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Electrocardiography basics 2022
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- 2. Myocardial Cell Atria :Myocardial Cells Ventricle: Myocardial cells SA Node, AV Node, Purkinjee Fibers Gap Junctions Myocardium : Na Ca K Dependent SA node & AV node : Ca Dependent Depolarization Repolarization Plateau Phase
- 3. Understanding Vector . Atria :Myocardial Cells Ventricle: Myocardial cells SA Node, AV Node, Purkinjee Fibers Positive wave towards positive charge + Negative wave towards negative charge + Depolarization -- +++ Negative wave away from positive charge Repolarization More cells: Larger vector Specialized conduction: Faster vector Direction of Vector Stimulus
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- 5. ECG Machine Ensure Earthing of machine Nowatch / Mobile / Metal on body
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- 7. Limb Leads Standard LimbLeads Augumented Limb Leads Hexa Axial System
- 8. Spatial 3D orientationof ECG
- 9. Where does ECGhelp us? Electrical Activity of Heart is graphically represented by ECG (Sophisticated Galvanometer) Atrial Enlargement Ventricular Hypertrophy Myocardial Ischemia Nonspecific ST T changes Unstable Angina / STEMI Cardiac Rhythm Abnormalities Metabolic Disturbance – Ca / K Effect of drugs – Digoxin etc ECG abnormalities : Acute Pericarditis, Cardiomyopathy, Valvular Heart Disease Pulmonary Embolism Cardiac Conduction Abnormalities
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- 11. Waveforms P wave Atrial Depolatization QRSComplex Ventricular Depolarization T wave Ventricular Repolarization U wave Significance not known
- 12. Segments & Intervals Segments Connectwaveforms Intervals = Waveforms + Segments PR Interval (0.12 to 0.2 Sec) QRS interval (<0.12 Sec) ST Segment QT interval
- 13. Waveforms (More on QRSComplex)
- 14. Reading a ECG Calibration Rate Rhythm Axis Pwave PR Interval QRS wave ST Segment T wave QTc interval
- 16. Normal Variants ofECG EARLY REPOLARIZATION SYNDROME PERSISTANT JUVENILE PATTERN
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- 18. Atrial Enlargement -Example Left Atrial Enlargement
- 19. Atrial Enlargement -Example Right Atrial Enlargement
- 20. Left Ventricular Hypertrophy ROMHILTESTES POINT CRITERIA Axis, V1, V6, Strain pattern Atria abnormality Other abnormalities SOKOLOW – LYON CRITERIA S V1 + R V5 or V6 > 35 mm ( > 3.5 mV) R wave in V5 or V6 > 26 mm (> 2.6 mV)
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- 22. Right Ventricular Hypertrophy BUTTLER– LEGGETT CRITERIA Rs Pattern in V1 SOKOLOW LYON CRITERIA R V1 + S V5 or V6 > 11 mm ( > 1.1 mV)
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- 25. Acute Coronary Syndrome STEMI STE in > 2 contiguous leads Troponin T Positive UNSTABLE ANGINA (Troponin T Normal) NON STEMI (Troponin T Positive)
- 26. ECG – ACUTESTEMI/ UNSTABLE ANGINA WAVE FORM STEMI NON STEMI AGE ACUTE SUBACUTE CHRONIC LOCALIZATION AFFECTED WALL CULPRIT VESSEL OTHER FINDINGS Pathological Q waves, Poor R wave progression Conduction Blocks Tachyarrhythmias Unexplained Heart Failure
- 27. Localization – Wall& Culprit Vessel
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- 31. Anatomical Localization Affected wallECG Lead Artery Affected SEPTAL V1 V2 LAD ANTERIOR V3 V4 LAD LATERAL V5 V6 Cx HIGH LATERAL I aVL LAD INFERIOR II III aVF RCA or Cx Anteroseptal V1 V2 V3 V4 LAD Anterolateral V3 V4 V5 V6 LAD Inferolateral II III aVF V5 V6 Cx
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- 33. Identify Arrhythmia Calibration Rate Rhythm Axis P wave PRInterval QRS wave ST Segment T wave QTc interval Rate Rhythm : Regular, occasional irregular , irregularly irregular Narrow or Broad QRS P wave morphology/ activity Establish relation with P wave and QRS complex Search for other clues : fusion beat / capture beat / Pauses Is rhythm onset abrupt or gradual
- 34. Intraventricular Conduction Abnormalities UNIFACICULAR BLOCK : Lt anterior fascicular block Lt posterior fascicular block BUNDLE BRANCH BLOCK RBBB LBBB BI FACICULAR BLOCK RBBB + Lt AF Block or Lt PF Block
- 35. LBBB / RBBB RBBBLBBB STRICT CRITERIA FOR LBBB QRS DURATION > 0.12 SEC V1 QS, Rs wave Mid QRS notching in 2 leads L1, aVL, V5, V6 CRITERIA FOR RBBB QRS DURATION > 0.12 SEC V1: R’ peak, RsR, qR wave L1 & V6: wide S wave Limit Diagnosis of LVH & STEMI Limit Diagnosis of RVH
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- 37. Ectopic Premature Atrial Ectopic JunctionalRhythm Premature Ventricular Ectopic Rate Regularity Narrow / wide QRS P wave morphology Relation of P & QRS Other Clues • 3 to 30 seconds it is Non Sustained Tachy • > 30 Sec it is Sustained Tachycardia • PB follow every alternate normal beat: Bigeminy • PB follow every second normal beat: Trigeminy Abnormal P wave Normal QRS complex Incomplete Compensatory pause Wide QRS complex Complete Compensatory pause Inverted P wave Normal QRS complex Incomplete Compensatory pause
- 38. Brady Arrhythmias FAILURE OFELECTRICAL IMPULSE GENERATION (Sinus node Dysfunction) FAILURE OF EFFECTIVE CONDUCTION ( AV Node Block) Sick Sinus Syndrome Sinus Bradycardia Inability to increase rate with increased sympathetic activity Absence of escape rhythms when sinus rate slows Tachy-brady syndrome
- 39. Tachyarrhythmias - Mechanisms INCREASED AUTOMATICITY REENTRY TRIGGERED ACTIVITY Wide Complex Tachycardia Ventricular tachycardia Other: SVT with BBB SVT with WPW syndrome (Antidromic AVRT) A fib/A flutter with variable conduction
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- 41. Narrow complex Tachycardia AtrialFlutter Atrial Fibrillation Multifocal Atrial Tachycardia Paroxysmal Supraventricular Tachycardia
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- 43. Example Rate Regularity Narrow/wide QRS P wavemorphology P wave & QRS complex relation Others PSVT
- 44. Example Rate Regularity Narrow/wide QRS P wavemorphology P wave & QRS complex relation Others AF
- 45. Example Rate Regularity Narrow/wide QRS P wavemorphology P wave & QRS complex relation Others VT
- 46. QUESTIONS? Paintings made bymy Daughter Patience + Dedication to work hard = Excellence