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# Systematic ECG Interpretation

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Systematic ECG Interpretation

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### Systematic ECG Interpretation

1. 1. ECG: Systematic Analysis Dr Nola McPherson CME SCGH 2014
2. 2. ECG Interpretation Overview 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment 5. Q Waves, R waves 6. QRS complex 7. ST segment 8. T wave 9. U wave 10. QT interval
3. 3. ECG Interpretation Overview 11. Additional waves (D O E) 12. Chamber hypertrophy 13. Other - T oxicology - I schaemia - E lectrolytes - sudden death ECG Q B R A D W H - dextrocardia - lead reversals - artefacts - pacing spikes
4. 4. Putting it all together… Diagnosis Differential diagnoses Life threats
5. 5. ECG Interpretation Template 1. ECG type & recording
6. 6. ECG TYPE & RECORDING  12 lead vs rhythm strip  Paper rate (N= 25mm/s)  Calibration (5mm wide, 10mm high = 1mV)  Unusual leads - right - posterior
7. 7. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis
8. 8. Rate, Rhythm, Axis RATE Normal 60-100/min (tachy/bradycardia) Method: 300/RR(large squares) OR 1500/RR(small squares) OR number of QRS x 6 (if 25mm/s) RHYTHM Pattern: regular or irregular (reg irreg or irreg irreg) 7 STEP APPROACH
9. 9. Rate, Rhythm, Axis AXIS Normal (-30 to +90) RAD LAD NW axis
10. 10. NORMAL SINUS RHYTHM 12 Lead ECG
11. 11. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave
12. 12. P Wave  ?present or absent  Amplitude & duration (LAE/RAE/BAE) <2.5mm amp limb leads, <1.5mm amp chest leads <3mm duration  Contour monophasic lead II, biphasic lead V1 inverted aVR, upright I, II, V2-6
13. 13. Left Atrial Enlargement
14. 14. Left Atrial Enlargement
15. 15. Right Atrial Enlargement
16. 16. Right Atrial Enlargement
17. 17. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment
18. 18. PR Interval  Duration (N= 120-200ms) Short (<120ms) 1. Preexcitation Syndrome eg WPW, Lown - Ganong- Levine (LGL) 2. AV (nodal) junctional Rhythm Long (>200ms) 1. 1 HB (alone or with other blocks) Varying (blocks)
19. 19. Short PR Interval - WPW  Short PR interval (<120ms)  Prolonged QRS (>110ms) + early slurred upstroke (delta wave)  Dominant R in V1-3  ST seg & T wave discordant changes
20. 20. Short PR Interval - LGL
21. 21. Short PR – AV (nodal) Junctional Rhythm
22. 22. Long PR Interval
23. 23. PR Segment  Elevation or Depression 1. pericarditis 2. atrial ischaemia - Liu’s Criteria
24. 24. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment 5. Q Waves, R waves
25. 25. Q waves  NORMAL <1mm wide, <2mm deep  PATHOLOGICAL Criteria: - >40ms (>1mm wide) - > 2mm deep - >25% depth of QRS complex - seen in lead V1- V3 DDX: 1. Myocardial infarction 2. Cardiomyopathies Hypertrophic Infiltrative disease
26. 26. Pathological Q Waves
27. 27. R waves  NORMAL Transition point V3-V4  ABNORMAL Dominant R wave in aVR Dominant R wave in V1 Poor R wave progression (Ht ≤ 3 mm in V3)
28. 28. Dominant R Wave in aVR CAUSES 1. Poisoning with Na channel blocking medications (Criteria: R wave height > 3 mm, R/S ratio > 0.7) 2. Dextrocardia 3. Incorrect lead placement (L & R arms reversed)
29. 29. Dominant R Wave in V1 CAUSES 1. RVH (PE, L to R shunt) 2. RBBB 3. POSTERIOR MI (+ STE in leads V7,8,9) 4. WPW TYPE A 5. Hypertrophic Cardiomyopathy 6. Dextrocardia 7. Normal in children and young adults
30. 30. Poor R Wave Progression CAUSES 1. Prior anteroseptal infarction 2. LVH 3. Dilated cardiomyopathy 4. Transpositioin of leads V1 & V3 5. May be normal
31. 31. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment 5. Q Waves, R waves 6. QRS complex
32. 32. QRS Complex  Duration N = 70-100ms narrow (Supraventricular) wide (ventricular or SVT with aberrant conduction)  Amplitude High voltage eg LVH Low voltage Alternans eg pericardial effusion  Morphology Notched RBBB LBBB  Spot Diagnoses Brugada Syndrome WPW Syndrome (delta waves) Tricyclic poisoning (wide QRS + dom R in aVR
33. 33. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment 5. Q Waves, R waves 6. QRS complex 7. ST segment
34. 34. ST Segment  Displacement Elevation Depression  ST Depression Morphology Horizontal Up sloping Down sloping
35. 35. ST Segment Elevation
36. 36. ST Segment Depression
37. 37. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment 5. Q Waves, R waves 6. QRS complex 7. ST segment 8. T wave
38. 38. T Wave Normal = < 5mm height in limb leads = < 15mm height in precordial leads = < 2/3 R
39. 39. T Wave Amplitude & Morphology Peaked eg hyperkalaemia Flat eg myocardial ischaemia, hypoK Hyperacute eg early STEM, Prinzmetal angina Inverted eg ischaemia & infarction, increased ICP Biphasic eg Myocardial ischaemia, hypoK, Wellens
40. 40. T Wave Morphology
41. 41. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment 5. Q Waves, R waves 6. QRS complex 7. ST segment 8. T wave 9. U wave
42. 42. U Wave  Normal = 0.5 mm (max 2mm) = 10% TW (max 25% TW)  Prominent  Inverted
43. 43. U Wave  Prominent > 1-2mm or > 25% ht TW CAUSES Bradycardia HypoK HypoCa, HypoMg Hypothermia Increased ICP LVH Hypertrophic cardiomypy Digoxin  Inverted abnormal if in leads with upright T waves CAUSES Heart disease **HIGHLY SPECIFIC FOR HEART DISEASE** **Predicts >75% stenosis of LAD/LMCA and suggests LV dysfn**
44. 44. ECG Interpretation Template 1. ECG type &recording 2. Rate, Rhythm, Axis 3. P wave 4. PR interval + segment 5. Q Waves, R waves 6. QRS complex 7. ST segment 8. T wave 9. U wave 10. QT interval
45. 45. QT Interval  Normal QTc = 390-440ms M/460 ms F < ½ preceding RR inversely prop to HR Measure in lead II or V5-6 Large U waves (>1 mm) fused to T included in measurement Small, separate U waves excluded in measurement  Long (>440/460 ms)  Short (<350ms)
46. 46. QT Interval
47. 47. ECG Interpretation Template 11. Additional waves (D O E)
48. 48. Additional Waves (D O E)  Delta Wave WPW = slurred upstroke to QRS Additional Features: Short PR interval (<120ms) Broad QRS (>100ms)
49. 49. Additional Waves (D O E)  Osborn Wave (J waves) = positive deflection at J point Most prominent in precordial leads Causes Hypothermia Hyper Ca Medications Raised ICP Normal varient
50. 50. Additional Waves (D O E)  Epsilon Wave Arrythmogenic RV dysplasia (in 30% patients) = pos deflection buried in end of QRS Additional Features TWI V1-3 Prolonged S Wave upstroke V1-3
51. 51. ECG Interpretation Template 11. Additional waves (D O E) 12. Chamber hypertrophy 13. Other - T oxicology - I schaemia - E lectrolytes - sudden death ECG - dextrocardia - lead reversals - artefacts - pacing spikes
52. 52. Lethal Causes Syncope Q BRAD W H 1. QT syndrome (Long/short) 2. Brugada Syndrome 3. RV infarction 4. Arrythmogenic RV Dysplasia 5. Dilated Cardiomyopathy 6. WPW 7. Hypertrophic Cardiomyopathy