1.
Electrocardiographic Cases Crisbert I. Cualteros, M.D.

2.
Sinus Rhythm

3.
SR frequent PVDs PRWP lat wall ischemia

4.
ECG Indications <ul><li>determine cardiac rate </li></ul><ul><li>define cardiac rhythm </li></ul><ul><li>diagnose old or new MI </li></ul><ul><li>identify intracardiac conduction disturbances </li></ul><ul><li>aid in the diagnosis of IHD, pericarditis, myocarditis, electrolyte abnormalities and pacemaker malfunction </li></ul>

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

6.
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

7.
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

9.
RRAHIM <ul><li>Components of ECG interpretation </li></ul><ul><li>R ate </li></ul><ul><li>R hythm </li></ul><ul><li>A xis </li></ul><ul><li>H ypertrophy </li></ul><ul><li>I schemia and Infarction </li></ul><ul><li>M iscellaneous (normal variants) </li></ul>

16.
Rate <ul><li>Mnemonic: 300, 150, 100, 75, 60, 50 </li></ul><ul><li>Formula: 1500 / # of small boxes </li></ul><ul><li> 300 / # of big boxes </li></ul><ul><li>Bradycardia = <60 bpm </li></ul><ul><li>Normal Rate = 60-100 bpm </li></ul><ul><li>Tachycardia = >100 bpm </li></ul>

17.
What is the rate? 1500/28 or 300/5.6 53 bpm

18.
What is the rate? 1500/12 or 300/2.4 125 bpm

19.
Rhythm <ul><li>Identify the P wave </li></ul><ul><li>Check relation of P wave to QRS </li></ul><ul><ul><li>Normal: P wave is before QRS </li></ul></ul><ul><ul><li>SVT, heart blocks: P wave after QRS or burried </li></ul></ul><ul><li>Check PR interval ( 0.12 - 0.20s ) </li></ul><ul><ul><li>Shortened: WPW </li></ul></ul><ul><ul><li>Prolonged: 1 st and 2 nd degree AV block </li></ul></ul>

20.
<ul><li>Check QRS duration (< 0.10 s ) </li></ul><ul><ul><ul><li>Widened: bundle branch blocks </li></ul></ul></ul><ul><li>Check relation of R-R and P-P int </li></ul><ul><ul><ul><li>PP < RR: complete heart block </li></ul></ul></ul><ul><ul><ul><li>PP > RR: AV dissociation </li></ul></ul></ul>

21.
Common Rhythm Interpretations <ul><li>Sinus rhythm </li></ul><ul><li>Supraventricular arrhythmias </li></ul><ul><ul><ul><li>Atrial fibrillation </li></ul></ul></ul><ul><ul><ul><li>Atrial flutter </li></ul></ul></ul><ul><ul><ul><li>Supraventricular tachycardia (SVT) </li></ul></ul></ul><ul><li>Heart Blocks </li></ul><ul><ul><ul><li>First-degree AV block </li></ul></ul></ul><ul><ul><ul><li>Second-degree AV block </li></ul></ul></ul><ul><ul><ul><ul><li>Mobitz Type I (Wenckebach) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mobitz Type II </li></ul></ul></ul></ul>

22.
<ul><ul><ul><li>Third-degree AV block </li></ul></ul></ul><ul><ul><ul><li>Left or Right Bundle Branch Block </li></ul></ul></ul><ul><ul><ul><ul><li>Complete </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Incomplete </li></ul></ul></ul></ul><ul><li>Ventricular Arrhythmias </li></ul><ul><ul><ul><li>Premature Ventricular Depolarization (PVD) </li></ul></ul></ul><ul><ul><ul><li>Ventricular Tachycardia (V-tach) </li></ul></ul></ul><ul><ul><ul><ul><li>Sustained </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Non-sustained </li></ul></ul></ul></ul><ul><ul><ul><li>Ventricular fibrillation (V-fib) </li></ul></ul></ul>

23.
Axis Determination <ul><li>get the average QRS vector from the isoelectric baseline in Leads I and AVF </li></ul><ul><ul><ul><li>if the average QRS vector is above baseline -> (+) QRS deflection </li></ul></ul></ul><ul><ul><ul><li>if the average QRS vector is below baseline </li></ul></ul></ul><ul><ul><ul><li>-> (-) QRS deflection </li></ul></ul></ul>

24.
Axis -- -- indeterminate + -- RAD -- + LAD + + Normal Axis AVF Lead 1

26.
Normal (-30 to +90) RAD Indeterminate LAD

27.
Axis <ul><li> - 90 AVF </li></ul><ul><li>indeterminate LAD </li></ul><ul><li>± 180 0 I </li></ul><ul><li> RAD normal </li></ul><ul><li> (-30 to +90) </li></ul><ul><li> + 90 </li></ul>

28.
What is the axis?

29.
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

30.
Hypertrophy <ul><li>Six Possibilities </li></ul><ul><li>No hypertrophy </li></ul><ul><li>LVH </li></ul><ul><li>RVH </li></ul><ul><li>LAE </li></ul><ul><li>RAE </li></ul><ul><li>combination </li></ul>

31.
LVH criteria <ul><li>3 Methods </li></ul><ul><li>1) S wave in V1 + </li></ul><ul><li>R wave in V5/6 > 35mm </li></ul><ul><li>2) R in AVL > 11mm </li></ul><ul><li>3) Romhilt and Estes Criteria (best) </li></ul>

32.
SR, LVH with Strain Pattern, Old Anteroseptal Wall MI

33.
RVH Criteria <ul><li>RAD of ≥ +110, with any of the ff: </li></ul><ul><ul><ul><li>V1: R wave > S wave </li></ul></ul></ul><ul><ul><ul><ul><ul><li>COPD </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>RBBB </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>True posterior infarction </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>WPW </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Deep S wave in V5-6 </li></ul></ul></ul><ul><ul><ul><ul><ul><li>COPD </li></ul></ul></ul></ul></ul><ul><ul><ul><li>ST depression and T wave inversion in V1-3 </li></ul></ul></ul>

34.
LAE (p mitrale) <ul><li>2 Methods </li></ul><ul><li>V1: wide terminal component of P wave ≥ 1 mm wide (0.04 s) and ≥ 1 mm deep </li></ul><ul><li>Any lead: P wave wider than 0.12s or with a ≥ 1 mm notch in the middle </li></ul>

35.
ST, RAD, LAE, RVH

36.
RAE (p pulmonale) <ul><li>2 Methods </li></ul><ul><li>V1: tall initial component of P wave ≥ 2mm wide and ≥ 2 mm tall </li></ul><ul><li>Any Lead: P wave ≥ 2.5 mm tall </li></ul>

37.
RRAHIM <ul><li>Components of ECG interpretation </li></ul><ul><li>Rate </li></ul><ul><li>Rhythm </li></ul><ul><li>Axis </li></ul><ul><li>Hypertrophy </li></ul><ul><li>Ischemia and Infarction </li></ul><ul><li>Miscellaneous (normal variants) </li></ul>

38.
Myocardial Ischemia <ul><li>1 mm ST-segment depression </li></ul><ul><li>Symmetrically/inverted T waves </li></ul><ul><li>Abnormally tall T waves </li></ul><ul><li>Normalization of abnormal T waves </li></ul><ul><li>Prolongation of QT interval </li></ul><ul><li>Arrhythmias, BBB, AV blocks or electrical alternans </li></ul>

39.
SR, Anterolateral Wall Ischemia

40.
Myocardial infarction <ul><li>Criteria (any) </li></ul><ul><li>ST elevation </li></ul><ul><ul><ul><li>≥ 2 Chest leads: ≥ 2 mm elevation or </li></ul></ul></ul><ul><ul><ul><li>≥ 2 Limb leads: ≥ 1 mm elevation </li></ul></ul></ul><ul><li>Q waves ≥ 0.04s (1 small square) </li></ul>

41.
Timing of MI/ECG 0-6 hours 6-24 h 24 -72 h 72 h – 6 weeks > 6 wk

42.
<ul><li>Differentials for ST elevation </li></ul><ul><li>Acute pericarditis </li></ul><ul><li>Ventricular aneurysm </li></ul><ul><li>Severe LV wall hypokinesia </li></ul><ul><li>Early repolarization changes </li></ul><ul><li>Variant (prinzmetal) angina </li></ul>

43.
<ul><li>Q waves </li></ul><ul><ul><li>never significant in aVR </li></ul></ul><ul><ul><li>not significant in V1 unless with abnormalities in other precordial leads </li></ul></ul><ul><ul><li>not significant in III unless with abnormalities in II, aVF </li></ul></ul><ul><ul><li>more reliable if associated with ST changes </li></ul></ul><ul><ul><li>Not significant in V1-V3 if (+) LBBB , but significant if (+) RBBB </li></ul></ul>

44.
<ul><li>Criteria for Pathologic Q waves </li></ul><ul><li>≥ 0.04 sec in duration </li></ul><ul><li>≥ 25% of the R wave amplitude </li></ul>

45.
Recent Anteroseptal Wall MI

46.
SR, Acute Inferior Wall MI

47.
RRAHIM <ul><li>Components of ECG interpretation </li></ul><ul><li>R ate </li></ul><ul><li>R hythm </li></ul><ul><li>A xis </li></ul><ul><li>H ypertrophy </li></ul><ul><li>I schemia and Infarction </li></ul><ul><li>M iscellaneous (normal variants) </li></ul>

48.
<ul><li>Hypokalemia </li></ul><ul><ul><ul><li>V2, V3: u wave as tall or taller than T wave </li></ul></ul></ul><ul><li>Hyperkalemia </li></ul><ul><ul><ul><li>Chest leads: height of T wave > 10 mm </li></ul></ul></ul><ul><ul><ul><li>Limb leads: height of T wave > 5 mm </li></ul></ul></ul><ul><li>Hypocalcemia </li></ul><ul><ul><ul><li>Prolonged QT interval, longer than ½ the RR interval </li></ul></ul></ul><ul><li>Hypercalcemia </li></ul><ul><ul><ul><li>Shortened QT interval </li></ul></ul></ul>

50.
<ul><li>Poor R wave Progression (PRWP) </li></ul><ul><ul><ul><li>Height of Rwave in V3 < 3 mm </li></ul></ul></ul><ul><ul><ul><li>Differentials </li></ul></ul></ul><ul><ul><ul><ul><li>Old anteroseptal wall MI </li></ul></ul></ul></ul><ul><ul><ul><ul><li>LVH </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Normal variant: heart rotated clockwise </li></ul></ul></ul></ul><ul><ul><ul><ul><li>LBBB </li></ul></ul></ul></ul><ul><li>Early Repolarization Changes (ERP) </li></ul><ul><ul><ul><li>V2-V4: ST segment elevation of 2-3 mm </li></ul></ul></ul><ul><ul><ul><ul><li>Normal variant, usually in males < 40y </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Differentials </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Acute anteroseptal wall MI </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Acute pericarditis </li></ul></ul></ul></ul></ul>

51.
SR, ERP

52.
SR, ERP

53.
SR, PRWP

54.
Hyperkalemia tall, peaked T waves usually >10 mm in the chest leads

55.
Hypokalemia abnormally tall U waves most prominent in V2 and V3

56.
<ul><li>Low-voltage QRS </li></ul><ul><ul><ul><li>QRS in all limb leads is < 5 mm </li></ul></ul></ul><ul><li>Artifacts </li></ul><ul><ul><ul><li>Irregular spikes or undulations on the ECG baseline not found in other segments </li></ul></ul></ul><ul><ul><ul><li>Causes </li></ul></ul></ul><ul><ul><ul><ul><li>Patient movement (shivering) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Poor electrode contact </li></ul></ul></ul></ul>

57.
Atrial Fibrillation <ul><li>Criteria </li></ul><ul><li>No P waves </li></ul><ul><li>Irregular fibrillatory waves </li></ul><ul><li>Irregularly irregular ventricular rhythm </li></ul><ul><li>Acute if < 48h </li></ul>

58.
<ul><li>Top 5 causes of AF </li></ul><ul><li>(EVICT) </li></ul><ul><li>E thanol (Holiday Heart Syndrome) </li></ul><ul><li>V alvular heart disease (MS) </li></ul><ul><li>I HD </li></ul><ul><li>C ardiomyopathy </li></ul><ul><li>T hyrotoxicosis </li></ul>

60.
AF with RVR PRWP NSSTTWC

62.
AF with MVR, RBBB

63.
AF with RVR, lateral wall ischemia

64.
AV Nodal Blocks <ul><li>First Degree AV Block </li></ul><ul><ul><ul><li>P-R interval > 0.21 sec </li></ul></ul></ul><ul><ul><ul><li>One-to-one AV conduction </li></ul></ul></ul>

65.
Sinus Bradycardia with first degree AV block

66.
AV Nodal Blocks <ul><li>Second Degree AV Block </li></ul><ul><ul><ul><li>Sinus rhythm </li></ul></ul></ul><ul><ul><ul><li>Some P waves not followed by QRS complx </li></ul></ul></ul><ul><ul><ul><ul><li>Mobitz I (Wenckebach) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increasing PR interval -> dropped beat </li></ul></ul></ul></ul></ul>

67.
<ul><ul><li>Mobitz II </li></ul></ul><ul><ul><ul><ul><li>PR interval prolonged but constant </li></ul></ul></ul></ul><ul><li>Third Degree AV Block or </li></ul><ul><li>Complete Heart Block </li></ul><ul><ul><ul><li>AV dissociation </li></ul></ul></ul><ul><ul><ul><li>P waves seen marching through the QRS </li></ul></ul></ul><ul><ul><ul><li>PP interval < RR interval </li></ul></ul></ul><ul><ul><ul><li>Idioventricular rhythm </li></ul></ul></ul>

68.
SR with 2 nd degree AV block (Wenckebach)

69.
3 rd degree AV block

70.
Intraventricular Blocks <ul><li>Complete RBBB </li></ul><ul><ul><ul><li>QRS duration ≥ 0.12 seconds </li></ul></ul></ul><ul><ul><ul><li>QRS in V1 has an rsR’ configuration or is a solitary R wave </li></ul></ul></ul>

71.
Intraventricular Blocks <ul><li>Complete LBBB </li></ul><ul><ul><ul><li>QRS duration ≥ 0.12 seconds </li></ul></ul></ul><ul><ul><ul><li>QRS is notched and splintered </li></ul></ul></ul><ul><ul><ul><li>QRS has a QS or rS deflection in V1 </li></ul></ul></ul>

72.
.

73.
SR with cRBBB

74.
ST with cRBBB

75.
V-Tach <ul><li>Criteria </li></ul><ul><li>≥ 3 consecutive QRS complexes… </li></ul><ul><ul><ul><li>of uniform configuration </li></ul></ul></ul><ul><ul><ul><li>of ventricular origin </li></ul></ul></ul><ul><ul><ul><li>> 100 bpm </li></ul></ul></ul>

76.
<ul><li>Monomorphic </li></ul><ul><li>Sustained VT: </li></ul><ul><ul><li>> 30 s </li></ul></ul><ul><ul><li>Hemodynamic compromise </li></ul></ul><ul><ul><li>Requires intervention for termination </li></ul></ul><ul><li>Non-sustained </li></ul>V-Tach Morphology

77.
<ul><li>Polymorphic </li></ul><ul><li>beat to beat variation in QRS complexes </li></ul>V-Tach Morphology

78.
SupraV Tach <ul><li>Criteria </li></ul><ul><li>regular succession of QRS complexes with normal duration and configuration </li></ul><ul><li>rate 150 – 250 bpm </li></ul><ul><li>P waves not identifiable (superimposed on QRS) or preceed / succeed the QRS complex </li></ul>

81.
Sinus Rhythm

82.
Second-degree AV block, type II

83.
Third Degree AV Block

84.
Acute Inferior Wall MI

85.
AF with RVR

86.
AF with SVR

87.
Anteroseptal Wall MI

88.
Atrial Flutter with 2:1 conduction

89.
Digoxin Effect

90.
ERP

91.
First-Degree AV block, SB

92.
Frequent PVCs in Bigeminy

93.
Hyperkalemia

94.
Left Bundle Branch Block

95.
Right Bundle Branch Block

96.
SVT

97.
Ventricular Fibrillation

98.
Ventricular Tachycardia

99.
Ventricular Tachycardia

100.
WPW Syndrome

102.
SR LAE LVH with strain Pattern ERP vs Acute injury pattern in the anteroseptal wall

103.
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

104.
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

105.
Atrial flutter/atrial fibrillation with NSSTTWC

106.
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