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Features of ECG Basics PDF By Dr. Anas Yasin – MD

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Dr. Anas Yasin – MD

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Basics

• ECG is a recording of electrical activity. • Records average of all electrical activity. • 12 recording leads.

• Toward lead – Positive deflection. • Away – Negative deflection.

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P wave

Atrial contraction

QRS complex

Ventricular depolarization and

contraction

T wave

Ventricular repolarization

U wave

Represents final stage of ventricular

repolarization (papillary muscle)

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ECG Leads

• I & aVL: Lateral.

• II & III & aVF: Inferior. • aVR: R.A

• V1 & V2: RV

• V3 & V4: Septum & Anterior LV • V5 & V6: Anterior & Lateral LV. • Posterior ??? & R.V

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QRS

shape

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ECG Reading 1

 Prerequisites (Practical points):

1. Electrodes are attached to correct arms.

(legs??)

2. Good electrical contact. 3. Calibration & speed rate. 4. Patient relaxed.

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ECG Reading 2

 5 Steps:

1. Rhythm / Rate.

2. Conduction interval. 3. Axis.

4. QRS >> (wide, narrow, morphology).

5. ST segment and T-wave >>>> (depression,

elevation, inversion).

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Rhythm

• Refers to part of heart which is controlling the

activation sequence.

• Normal is sinus ( there is P – wave) — SA is

the leader.

• P wave best seen on lead 2 & V1.

• No P – wave : Arrhythmia __ another story.

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Rate

 Rule of 300:

• ECG machine velocity: 25mm/s = 5 large squares/s. How many squares per min??

 Rule of 10 sec:

• Count QRS complex in 10 sec (how many

squares) then multiply by 6.

• Good for irregular heart beats.

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What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm

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What is the heart rate?

www.uptodate.com

(300 / ~ 4) = ~ 75 bpm

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What is the heart rate?

(300 / 1.5) = 200 bpm

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Conduction intervals

 PR interval : time from SA node till ventricular depolarization (Through out conduction system). (0.08 – 0.2 s) (3-5 squares).

• Short < 3: near AV or Accessory bundle • Long > 5: Block

 QRS : Time of ventricular depolarization.(0.12 s)

(3 squares).

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Cont ,,,

 QT : Time of ventricular depolarization &

repolarization.

• Varies with HR >> correction: QTc = QT/RR 1/2 • QTc is prolonged if > 440ms in men or > 460ms in

women

• QTc > 500 is associated with increased risk of

torsades de pointes

• QTc is abnormally short if < 350ms

• A useful rule of thumb is that a normal QT is less

than half the preceding RR interval

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Cardiac Axis

11 – 5 o’clock

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Right Axis deviation

 Tall thin person.

 Lung problems: PE, RVH, pneumothorax.  Posterior fascicular block.

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Left axis deviation

 Short fatty persons.  LVH

 Anterior fascicular block.  IWMI.

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Common topics

 Heart Block: 1. AV – Block

2. Bundle Block.

 Myocardial infarction.  LVH & RVH.

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1 st degree heart block

• How did you know???

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Second-Degree Heart Block: Mobitz Type I – Wenckebach

P

 Progressive lengthening of PR interval until a QRS is not conducted (ventricular contraction does not occur)

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Second-Degree Heart Block

Mobitz Type II

How did you know???

 Constant PR interval before a skipped ventricular conduction

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THIRD DEGREE AV BLOCK

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Bundle block

• RSR 1 (V1,V2) : RBBB • RSR 1 (V5,V6) : LBBB

• RBBB + LAD : Bifasicular block.

• 1 st degree + bifasicular : Trifasicular block.

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RBBB

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LBBB

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Low voltage ECG

• The amplitudes of all the QRS complexes in the limb leads are < 5 mm; or • The amplitudes of all the QRS complexes in the precordial leads are < 10

mm

• Causes:

 Pericardial effusion  Pleural effusion  Obesity

 Emphysema

 Pneumothorax

 Constrictive pericarditidis  Previous massive MI

 End-stage dilated cardiomyopathy

 Restrictive cardiomyopathy due to amyloidosis, sarcoidosis,

haemochromatosis

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Low voltage ECG

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MI – changes

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MI – Leads – vessel

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For previous ECG

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For previous ECG

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What is the DX ?

www.uptodate.com

Inferior – posterior MI

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What is the DX ?

www.uptodate.com

Anterior MI

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What is the DX ?

www.uptodate.com

LBBB

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RBBB – LAFB

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What is the DX ?

www.uptodate.com

Third Degree Heart

Block

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What is the DX ?

www.uptodate.com

Normal sinus rhythm

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What is the DX ?

www.uptodate.com

SVT

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What is the DX ?

www.uptodate.com

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• Sinus rhythm.

• Cardiac axis is normal.

• Pathologic Q waves can be seen in leads V2 and

V4.

• There are raised ST segments in leads V2-V4. • There are T wave inversion in leads V2 – V6, I &

aVL.

• This is acute anterolateral myocardial infarction.

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• Ventricular rate of approximately 175 bpm. • Broad QRS complexes. • Left axis deviation.

• This is a ventricular tachycardia.

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• Irregular ventricular contraction. • Irregular trace baseline. • Cardiac axis normal.

• Narrow QRS complexes. • This is atrial fibrillation.

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• Sinus rhythm.

• Normal conduction intervals. • Normal cardiac axis.

• There are Q waves in leads V2 to V4.

• There are inverted T waves in leads V2 to V6,

VL and I.

• This is an old anterior myocardial infarction.

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