Q• Present in indicative leads• 0.04s in duration• >4 mm deep• >1/4thof R wave magnitudePhysiological Q• Septal depolarisation from left to right• Present in lateral leads I, aVL, v5,v6Loss of Q : early feature of LBBBDeep Q with giant negative T : HOCM
  36. 36. • Sinus rhythm : 60-100 beats/min• Sinus arrythmia (sinus node rate can change withinspiration/expiration, especially in younger peoplevariation of the P-P interval from one beat to thenext by at least 0.12 seconds• Sinus tachycardia : regular sinus rhythm with sinusnode rate > 100/min• Sinus bradycardia : regular sinus rhythm with sinusnode rate < 60 / min
  37. 37. Similarities :PrematureEctopicEtiologyDissimilarities :SVPB VPBFocus in Atrium ( other than SAnode)VentricleQRS complex Morphology similarNarrowMorphology dissimilarWideST-T No significant change Usually displaced inopposite direction of QRSCompensatory pause Incomplete CompleteAPC / SVPB vs. VPC / VPB
  38. 38. SUPRAVENTRICULARTACHYARRYTHMIASVTs from a sinoatrial source:• Inappropriate sinus tachycardia• Sinoatrial node reentrant tachycardia (SANRT)SVTs from an atrial source:• Ectopic (unifocal) atrial tachycardia (EAT)• Multifocal atrial tachycardia (MAT)• Atrial fibrillation with a rapid ventricular response• Atrial flutter with a rapid ventricular responseSVTs from an atrioventricular source (junctional tachycardia):• AV nodal reentrant tachycardia (AVNRT) or junctional reciprocatingtachycardia (JRT)• AV reentrant tachycardia (AVRT) - visible or concealed (includingWolff-Parkinson-White syndrome)• Junctional ectopic tachycardia
  39. 39. PAT / PSVT / AVNRT• A run of rapidly repeated SVPBs ( usually ≥ 3 )• Narrow QRS• Rate around 160-220/ min• Usually 1:1 conduction; sometimes AV block associated(PAT with block)• Prolonged PR• Management : carotid sinus massage, adenosine,verapamil, DC cardioversion
  40. 40. Atrial fibrillation• Chaotic atrial excitation & contraction• Atrial rate 350-600 / min• No definite P; replaced by ‘f’ wave• Irregularly irregular ventricular rhythm• Narrow QRS• Etiology :• Management :
  41. 41. Atrial flutter• Regular atrial contraction• Atrial rate 220-350 / min• Ventricular rate ½ - ¼ th of atrial rate; may beirregular; QRS complex : normal morphology• “Saw-toothed” appearance; flutter wave
  42. 42. VENTRICULARTACHYARRYTHMIAVTVFlVFVPCBigeminy : alternate sinus beat & VPCTrigeminy : 2 sinus beat followed by VPCCouplets / pairs : 2 successive VPCsVT : ≥ 3 consecutive VPCs with rate >100
  43. 43. VTSustained VT : >30s in duration & symptomatic :generally requires termination by anti-tachycardiapacing techniquesNon-sustained VT : episodes are short (≥3 beats) andterminate spontaneouslyMonomorphic VT : regular rate and rhythm and fixedshape or morphology of the ECG tracePolymorphic VT : irregular in rate and rhythm and hasvarying shapes or morphologies on the ECGMonomorphic VT may deteriorate into polymorphicVT to VF
  44. 44. VFl• High frequency (250- 350/min) beats• The ECG signal looks like sinusoidal or ‘sine-like wave’ form• High rate of contraction of heart chambers : timeof blood flow into the chamber becomes verysmall : very little blood flows to body• The person who is experiencing VFl is close tounconsciousness
  45. 45. VF• Most dangerous arrythmia• Ventricular rate 350-450/min• Totally uncoordinated : no discriminate waves :totally irregular, bizarre & deformed deflectionsof varying width, height & shape• No audible heart sounds, no palpable pulse• Treatment : immediate electrical defibrillation• If lucky to survive from VT, chance of VF in nearfuture
  46. 46. ATRIOVENTRICULARCONDUCTION DEFECTS• 1stdegree• 2nddegree~ Mobitz type I~ Mobitz type II~ Constant / fixed AV block• 3rddegree / Complete block
  47. 47. 1stdegreeProlonged PR interval (>0.2 s)2nddegreeMobitz type IMobitz type IIConstant / fixed AV block3rddegree / Complete blockNo SA impulse pass through AVnodeIdioventricular rhythmNo synchrony between atrial rhythm& ventricular rhythmMobitz type I Mobitz type IIMore common Less commonBenign SeriousInf wall MI Ant wall MIProximal tobundle of HisDistal to bundle ofHisPrognosis better Prognosis worse
  48. 48. INTERVENTRICULARCONDUCTION DEFECTS• Unilateral bundle branch block ( LBBB,RBBB)• Peripheral block ( LAHB, LPHB, Septalblock)• Bifascicular block• Trifascicular block
  49. 49. BBB
  50. 50. LBBB• M pattern or M-shaped complexes in lead I, aVL, v5, v6• Absent Q• ST depression with T inversion• QRS interval more or less 0.12s• Usually LAD• Usually VAT prolongedMost cases have organic heart diseaseRecent onset LBBB : think of AMIPresence of Q in lateral leads : never LBBB
  51. 51. RBBB• RSR’ pattern in v1, v2, aVR, v3R• ST depression with T inversion• Wide & slurred S in I, aVL, v5, v6• QRS interval more or less 0.12 s• Usually VAT prolongedCommoner than LBBB, often without anycardiac diseases
  52. 52. LAHB• LAD• qR in I, aVL & rS in II, III, aVFLPHB• RAD• qR in II, III, aVF
  53. 53. Bifascicular block• RBBB + LAHB• RBBB + LPHB• LAHB + LPHBTrifascicular block• LAD + RBBB + Prolonged PR

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