The document outlines a detailed ECG analysis methodology, which includes a 7-step approach to rhythm analysis focusing on rate, morphology, and the relationship between P waves and QRS complexes. It further categorizes various types of tachycardia and bradycardia, alongside providing case studies demonstrating ECG interpretations and potential diagnoses. Additionally, it discusses the classification of syncope and the necessary guidelines for diagnosis and management as per the 2018 ESC guidelines.

1. ECG
Fakhir
SIUT
22-Jan-2020

2. Leads
• 6 Limb Lead
• 6 Chest Leads
Looking at heart from different angles.

7. Rate

9. Rythm

10. 7 step approach to ECG rhythm
analysis
1. Rate
• Tachycardia or bradycardia?
• Normal rate is 60-100/min.
2. Pattern of QRS complexes
• Regular or irregular?
• If irregular is it regularly irregular or irregularly
irregular?

11. 7 step approach to ECG rhythm
analysis
3. QRS morphology
• Narrow complex: sinus, atrial or junctional origin.
• Wide complex: ventricular origin, or
supraventricular with aberrant conduction.
4. P waves
• Absent: sinus arrest, atrial fibrillation
• Present: morphology and PR interval may suggest
sinus, atrial, junctional or even retrograde from
the ventricles.

12. 7 step approach to ECG rhythm
analysis
5. Relationship between P waves and QRS complexes
• AV association (may be difficult to distinguish from
isorhythmic dissociation)
• AV dissociation
– complete: atrial and ventricular activity is always
independent.
– incomplete: intermittent capture.
6. Onset and termination
• Abrupt: suggests re-entrant process.
• Gradual: suggests increased automaticity.

13. 7 step approach to ECG rhythm
analysis
7. Response to vagal manoeuvres
• Sinus tachycardia, ectopic atrial
tachydysrhythmia: gradual slowing during the
vagal manoeuvre, but resumes on cessation.
• AVNRT or AVRT: abrupt termination or no
response.
• Atrial fibrillation and atrial flutter: gradual
slowing during the manoeuvre.
• VT: no response.

14. Narrow Complex (Supraventricular)
Tachycardia
ATRIAL – REGULAR
• Sinus tachycardia
• Atrial tachycardia
• Atrial flutter
• Inappropriate sinus tachycardia
• Sinus node re-entrant tachycardia

17. ATRIAL FLUTTER

18. Narrow Complex (Supraventricular)
Tachycardia
ATRIAL – IRREGULAR
• Atrial fibrillation
• Atrial flutter with variable block
• Multifocal atrial tachycardia

19. Atrial Fibrillation

20. Multifocal atrial tachycardia

21. Narrow Complex (Supraventricular)
Tachycardia
ATRIOVENTRICULAR
• Atrioventricular re-entry tachycardia (AVRT)
• AV nodal re-entry tachycardia (AVNRT)
• Automatic junctional tachycardia

22. Broad Complex Tachycardia (BCT)
REGULAR BCT
• Ventricular tachycardia
• Antidromic atrioventricular re-entry
tachycardia (AVRT).
• Any regular supraventricular tachycardia with
aberrant conduction — e.g. due to bundle
branch block, rate-related aberrancy
All regular BCTs should be considered to be VT until
proven otherwise

23. Ventricular Tachycardia

24. Broad Complex Tachycardia (BCT)
• IRREGULAR
• Ventricular fibrillation
• Polymorphic VT
• Torsades de Pointes
• AF with Wolff-Parkinson-White syndrome
• Any irregular supraventricular tachycardia
with aberrant conduction — e.g. due to
bundle branch block, rate-related aberrancy

25. Ventricular Fibrillation

28. Polymorphic VT

29. Torsades de Pointes

30. Bradycardia
P WAVES PRESENT
1. Every P wave is followed by a QRS complex
(= sinus node dysfunction)
• Sinus bradycardia
• Sinus node exit block
• Sinus pause / arrest

31. Bradycardia
P WAVES PRESENT
2. Not every P wave is followed by a QRS complex
(= AV node dysfunction)
• AV block: 2nd degree, Mobitz I (Wenckebach)
• AV block: 2nd degree, Mobitz II (Hay)
• AV block: 2nd degree, “fixed ratio blocks” (2:1,
3:1)
• AV block: 2nd degree, “high grade AV block”
• AV block: 3rd degree (complete heart block)

32. Mobitz Type I

33. Mobitz Type II

34. 3rd Degree Heart Block

35. What is This

36. Bradycardia
• P WAVES ABSENT
• Narrow complex: Junctional escape rhythm
• Broad complex: Ventricular escape rhythm

37. Axis

38. ECG Axis Interpretation
• Normal Axis = QRS axis between -30° and +90°.
• Left Axis Deviation = QRS axis less than -30°.
• Right Axis Deviation = QRS axis greater than +90°.
• Extreme Axis Deviation = QRS axis between -90°
and 180° (AKA “Northwest Axis”)

39. Methods of ECG Axis Interpretation
There are several complementary approaches to
estimating QRS axis, which are summarized
below:
• The Quadrant Method – (Lead I and aVF)
• Three Lead analysis – (Lead I, Lead II and aVF)
• Isoelectric Lead analysis
• Super SAM the Axis Man

43. Intervels

46. Cases
Sycope

47. Case 1: 20yo previously well with half
an hour of palpitations and
presyncope, resolved

48. Case 2: 80yo recurring presyncope
while sitting

49. Case 3: 25yo with exertional syncope

50. Case 4: 70yo history of cancer,
presents with shortness of breath.
Shortly after ECG patient collapsed

51. Case 5: 70yo unwell. After ECG patient
collapsed

52. Case 6: 60yo chest pain then syncope

53. Case 7: 60yo syncope, BP 70. First ECG
then post-cardioversion ECG

54. Case 7: 60yo syncope, BP 70. First ECG
then post-cardioversion ECG

55. Syncope
The 2018 ESC guidelines for the diagnosis and
management of syncope classifies syncope as
• Reflex (vasovagal, situational or carotid sinus)
• Orthostatic (drug-induced, volume depletion
or autonomic)
• Cardiac

56. Cardiac syncope
• arrhythmia
– bradycardia: sinus or AV conduction disease
– tachycardia: supraventricular or ventricular
• structural
– tamponade
– ACS
– aortic stenosis
– hypertrophic cardiomyopathy (HCM)
– cardiac mass
– prosthetic valve dysfunction
• cardiopulmonary
– PE
– aortic dissection
– pulmonary hypertension

57. HEARTS
• Heart rate/rhythm
– tachy
– brady
• Electrical conduction
– PR long (AV block) or short+delta (WPW)
– QRS wide: BBB
– QT prolongation
• Axis
– right: PHTN, PE, LPFB
– left: LAFB

58. HEARTS
• R wave size/progression
– early R wave: RBBB, WPW type A, posterior MI, pulmonary
hypertension
– late R wave: cardiomyopathy
– high voltages: hypertrophy
– low voltages: pericardial effusion
• Tension (hypertrophy)
– aortic stenosis
– HCM
• ST/T wave changes
– inherited: ARVD, Brugada
– ischemic: ACS, PE, dissection

59. Back to the cases

60. Case 1: 20yo previously well with half
an hour of palpitations and
presyncope, resolved
HR/rhythm: NSR.
Electrical conduction: short PR with delta wave
in precordial leads.
Axis: normal.
R wave: early progression.
Tension: none.
ST/ T changes: mild anterior ST depression,
discordant to delta.
WPW. Referred for ablatation

61. Case 2: 80yo recurring presyncope
while sitting
“trifascicular block” HR/rhythm: sinus brady.
Electrical conduction: first degree AV block +
RBBB + LAFB.
Axis: left (from LAFB).
R wave: early (from RBBB)
Tension: none
ST/T wave changes: none
bifascicular block with first degree AV block.
Admitted for pacemaker

62. Case 3: 25yo with exertional syncope
HR/rhythm: borderline sinus tach
Electrical conduction: normal
Axis: normal
R wave: large voltages with deep inferolateral
Q waves
Tension: LVH
ST/T wave: no changes
POCUS: HCM

63. Case 4: 70yo history of cancer, presents with shortness
of breath. Shortly after ECG patient collapsed
HR/rhythm: sinus tach
Electrical conduction: normal
Axis: normal
R wave: small voltages
Tension: none
ST/T wave: no significance changes
POCUS: no pericardial effusion but RV>LV.
Patient arrested, achieved ROSC after tPA and
CT showed massive PE

64. Case 5: 70yo unwell. After ECG patient collapsed
HR/rhythm: NSR
Electrical conduction: RBBB
Axis: normal
R wave: normal size/progression
Tension: none
ST/T wave: V1-2 coved ST elevation
Diagnosis: Brugada. Patient had VF arrest
shortly after ECG, was cardioverted and
admitted for ICD

65. Case 6: 60yo chest pain then syncope
HR/rhytm: sinus bradycardia
Electrical conduction: normal
Axis: normal
R wave: normal size/progression
Tension: none
ST/T wave: anterior ST depression with T wave
inversion
No early R waves/right axis to suggest
pulmonary hypertension, no other features to
suggest PE.
Posterior leads showed ST elevation and cath
lab activated: occluded circumflex artery

66. Case 7: 60yo syncope, BP 70. First ECG
then post-cardioversion ECG

67. Case 7: then post-cardioversion ECG
HR/rhythm: VT cardioverted into junctional rhythm
Electrical conduction: RBBB + LAFB
Axis: left (from LAFB)
R wave: RBBB superimposed on anterior Q and delayed R
wave progression
Tension: none
ST/T wave: diffuse ST depression with reciprocal elevation in
aVR. This pattern can be seen post-cardioversion, but this
patient also had anterior Q waves and a bifasicular block

68. Shukria and JazakAllah for listening
‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬ ‫ک‬ ‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬ ‫ک‬ ‫ا‬ ‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫س‬‫ک‬ ‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬ ‫کانک‬ ‫کد‬‫تئ‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫و‬‫ک‬‫ان‬ ‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫ت‬‫س‬‫دا‬
‫ت‬‫ت‬‫ت‬ ‫ک‬ ‫ت‬‫ت‬‫ت‬ ‫ک‬ ‫تا‬‫ت‬‫ت‬ ‫کب‬ ‫ت‬‫ت‬‫ت‬ ‫ک‬ ‫تگ‬‫ت‬‫ت‬ ‫تنکای‬‫ت‬‫ت‬‫ک‬ ‫ک‬ ‫ت‬‫ت‬‫ت‬ ‫کھ‬‫ک‬ ‫ت‬‫ت‬‫ت‬ ‫تاگکب‬‫ت‬‫ت‬‫ب‬
(‫ادکآبادک‬‫ر‬‫رکم‬ ‫ج‬)