ECG in GP By Prof.Dr.R.R.Deshpande

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ECG PPT – Every Medical General Practitioner must Know Basics of ECG.This is important Diagnostic tool. This PPT of Prof.Dr.Deshpande will definitely built up confidence in Doctors. He has explained the importance of ECG waves, how to calculate Heart rate, how to decide right or left axis deviation, how to diagnose Heart Attack, Left & Right ventricular Hypertrophy(LVH& RVH),Bundle Branch Block(BBB) ,Electrolyte imbalance etc .Pictures are self
explanatory .Also visit www.ayurvedicfriend.com

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ECG in GP By Prof.Dr.R.R.Deshpande

  1. 1. TITLE 1. Introduction Slide Number 5 to 10 2. Electric circuit of heart 11 3. Waves of ECG 12 4. Normal ECG of chest leads 13 5. ECG of I,II,III,aVR,aVL,aVF leads 14 6. Sinus Rhythm 15 & 16 7. Sinus Bradycardia 17 & 18 8. Sinus Tachycardia 19 to 21 9. Left Axis Deviation 22 & 23 10. Right Axis Deviation 24 to 26 2
  2. 2. 11. Normal pattern of QRS complex 12. LVH 13. RVH 14. RAH 15. LAH 16. M.I 17. Angina 18. M.I 19. Stress Test 20. 1st Degree Heart block 21. Mobitz type 1 AV block 22. Mobitz type 2 AV block 27 28 to 31 32 to 34 35 to 37 38 to 40 41 to 43 44 to 47 48 to 63 64 to 66 67 to 69 70 to 72 73 to 75 3
  3. 3. 23. 3rd Degree Heart block 24. 2:1 AV Block 25. LBBB 26. RBBB 27. Hyper Ca++ 28. Hypo Ca++ 29. Hyper Kalaemia 30. Hypo Kalaemia 31. Digoxin effect 32. Dextrocardia 76 to 78 79 to 81 82 to 84 85 to 87 88 to 90 91 to 93 94 & 95 96 & 97 98 to 100 101 & 102 4
  4. 4. Important definitions 1) ECG (Electro Cardio Gram) : It is the Graphical record of Electrical Activity of Heart. 2) What are Leads? - Potentials produced in heart are conducted all over body. These potentials are picked by electrodes, amplified & recorded on paper. Electrodes are called as leads. 3) Classification of Leads : i) Bipolar or standard LeadsTwo leads are used positive & Negative electrodes. Leads – I, II, III ii) Unipolar LeadOnly one electrode is used, other is earthed. 2 Typesa)Unipolar chest Leads (V1 to V6) b)Unipolar Limb leads (aVR aVL, aVF) 5
  5. 5. ECG – Graph Measurements i) X axis - Indicates Duration or Time Dot square = 0.04 sec Big square = 0.2 sec ii) Y Axis - Indicates Intensity of contraction 1 Dot square = 0.1 mV (milli volt) 1 Big square = 0.5 mV = 5 mm 2 Big squares = 1.0 mV = 10 mm 6
  6. 6. 1) Important measurements P wave - contraction of Atria Amplitude = 0.2 mV (2dot squares) Duration = 0.08 sec (2 dot squares) (Note - In Atrial Hypertrophy P wave is either Tall or broad) 2) QRS Complex - Depolarization of both ventricles Amplitude = 1.5 – 2.5 mV (3-5 large squares) Duration = 0.08 sec (2 dot squares) (Note - In ventricular Hypertrophy QRS complexes are tall) 3) T wave - Depolarization of ventricles. Amplitude = 0.04 mV (4 dot squares) Duration = 0.24 sec (6 dot squares) (Note : In M. I. – T wave is flat or inverted.) 4) PR Interval - Indicates AV conduction time. Normal = 0.12 to 0.16 sec (3-4 dot squares) (Note - PR Interval is prolonged in AV Heart block) 7
  7. 7. Position of Chest leads (Note - Space just below the sternal angel is 2nd Intercostal space.) V1 = 4th Intercostal space, at Right sternal border. V2 = 4th Intercostal space at Left sternal border. V3 = In between V2 & V4. V4 = 5th Intercostal space, at mid clavicular line. V5 = Same horizontal level at V4 – Anterior axillary line (6th Intercostal space) V6 = Same horizontal level at V4 – mid axillary line (7th Intercostal space) 8
  8. 8. Bipolar & Unipolar leads 9
  9. 9. ECG Normal waves 10
  10. 10. 11
  11. 11. 12
  12. 12. 13
  13. 13. 14
  14. 14. Sinus Rhythm H. R = 60 – 100 / min. - P is upright in II & inverted in AVR - Every P wave is followed by QRS complex. 15
  15. 15. Sinus Rhythm - Normal cardiac Rhythm in which SA Node acts as Natural Pacemaker, discharging 60 – 100 times / min. - H.R. - 60 – 100 / min. - P is upright in II & inverted in aVR - Every P wave is followed by QRS complex. 16
  16. 16. Sinus Brady cardia H.R < 60 / min 17
  17. 17. - Sinus Bradycardia H. R. < 60/min. P is upright in II & inverted in aVR Every P wave is followed by QRS. Unusual - sinus Bradycardia < 40/min. ( Consider – Heart Block) Normal in athletes or during sleep. - Other causes – - Drugs - Digoxin, Beta blockers (Including Eye drops) IHD or M.I. Hypothyroidism. Hypothermia Electrolyte abnormalities. Obstructive Jaundice Uraemia Raised Intracranial pressure 18 Sick sinus syndrome. -
  18. 18. Sinus Tachycardia H. R > 100 / min. 19
  19. 19. Sinus Tachycardia -H. R. > 100 / min. -P upright in II & Inverted in aVR -Every P wave is followed by QRS.  Rare, that sinus Tachycardia > 180 / min. (Difficult to differentiate P wave from T waves – Rhythm can be mistaken for AV nodal Re-entry Tachycardia.)  Physiological causes: (Anything which stimulate sympathetic N. S. – Anxiety, Pain, Fever, Exercise.)  Other causes - Drugs - Adrenaline, Atropine, Salbutamol (Inhalers & Nebulizers), Caffeins & Alcohol. - IHD or Acute M. I. - Heart failure - Fluid Loss - Anemia - Hyperthyroidism. 20
  20. 20. If Appropriate Tachycardia • (Compensating for Low Bp e.g. Fluid Loss / Anemia) – • with β blockers is Dangerous. But, •If sinus Tachycardia is Inappropriate (Anxiety or Hyperthyroidism) – with β blocker is O. K. •Warning : •In sinus Tachycardia • - Never use β blocker to slow the Heart Rate unless you establish the cause. 21
  21. 21. Lt. Axis Deviation a) Left Leaves 22 b) QRS +ve in I & -ve in III
  22. 22. Lt. Axis Deviation a) Left Leaves. b) QRS +ve in I & -ve in III. Causes - Sometimes in Normal - WPW syndrome - Lt. anterior hemi block. - Ventricular tachycardia 23
  23. 23. In Right Axis Deviation I lead - R –ve III lead - R +ve Right – Reaches Nemonic a) Lt Axis deviation -LVH, LBBB, Interior wall infarct. b) Rt Axis deviation -RVH, RBBB, Anterior wall infarct. 24
  24. 24. Rt. Axis Deviation a) Right Reaches b) QRS is –ve in I & +ve in III 25
  25. 25. R.T Axis Deviation a) Right Reaches b) Observe only Lead I & III c) QRS is –ve in I & +ve in III Causes: -May occur in Normal individual -RVH -Antero lateral M.I. -Dextrocardia (Heart lies on Rt side of chest) -Lt. Posterior hemi block -W.P.W Syndrome. 26
  26. 26. Ventricular Hypertrophy 1)Normal pattern & Amplitude of QRS complexes in chest , leads. V1 = V2 V3 V4 V5 V6 Small R wave & Deep S wave When Proceeds towards V6 – Height of R wave increases & Depts., of s wave progressively decreases. R 27 V1 V2 V3 V4 V5 V6 s
  27. 27. LVH Pattern remains the same But Amplitude Increases. If , SV1 > 25mm OR (5 Big squares). RV6 > 25mm OR (5 Big squares). SV1 + RV6 > 35 - LV (7 Big squares.) Normal QRS complex = 3 to 5 large squares. QRS - 1.5 – 2.5 mV 0.08 sec - (3-5 large squares) (2dot squares) R 28 V1 V2 V3 V4 V5 V6 s
  28. 28. LVH a) R in V5 or V6 >25mm b) S in V1 or V2 >25 mm c) R + S > 35 mm 29
  29. 29. a) R in V5 or V6 > 25mm b) S in V1 or V2 > 25mm30
  30. 30. LVH -R in V5 or V6 > 25 mm. S in V1 or V2 > 25 mm. -R V5/V6 + S V1 / V2 > 35 mm This is not diagnostic Young, thin people with Normal hearts have R & S >Normal. -If LVH - Look for evidence of strain (ST depression & T Inversion) -Eco-cardiography is Diagnostic for LVH. - according to cause. Causes : - Hypertension - Aortic stenosis - Coaractation of Aorta - Hypertrophic cardiomyopathy. 31
  31. 31. RVH Prominent R wave in V1 or Deep S wave in V6 SV1 to RV6 - Normal pattern. OR RV1 > 7 mm SV6 > 7 mm = 1 Big squares + 2 dot. = 1 Big squares + 2 dot. OR RV1 + SV6 > 10 mm (2 big squares) 32
  32. 32. RVH a) Rt. Axis Deviation. (RT. Reaches – I & III) b) Deep S waves in V5 & V6 c) RBBB (Broad QRS 33 M & in V1 & W in V6)
  33. 33. RVH - Dominant R waves in V1 - V4 a) Rt Axis Deviation b) Deep ‘S’ waves in V5 & V6 c) RBBB - If strain - ST depression & T Inversion. - Causes - Pulmonary Hypertension Pulmonary stenosis - of underlying cause. - 34
  34. 34. P – Pulmonale -Rt. Atrial Enlargement - Tall P wave > 2.5 mm. (2.5 dot squares) in II, III, avF 35
  35. 35. Tall P wave > 2.5 mm. (2.5 dot squares) in II, III, avF 36
  36. 36. P Pulmonale Rt Atrial Enlargement = Tall P wave > 2.5 mm (2.5 dot squares) in II, III, avF. = Causes - RA – Enlargement - Primary Pulmonary Hypertension. Secondary Pulmonary (Chr. Bronchitis, Emphysema) Pulmonary stenosis Tricuspid stenosis. = patient’s H/O, Chest x-ray (to assess cardiac dimensions & lung fields) - Echo-cardiogram-to assess valvular disorders - Estimate pulmonary artery pressure. 37
  37. 37. P – mitrale -Lt. Atrial Enlargement - P. wide > 0.08 sec or (2 dot squares) & Bifid 38
  38. 38. P. wide > 0.08 sec or (2 dot squares) & Bifid 39
  39. 39. P-mitrale Lt. Atrial Enlargement = p wide > 0.08 sec, or > 2 dot square & Bifid - Usually Result of mitral valve disease : called as P-mitrale. -Lt. Atrial can also accompany LVH (e.g. secondary to Hypertension, Aortic valve Disease & Hypertrophic cardiomyopathy). = - As like P pulmonale. ‘P mitrale’ – does not require treatment of its own. 40
  40. 40. Myocardial Infarction 3 cardinal signs on ECG in AMI - 1)Elevation of ST segment. 2)Inverted T wave. 3)Deep & wide Q wave. 41
  41. 41. Events in chronological Order 1)on 1st day - ST elevated - with upright tall T wave - but No Q wave 2)Over Next 2 day T wave will slowly become Inverted, ST seg still raised. 3)Towards the end of 1st wk - ST seg returning to base Level, T wave deeply inverted - Q wave starts appearing. - T wave - Pointed, Inverted & symmetrical Limbs. 42
  42. 42. 4)In 3rd week - Q wave fully developed. - ST - Base - T – wave flat & Returning to Normal. 5)By the end of 3 month -St seg & T wave – Return to Normal. -Only Q wave remains permanent. (of course if size of infarct is TOO small -Q wave may disappear) -Q wave size is proportional to size of infarct. 43
  43. 43. Acute myocardial Ischemia Angina = I cry -Atherosclerotic Narrowing of coronary vessels. -Pt. is comfortable at rest but anginal pain after exertion. -After exercise, myocardium demand increases but sufficient blood flow can not occur due to, partially occluded coronary artery. -Anginal pain disappears after Rest when demand decreases. -Acute myocardial ischemia can be seen during stress test. -Positive stress test - ST Depression. 44
  44. 44. Types of ST seg Depression. 1) Horizontal or plain ST seg Depression. This signifies myocardial ischemia. 2) Upward slopping ST seg Depression. This is variant of Normal & significant only if, point Depression > 2mm 45
  45. 45. 1)Horizontality of ST seg - -ST seg – Horizontal & Isoelectric -This is early manifestation of ischemia. 2)Downward slopping of ST seg - This indicates severe Ischaemia 46
  46. 46. 1)Slaggy, concave upward ST seg- Suggestive of Ischaemia. 2)Non Acute myocardial Ischaema- Slight ST depression in V5, V6 & similar T inversion (Limb leads) OR Sometimes flattening of T wave in V5 & V6 47 (Just like strain pattern LVH)
  47. 47. Anterior M.I. = T Inversion in V1 – V4 48
  48. 48. V3 V1 V2 49
  49. 49. Anterior M.I. - Q waves in Lead V4 – V4 - T Inversion in V1 – V4 ECG recorded, 5 days after Anterior M.I. - Q waves, start to appear within few hrs of onset & in 90% cases, becomes permanent. - Of M.I. – chest pain, Nausea, Sweating. 50
  50. 50. Anterior M.I. = S T Elevation in V1 – V4 51
  51. 51. V1 V2 V3 52
  52. 52. Inferior M.I i) Q in II, III aVF ii) T Inversion in II, III, aVF 53
  53. 53. i) Q in II, III aVF ii) T Inversion in II, III, aVF 54
  54. 54. Inferior M.I. 1. Q in II, III, aVF 2.T Inversion in II, III & aVF (2 yrs. previously attack.) 55
  55. 55. Inferior M. I i) Q in II, III avF ii) ST Elevation in II, III & avF 56
  56. 56. i) Q in II, III avF ii) ST Elevation in II, III & avF 57
  57. 57. Lateral M. I. - S T Elevation in I, aVL, V4 – V6 - Hyper acute T waves in V4 & V5 58
  58. 58. i) S T Elevation in I, avL, V4 – V6 ii) Hyper acute T waves in V4 & V5 59
  59. 59. Lateral M. I. -ST elevation in I, aVL, V4-V6. -Hyper – acute T waves in Leads V4 & V5. -R in V1-V3 -ST depression in V1-V3 -Upright Tall T waves in V2 & V3 60
  60. 60. Post. M. I i) S T Depression in V1 – V3 61
  61. 61. S T Depression in V1 – V3 62
  62. 62. i) Anterior M. I. ii) Lateral M. I. - V1 to V4 - I, aVL, V5 – V6 iii) Antero Lateral - I, aVL, V1 – V6. iv) Antero-septal - V1 – V3 v) Interior M.I. - II, III, aVF vi) Infero Lateral - I, II, III aVL, aVF, V5-V6. 63
  63. 63. Exercise (stress) Test 1) ST Depression 2) Sometimes T Inversion 64
  64. 64. 1) ST Depression 2) Sometimes T Inversion 65
  65. 65. Exercise Test 1. -Most common Indicator of coronary Artery Disease. 2. J point is the Junction of S wave & ST segment. 3. Measure ST Depression, 2 dot square after J point. 4. T Inversion, may develop during exercise (as may BBB) 5. A fall in systolic pressure indicates sever coronary Disease 6. Greater the Depression - Higher probability of coronary Heart Disease. 66
  66. 66. -1st degree Heart Block. -Long PR interval. (Normal-PR) = 0.12-0.20 sec. = 3-5 dot squares.
  67. 67. (Normal-PR) = 0.12-0.20 sec. = 3-5 dot squares 68
  68. 68. 1st Degree Heart block Long PR Interval 0.12 3 small sq. Causes = = 0.2 sec 5 small sq. -IHD -Hypokalaemia (Low potassium, due to Diver tics) -Acute Rheumatic myocarditis, -Drugs (Digoxin ,B blockers, Ca+ channel blocks) Asymptomatic. No specific Rx 69
  69. 69. Mobitz Type1-AV Block =Progressive lengthening of PR interval. =Then P wave-fails to be conducted. =PR interval Resets & cycle repeats. 70
  70. 70. 71
  71. 71. Mobitz Type I - AV Block One of the types of 2nd degree Heart block – Also known as “Wenckebach phenomenon”. a) b) c) Progressive Lengthening of PR Interval Then p wave – fails to be conducted PR Interval resets 7 cycle repeats = Abnormal conducting, through AV node (during High vagal activity – some times during sleep.) = In Generalized disease of conducting tissues. = Benign form of AV block . (permanent pace maker not required) – Temporary pacing before surgery. 72
  72. 72. Mobitz Type 2-AV Block =PR Normal & constant. =Occasional P wave-fails to be conducted. 73
  73. 73. Mobitz Type II - AV Block a) PR - Normal & Constant b)Occasional P wave – fails to be conducted. = Result from abnormal conduction, below AV node (in Bundle of His) = More serious than type I = Refer to cardiologist: Pacemaker may be needed = Indications for pacing – Acute M.I or pre-operatively. 75
  74. 74. Third-degree AV block 3rd degrees Heart Block a) b) c) d) P wave (atrial) Rate = 85 / min QRS complex (ventricular) rate = 54 / min Broad QRS complexes No Relation between – P waves & QRS complexes 76
  75. 75. 77
  76. 76. 3rd degree Heart Block Complete Heart Block Complete Interruption of conduction between, Atria & ventricles & two are working Independently. - In Acute inferior M.I. - 3rd deg. AV Block – Pacing. - Acute Anterior wall M.I – 3rd degree heart Block. Indicates extensive infarct & poor prognosis. - Temporary pacing – pri-operatively - If due to 3rd degree Block Heart failure, Dizziness, fall, loss of consciousness-Permanent pacing is indicated. a) P wave (atrial) rate = 85 / min. b) QRS complex (ventricular) rate = 54 / min. c) Broad QRS complexes. d) No Relation between – P waves & QRS complexes 78
  77. 77. 2:1 AV block 2 : 1 AV Block a) Alternate P waves fail to be conducted (Alternate P waves are not followed by QRS complexes) b) AV block is a special form of 2nd degree Heart block 79
  78. 78. Non-conducted P Wave conducted P Wave 80
  79. 79. 2: 1 AV Block - Alternate P waves fail to be conducted . (Alternate P waves are not followed by QRS complexes) - AV block is a special form of 2nd degree Heart Block. 81
  80. 80. LBBB a) Broad QRS complexes. Normal – QRS < 0.12 sec QRS < 3 small square b) QRS looks like W in V1 & M in V6 (william). 82
  81. 81. QRS looks like W in V1 Q & M in V6 (william). 83
  82. 82. B.B.B LBBB a) b) Broad QRS complexes QRS morphology – as explained in Text. Normal: QRS < 0.12 sec QRS < 3.5 small squares QRS looks like W in V1 & M in V6 (William) Causes- IHD - LVH (Hypertension, aortic stenosis), - Fibrosis of conduction system. Asymptomatic & do not required right. of their own 84
  83. 83. RBBB a) Broad QRS complexes. b) QRS looks like M in V1 & W in V6 (M orro w) 85
  84. 84. QRS looks like M in V1 & W in V6 (M orro w) 86
  85. 85. RBBB a)Broad QRS complexes b)QRS morphology as explained in Text. Normal QRS < 0.12 sec. QRS < 3 dot squares. QRS Looks like ‘M’ in Lead V1 & ‘w’ in lead V6 (morrow). Causes - IHD, - Cardiomyopathy, - Atrial septal defects, - Massive pulmonary embolism. -RBBB is relatively common finding in otherwise normal hearts. -Both LBBB & RBBB are asymptomatic in themselves & do not require treatment in their own right. 87
  86. 86. Hyper Ca ++ Normal QTC = 0.35 – 0.43 sec Short QT 88
  87. 87. causes of hypercalcaemia - Hyperparathyroidism. (Primary or Tertiary) Malignancy (Myeloma) Drugs (Thiazide Diuretics, excessive vit D intake. Sarcoidosis Thyrotoxicosis. = Risk of cardiac arrest with Severe Hypercalcaemia. = Severe symptoms : - vomiting, Drowsiness & plasma Ca+ > 3.5 mmol / L Urgent Rx - I / V - 0.9 % saline (3 to 4 lit / 24 hrs) - I / V Frusemide (20-40 mg/ every 6 – 12 hrs) - Disodium pamidronate – single Infusion. Monitor Urea & Electrolytes ca+ level – Every 12 hrs 89
  88. 88. Hyper Ca+ - To calculate QT Interval is not straight forward: Duration varies with H. R. Faster H. R. - Shorter QT QTC = QT RR Normal QTC = 0.35 - 0.43 sec. = Fig. - QT = 0.26 sec. HR = 100 / min. QTC = 0.34 sec. = Sym of Hypercalcaemia. Anorexia, wt. Loss, Nausea, Vomiting, abdominal pain, constipation, polydypsia, polyuria, weakness & depression. = Prominent U wave = Confirm by Plasma ca+ Level. 90
  89. 89. Hypocalcaemia - Long QT Interval 91
  90. 90. Hypocalcaemia -Long QT Interval (0.57 s) -H. R = 51 / min. -Q TC = 0.52 sec. = C/F - Peripheral & circumoral paraesthesiae, Tetany, Fits & Psychiatric Disturbance. - Trousseaus sign : (carpal spasm, when Brachial Artery is occluded with BP cuff) - Chovosteks sign : Twitching of facial muscles, when tapping over facial Nerve. - Papilloedema 92
  91. 91. -Confirm - By plasma Ca+ level -(Not forgetting to check simultaneous Alb. level) Causes – - Hypoparathyroidism. (Following Thyroid surgery, Auto immune or Congenital) - Chr. Renal failure - Vit. D Deficiency - Drugs like calcitonin - Acute pancreatitis = Inj. Ca- Gluconate 10% - 10ml. 93
  92. 92. Hyperkalaemia = Tall Tented T waves 94
  93. 93. Hyperkalaemia = Tall ‘Tented’ T wave Hyperkalaemia also cause: -Flattening & even loss of P wave. -Lengthening of PR -Widening of QRS complex. -Arrhythmias. - Confirmed by - Elevated plasma potassium level. -Underlying cause - Renal Failure. -Complete Drug H/O is Essential in any pt. with abnormal ECG. 95
  94. 94. Hypokalaemia -Small T wave & -Prominent U wave -Changes, which may accompany Hypokalaemia: - First degree Heart Block - Depression of ST segment - Prominent U wave. = C/F - muscle weakness & cramps. = Commonest cause for hypokalaemia is Diuretics. 96
  95. 95. Hypokalaemia - Small T wave & Prominent U wave 97
  96. 96. Digoxin Effect = Reverse Tick (ST depression) 98
  97. 97. Reverse Tick (ST depression) 99
  98. 98. Digoxin Effect = “Reverse Tick” - ST depression - Reduction of T wave size shortening of QT At. Toxic level-T Inversion -Arrhythmias, Sinus Bradycardia ,Ventricular Tachycardia = Reverse Tick. 100
  99. 99. Heart Lies on Rt. side - P wave Inverted in I & Rt. Axis Deviation - Decrease in R wave height, across chest leads. 101
  100. 100. Heart lies on Rt. side -Decrease in R wave height across chest leads. -Heart lies on RT side. -P wave Inverted in I & Rt Axis Deviation. -For - Location of Apex beat, do the chest x-ray Kartagener’s syndrome: -Dextrocardia + Bronachiectasis + sinusitis. -No. specific . 102
  101. 101. 1. Introduction 5 to 10 2. Electric circuit of heart 11 3. Waves of ECG 12 4. Normal ECG of chest leads 13 5. ECG of I,II,III,aVR,aVL,aVF leads 14 6. Sinus Rhythm 15 & 16 7. Sinus Bradycardia 17 & 18 8. Sinus Tachycardia 19 to 21 9. Left Axis Deviation 22 & 23 10. Right Axis Deviation 24 to 26 103
  102. 102. 11. Normal pattern of QRS complex 12. LVH 13. RVH 14. RAH 15. LAH 16. M.I 17. Angina 18. M.I 19. Stress Test 20. 1st Degree Heart block 21. Mobitz type 1 AV block 22. Mobitz type 2 AV block 27 28 to 31 32 to 34 35 to 37 38 to 40 41 to 43 44 to 47 48 to 63 64 to 66 67 to 69 70 to 72 73 to 75 104
  103. 103. 23. 3rd Degree Heart block 24. 2:1 AV Block 25. LBBB 26. RBBB 27. Hyper Ca++ 28. Hypo Ca++ 29. Hyper Kalaemia 30. Hypo Kalaemia 31. Digoxin effect 32. Dextrocardia 76 to 78 79 to 81 82 to 84 85 to 87 88 to 90 91 to 93 94 & 95 96 & 97 98 to 100 101 & 102 105
  104. 104. 106

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