basics of ecg
TRANSCRIPT
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Basics of ECG
Dr. Sreedhar RaoMD(Rog Nidan), (Ph.D), MBA (Hospital Management)
Asst. Professor, Dept. of Rog Nidan
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Module 1 - Objectives
• Define ECG
• Describe heart anatomy and circulation
Describe the fundamentals of heart • Describe the fundamentals of heart electrophysiology
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What is ECG?
• Electrocardiogram is the physical translation of the electrical phenomena created in the heart created in the heart muscles.
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The graph paper recording produced by the machine is termed an electrocardiogram,It is usually called ECG or EKG
STANDARD CALLIBRATION
Speed = 25mm/sAmplitude = 0.1mV/mm
1mV à10mm high1 large square à 0.2s(200ms)
1 small squareà 0.04s (40ms) or 1 mV amplitude
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With ECGs we can identify
•Arrhythmias•Myocardial ischemia and infarction•Pericarditis•Pericarditis•Chamber hypertrophy•Electrolyte disturbances (i.e. hyperkalemia, hypokalemia)•Drug toxicity (i.e. digoxin and drugs which prolong the QT interval)
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THE HISTORY OF ECG MACHINE
1903
A Dutch doctor and physiologist. He invented the first practical electrocardiogram and received the Nobel Prize in Medicine in 1924 for it
Willem EinthovenNOWModern ECG machinehas evolved into compact electronic systems that often include computerized interpretation of the electrocardiogram.
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Basic Regions of the heart
This is where the blood from the
body enters
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Basic Regions of the heart
The Triscuspidvalve is a three-flap valve that
lies between the lies between the right atrium and right ventricle
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Basic Regions of the heart
This chamber empties its
content into the pulmonary artery pulmonary artery
going to the lungs.
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Basic Regions of the heart
This chamber empties its
content into the pulmonary artery pulmonary artery
going to the lungs.
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Basic Structures inside the heart
Pulmonary artery carries blood to
the lungs
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Basic Regions of the heart
Thicker heart muscles of the
left than the right ventricle due to ventricle due to
greater force needed to
circulate blood.
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Basic Regions of the heart
Pulmonary veins carries blood
back to the heart.
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Basic Structures inside the heart
Mitral Valve prevents the reflux of its
content back to content back to the left atria.
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Basic Structures inside the heart
The Aortic Valve is a 3-flap, semilunar
valve that keeps the blood from coming blood from coming
back to the ventricles at
diastole.
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Basic Regions of the heart
The blood from the lungs return to the body after
receiving oxygen receiving oxygen through here.
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Basic Structures inside the heart
The chordae tendinae is a fibrous cartilage like
tissue that controls the mechanical movement mechanical movement
of the valve.
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Basic Structures inside the heart
The papillary muscles suspends the chordae
tendinae.
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Basic Structures inside the heart
The septum divides the heart into two. The right
side receives the unoxygenated blood and unoxygenated blood and
the left side send the oxygenated blood to the
periphery.
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The Basics of Electrophysiology
In response to the stimulation to the
Vagus nerve, the SA node genertes its
own electrical conduction, conduction,
normally, 60 -100 impulses per
minute.
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The Basics of Electrophysiology
From the SA node the electrical
conduction will travel through a nodal pathway. That is Anterior, That is Anterior,
Middle, and Posterior Internodal
pathway
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The Basics of Electrophysiology
Bachmann bundle is the SA node pathway that
stimulates the left atrium.
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The Basics of Electrophysiology
The AV Node generates about 40-60
stimulations per minutes, if the SA
node fails to function.
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The Basics of Electrophysiology
The AV Bundle (also known as Bungle of His) branches into two main bundle.
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The Basics of Electrophysiology
The Left and Right Bundle Branches then attach to the
myocardial muscles through Purkinje
fibers.fibers.
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Module 2 - Objectives
• Describe how the electrophysiological
Topic: ECG Calibration, Representation,
• Describe how the electrophysiological property of the heart influences its mechanical activity.
• Describe how ECG is calibrated.
• Describe the ECG waveforms.
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Electrophysiology Property of the heartElectrical Cells – make up the
cardiac conduction system.
Properties:ü Automaticity – the ability to
spontaneously generate and discharge an electric discharge an electric impulse.
ü Excitability – the ability of the cell to respond to an electrical impulse
ü Conductivity – the ability to transmit an electrical impulse from one cell to the next.
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Electrophysiology Property of the heartMyocardial cells – make
up the muscular walls of the atrium and ventricles of the heart.
ü Contractility – the ü Contractility – the ability of the cell to shorten and lengthen its fibers.
ü Extensibility – the ability of the cell stretch
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1. Place the patient in a supine or semi-Fowler's position. If the patient cannot tolerate being flat, you can do the ECG in a more upright position.
2. Instruct the patient to place their arms down by their side and to relax their shoulders.
3. Make sure the patient's legs are uncrossed.
4. Remove any electrical devices,
HOW TO DO ELECTROCARDIOGRAPHY
4. Remove any electrical devices, such as cell phones, away from the patient as they may interfere with the machine.
5. If you're getting artifact in the limb leads, try having the patient sit on top of their hands.
6. Causes of artifact: patient movement, loose/defective electrodes/apparatus, improper grounding. An ECG with artifacts.
Patient, supine position
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The limb electrodesRA - On the right arm, avoiding thick muscleLA – On the left arm this time.RL - On the right leg, lateral calf muscle
ElectrodesUsually consist of a conducting gel, embedded in the middle of a self-adhesive pad onto which cables clip. Ten electrodes are used for a 12-lead ECG.
Placement of electrodes
RL - On the right leg, lateral calf muscleLL - On the left leg this time.-
The 6 chest electrodesV1 - Fourth intercostal space, right sternal border.V2 - Fourth intercostal space, left sternal border.V3 - Midway between V2 and V4.V4 - Fifth intercostal space, left midclavicular line.V5 - Level with V4, left anterior axillary line.V6 - Level with V4, left mid axillary line.
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PEOPLE USUALLY REFER THE ELECTRODES CABLES AS
DUDE, THAT’S CONFUSING!
LEADS should be correctlydefined as the tracingof the voltagedifference betweenthe electrodes and iswhat is actuallyproduced by the ECGrecorder.
LEADS
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SO, WHERE ARE THE
LEADS?
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LEADS I, II, III THEY ARE FORMED BY VOLTAGE TRACINGS BETWEEN THE LIMB ELECTRODES (RA, LA, RL AND LL). THESE ARE THE ONLY BIPOLAR LEADS. ALL TOGETHER THEY ARE CALLED THE LIMB LEADS OR
THE EINTHOVEN’S TRIANGLE
RA LAI
IIIII
RL LL
I
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LEADS aVR, aVL, aVFTHEY ARE ALSO DERIVED FROM THE LIMB ELECTRODES, THEY MEASURE THE ELECTRIC POTENTIAL AT ONE POINT WITH RESPECT TO A NULL POINT. THEY ARE THE AUGMENTED LIMB LEADS
RA LA
RL LL
aVR
aVF
aVL
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LEADS V1,V2,V3,V4,V5,V6THEY ARE PLACED DIRECTLY ON THE CHEST. BECAUSE OF THEIR CLOSE PROXIMITY OF THE HEART, THEY DO NOT REQUIRE AUGMENTATION. THEY ARE CALLED THE PRECORDIAL LEADS
RA LA
RL LL
V1V2
V3V4
V5V6
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These leads help to determine heart’s electrical axis. The limb leads and the augmented limb leads form the frontal plane. The precordial leads form the horizontal plane.
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Leads Anatomical representation of the heart
V1, V2, V3, V4 Anterior
I, aVL, V5, V6 left lateral
II, III, aVF inferior
aVR, V1 Right atrium
The Different Views Reflect The Angles At Which LEADS "LOOK" At The Heart And The Direction Of The Heart's Electrical Depolarization.
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• Horizontally
• One small box - 0.04 s
• One large box - 0.20 s
• Vertically
• One large box - 0.5 mV
ECG Calibration
• One large box - 0.5 mV
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ECG Calibration
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A NORMAL ECG WAVE
REMEMBER
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THE NORMAL SIZE<3 small square
< 2 small square
< 2 large square
<3-5 small square
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ECG Representation
P wave represents Atrialdepolarization
Vector is from SA node to AV node
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ECG Representation
QRS Complex
represents Ventricular depolarization
Normal
0.06 to 0.10 seconds
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ECG Representation
T wave represents Ventricular
repolarizationrepolarization
Vector is from SA node to AV node
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ECG RepresentationPR Interval
0.12 – 0.20 seconds
Time for electrical impulse takes to travel from sinus node from sinus node through the AV node and entering the ventricles
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ECG RepresentationQT Interval
0.32 – 0.40 seconds
A prolonged QT interval is a risk factor for ventrialventrialtachyarrhythmias and sudden death
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ECG RepresentationST segment represents
the early phase of ventricular
repolarization
It is IsoelectricIt is Isoelectric
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ECG Representation
Isoelectric lineIsoelectric line
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If a wavefront ofdepolarizationtravels towards thepositive electrode, a
Understanding ECG Waveform
positive electrode, apositive-goingdeflection willresult. If thewaveform travelsaway from thepositive electrode, anegative goingdeflection will beseen.
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ECG RULES• Professor Chamberlains 10 rules of normal:-
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RULE 1
PR interval should be 120 to 200 milliseconds or 3 to 5 little squares
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RULE 2
The width of the QRS complex should not exceed 110 ms, less than 3 little squares
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RULE 3
The QRS complex should be dominantly upright in leads I and II
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RULE 4
QRS and T waves tend to have the same general direction in the limb leads
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RULE 5
All waves are negative in lead aVR
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RULE 6
The R wave must grow from V1 to at least V4
The S wave must grow from V1 to at least V3
and disappear in V6
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RULE 7
The ST segment should start isoelectric
except in V1 and V2 where it may be elevated
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RULE 8
The P waves should be upright in I, II, and V2 to V6
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RULE 9
There should be no Q wave or only a small q less than 0.04 seconds in width in I, II, V2 to V6
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RULE 10
The T wave must be upright in I, II, V2 to V6
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INTERPRETATION
The More You See, The More You Know
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RateRhythm
Cardiac AxisP – wave
PR - intervalQRS Complex
The best way to interpret an ECG is to do it step-by-step
QRS ComplexST Segment
QT interval (Include T and U wave)Other ECG signs
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RATERATE
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CALCULATING RATE
300
the number of BIG SQUARE between R-R intervalRate =
As a general interpretation, look at lead II at the bottom part of the ECG strip. This lead is the rhythm strip which shows the rhythm for the whole time the ECG is recorded. Look at the number of square between one R-R interval. To calculate rate, use any of the following formulas:
1500
the number of SMALL SQUARE between R-R interval
OR
Rate =
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CALCULATING RATE
For example:
300Rate =
3
1500
15Rate =or
Rate = 100 beats per minute
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If you think that the rhythm is not regular, count the number of electrical beats in a 6-second strip and multiply that number by 10.(Note that some ECG strips have 3 seconds and 6 seconds marks) Example below:
CALCULATING RATE
1 2 3 4 5 6 7 8
= (Number of waves in 6-second strips) x 10= 8 x 10= 80 bpm
Rate
There are 8 waves in this 6-seconds strip.
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You can also count the number of beats on any one row over the ten-second strip (the whole lenght) and multiply by 6. Example:
CALCULATING RATE
= (Number of waves in 10-second strips) x 6= 13 x 6= 78 bpm
Rate
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Interpretation bpm Causes
Normal 60-99 -
Bradycardia <60 hypothermia, increased vagal tone (due to vagal stimulation or e.g. drugs), atheletes (fit people) hypothyroidism, beta blockade, marked intracranial hypertension, obstructive jaundice, and even in uraemia, structural SA node
CALCULATING RATE
and even in uraemia, structural SA node disease, or ischaemia.
Tachycardia >100 Any cause of adrenergic stimulation (including pain); thyrotoxicosis; hypovolaemia; vagolyticdrugs (e.g. atropine) anaemia, pregnancy; vasodilator drugs, including many hypotensiveagents; FEVER, myocarditis
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RHYTHMRHYTHM
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Look at p waves and their relationship to QRS complexes. Lead II is commonly usedRegular or irregular?If in doubt, use a paper strip to map out consecutive beats and see whether the rate is the same further along the ECG.Measure ventricular rhythm by measuring the R-R interval and atrial rhythm by measuring P-P interval.
RHYTHM
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RHYTHM
Normal Sinus Rhythm
ECG rhythm characterized by a usual rate of anywhere between 60-99 bpm, every P wave must be followed by a QRS and every QRS is preceded by P wave. Normal duration of PR interval is 3-5 small squares. The P wave is upright in leads I and II
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Sinus Bradycardia
RHYTHM
Rate < 60bpm, otherwise normal
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RHYTHM
Sinus Tachycardia
Rate >100bpm, otherwise, normal
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RHYTHM
Sinus pause
In disease (e.g. sick sinus syndrome) the SA node can fail in its pacing function. If failure is brief and recovery is prompt, the result is only a missed beat (sinus pause). If recovery is delayed and no other focus assumes pacing function, cardiac arrest follows.
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RHYTHM
Atrial Fibrillation
A-fib is the most common cardiac arrhythmia involving atria.Rate= ~150bpm, irregularly irregular, baseline irregularity, no visible p waves, QRS occur irregularly with its length usually < 0.12s
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RHYTHM
Atrial Flutter
Atrial Rate=~300bpm, similar to A-fib, but have flutter waves, ECG baseline adapts ‘saw-toothed’ appearance’. Occurs with atrioventricular block (fixed degree), eg: 3 flutters to 1 QRS complex:
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RHYTHM
Ventricular Fibrillation
A severely abnormal heart rhythm (arrhythmia) that can be life-threatening. Emergency- requires Basic Life SupportRate cannot be discerned, rhythm unorganized
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RHYTHM
Ventricular tachycardia
fast heart rhythm, that originates in one of the ventricles- potentially life-threatening arrhythmia because it may lead to ventricular fibrillation, asystole, and sudden death.Rate=100-250bpm
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RHYTHM
Torsades de Pointes
literally meaning twisting of points, is a distinctive form of polymorphic ventricular tachycardia characterized by a gradual change in the amplitude and twisting of the QRS complexes around the isoelectricline. Rate cannot be determined.
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RHYTHM
Supraventricular Tachycardia
SVT is any tachycardiac rhythm originating above the ventricular tissue. SVT is any tachycardiac rhythm originating above the ventricular tissue. Atrial and ventricular rate= 150-250bpmRegular rhythm, p is usually not discernable.
*Types:•Sinoatrial node reentrant tachycardia (SANRT)•Ectopic (unifocal) atrial tachycardia (EAT)•Multifocal atrial tachycardia (MAT)•A-fib or A flutter with rapid ventricular response. Without rapid ventricular response both usually not classified as SVT•AV nodal reentrant tachycardia (AVNRT)•Permanent (or persistent) junctional reciprocating tachycardia (PJRT)•AV reentrant tachycardia (AVRT)
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RHYTHM
Atrial Escape
a cardiac dysrhythmia occurring when sustained suppression of sinus impulse formation causes other atrial foci to act as cardiac pacemakers. Rate= 60-80bpm, p wave of atrial escape has abnormal axis and different from the p wave in the sinus beat. However QRS complexes look exactly the same.
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RHYTHM
Junctional Escape
Depolarization initiated in the atrioventricular junction when one or more impulses from the sinus node are ineffective or nonexistent. Rate: 40-60 bpm, Rhythm: Irregular in single junctional escape complex; regular in junctional escape rhythm, P waves: Depends on the site of the ectopic focus. They will be inverted, and may appear before or after the QRS complex, or they may be absent, hidden by the QRS. QRS is usually normal
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RHYTHM
Ventricular escape
The depolarization wave spreads slowly via abnormal pathway in the ventricular myocardium and not via the His bundle and bundle branches.
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RHYTHM
Atrial premature beat (APB)
Arises from an irritable focus in one of the atria. APB produces different looking P wave, because depolarization vector is abnormal. QRS complex has normal duration and same morphology .
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RHYTHM
Junctional Premature Beat
Arises from an irritable focus at the AV junction. The P wave associated with atrial depolarization in this instance is usually buried inside the QRS complex and not visible. If p is visible, it is -ve in lead II and +ve in lead aVR and it itmay occur before or after QRS.
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RHYTHM
Premature Ventricular Complexes (PVCs)
is a relatively common event where the heartbeat is initiated by the heart ventricles(arrow) rather than by the sinoatrial node, Rate depends on underlying rhythm and number of PVCs. Occasionally irregular rhythm, no p-wave associated with PVCs. May produce bizarre looking T wave.
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RHYTHM
Asystole
a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow.Rate, rhythm, p and QRS are absent
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RHYTHM
Pulseless Electrical Activity (PEA)
Not an actual rhythm. The absence of a palpable pulse and myocardial muscle activity with the presence of organized muscle activity (excluding VT and VF) on cardiac monitor. Pt is clinically dead.
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RHYTHM
Artificial pacemaker
Sharp, thin spike. Rate depends on pacemaker, p wave maybe absent or present Ventricular paced rhythm shows wide ventricular pacemaker spikes
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CARDIAC AXISCARDIAC AXIS
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CARDIAC AXIS
The cardiac axis refers to the general direction of the heart's depolarization wavefront(or mean electrical vector) in the frontal plane. With a healthy conducting system the cardiac axis is related to where the major muscle bulk of the heart lies.
Electrical impulse that travels towards the electrode produces an upright (positive) deflection (of the QRS complex) relative to the isoelectric baseline. One that travels away produces negative deflection. And one that travels at a right angle to the lead, produces a biphasic wave.
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CARDIAC AXIS
Axis Lead I Lead II Lead III
Normal Positive Positive Positive/Negative
Right axis deviation
Negative Positive Positive
Left axis deviation
Positive Negative Negative
To determine cardiac axis look at QRS complexes of lead , II, III.
Remember, positive(upgoing) QRS omplex means the impulse travels towards Remember, positive(upgoing) QRS omplex means the impulse travels towards the lead. Negative means moving away.
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Positive
Positive
Positive
CARDIAC AXIS
Positive
Normal Axis Deviation
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Positive
Negative
Negative
CARDIAC AXIS
Negative
Left Axis Deviation
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Negative
Positive
CARDIAC AXIS
Positive
Right Axis Deviation
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Cardiac Axis Causes
Left axis deviation Normal variation in pregnancy, obesity; Ascites, abdominal distention, tumour; left anterior hemiblock, left ventricular hypertrophy, Q Wolff-Parkinson-White syndrome, Inferior MI
CARDIAC AXIS
Right axis deviation normal finding in children and tall thin adults, chronic lung disease(COPD), left posterior hemiblock, Wolff-Parkinson-White syndrome, anterolateral MI.
North West emphysema, hyperkalaemia. lead transposition, artificial cardiac pacing, ventricular tachycardia
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P- WAVEP- WAVE
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P -WAVE
Normal P- wave3 small square wide, and 2.5 small square high.Always positive in lead I and II in NSRAlways negative in lead aVR in NSRCommonly biphasic in lead V1
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P -WAVE
P pulmonaleTall peaked P wave. Generally due to enlarged right atrium- commonly associated with congenital heart disease, tricuspid valve disease, pulmonary hypertension and diffuse lung disease.
Biphasic P waveIts terminal negative deflection more than 40 ms wide and more than 1 mm deep is an ECG sign of wide and more than 1 mm deep is an ECG sign of left atrial enlargement.
P mitraleWide P wave, often bifid, may be due to mitral stenosis or left atrial enlargement.
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PR- INTERVALPR- INTERVAL
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PR INTERVAL
NORMAL PR INTERVAL
PR-Interval 3-5 small square (120-200ms)
Long PR interval may indicate heart block
Short PR interval may disease like Wolf-Parkinson-White
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PR-INTERVAL
First degree heart block
P wave precedes QRS complex but P-R intervals prolong (>5 small squares) and remain constant from beat to beat
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Second degree heart block
1. Mobitz Type I or Wenckenbach
PR-INTERVAL
Runs in cycle, first P-R interval is often normal. With successive beat, P-R interval lengthens until there will be a P wave with no following QRS complex. The block is at AV node, often transient, maybe asymptomatic
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Second degree heart block
2. Mobitz Type 2
PR-INTERVAL
P-R interval is constant, duration is normal/prolonged. Periodically, no conduction between atria and ventricles- producing a p wave with no associated QRS complex. (blocked p wave). The block is most often below AV node, at bundle of His or BB,May progress to third degree heart block
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Third degree heart block (Complete heart block)
PR-INTERVAL
No relationship between P waves and QRS complexesAn accessory pacemaker in the lower chambers will typically activate the ventricles- escape rhythm.Atrial rate= 60-100bpm. Ventricular rate based on site of escape pacemaker. Atrial and ventricular rhythm both are regular.
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PR-INTERVAL
Wolff–Parkinson–White syndrome
Wolf Parkinson White SyndromeOne beat from a rhythm strip in V2 demonstrating characteristic findings in WPW syndrome. Note the characteristic delta wave (above the blue bar), the short PR interval (red bar) of 0.08 seconds, and the long QRS complex (green) at 0.12
Accessory pathway (Bundle of Kent)allows early activation of the ventricle(delta wave and short PR interval)
the long QRS complex (green) at 0.12 seconds
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QRS-COMPLEXQRS-COMPLEX
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QRS COMPLEX
NORMAL QRS COMPLEX
Increased amplitude indicated cardiac hypertrophy
S amplitude in V1 + R amplitude in V5 < 3.5
Q wave amplitude less than 1/3 QRS amplitude(R+S) or < 1 small square
QRS complex< 3 small square (0.06 - 0.10 sec)
Prolonged indicates hyperkalemia or bundle branch block
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QRS COMPLEX
Left Bundle Branch Block (LBBB)indirect activation causes left ventricle contracts later than the right ventricle.
Right bundle branch block (RBBB)indirect activation causes right ventricle contracts later than the left ventricle
QS or rS complex in V1 - W-shapedRsR' wave in V6- M-shaped
Terminal R wave (rSR’) in V1 - M-shapedSlurred S wave in V6 - W-shaped
Mnemonic: WILLIAM Mnemonic: MARROW
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ST- SEGMENTST- SEGMENT
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ST SEGMENT
NORMAL ST SEGMENT
ST segment < 2-3 small square (80 to 120 ms)
ST segment is isoelectric and at the same level as subsequent PR-interval
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ST SEGMENT
THERE ARE 2 TYPES OF MI
ST-ELEVATION MI (STEMI) NON ST-ELEVATION MI (NSTEMI)AND
OK, WE GONNA TALK ABOUT MYOCARDIAL INFARCTION (MI)
Flat (isoelectric) ± Same level with subsequent PR segment
Elevation or depression of ST segment by 1 mm or more, measured at J point is abnormal.J point is the point between QRS and ST segment
NORMALST SEGMENT
WE DECIDE THIS BY LOOKING AT THE ST SEGMENT IN ALL LEADS
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ST-SEGMENT
Look at ST changes, Q wave in all leads. Grouping the leads into anatomical location, we have this:
Ischaemic change can be attributed to different coronary arteries supplying the area.
Location of MI
Lead with ST changes
Affected coronary artery
Anterior V1, V2, V3, V4
LAD
Septum V1, V2 LAD
left lateral I, aVL, V5, V6
Left circumflex
Localizing MI
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6V6 circumflex
inferior II, III, aVF RCA
Right atrium aVR, V1 RCA
*Posterior Posterior chest leads
RCA
*Right ventricle
Right sided leads
RCA
*To help identify MI, right sided and posterior leads can be applied
V6
(LAD)
(RCA)
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Criteria:ST elevation in > 2 chest leads > 2mm elevationST elevation in > 2 limb leads > 1mm elevationQ wave > 0.04s (1 small square).
*Be careful of LBBBThe diagnosis of acute myocardial infarction should be made circumspectively in the presence of pre-existing LBBB. On the other hand, the appearance of new LBBB should be regarded as sign of acute MI until proven
DIAGNOSING MYOCARDIAL INFARCTION (STEMI)
should be regarded as sign of acute MI until proven otherwise
Definition of a pathologic Q waveAny Q-wave in leads V2–V3 ≥ 0.02 s or QS complex in leads V2 and V3Q-wave ≥ 0.03 s and > 0.1 mV deep or QS complex in leads I, II, aVL, aVF, or V4–V6 in any two
leads of a contiguous lead grouping (I, aVL,V6; V4–V6; II, III, and aVF)R-wave ≥ 0.04 s in V1–V2 and R/S ≥ 1 with a concordant positive T-wave in the absence of a
conduction defect.A little bit troublesome to remember? I usually take pathological Q wave as >1 small square deep
Pathologic Q waves are a sign of previous myocardial infarction.
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ST SEGMENT
ST-ELEVATION MI (STEMI)
0 HOUR
1-24H
Pronounced T Wave initiallyST elevation (convex type)
Depressed R Wave, and Pronounced T Wave. Pathological Q waves may appear within hours or may take greater than 24 hr.- indicating full-thickness MI. Q wave is pathological if it is wider than 40 ms or deeper than a third of the height of the entire QRS complex
Day 1-2
Days later
Weeks later
Exaggeration of T Wave continues for 24h.
T Wave inverts as the ST elevation begins to resolve. Persistent ST elevation is rare except in the presence of a ventricular aneurysm.
ECG returns to normal T wave, but retains pronounced Q wave. An old infarct may look like this
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>2mm
Let’s see this
ST SEGMENT
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Check again!
Yup, It’s acute anterolateral MI!
ST elevation in > 2 chest leads > 2mm
Pathological Q wave
Q wave > 0.04s (1 small square).
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How about this one?
ST SEGMENT
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Check again!
Inferior MI!
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NSTEMI is also known as subendocardial or non Q-wave MI.In a pt with Acute Coronary Syndrome (ACS) in which the ECG does not show ST elevation, NSTEMI (subendocardial MI) is suspected if
ST SEGMENT
NON ST-ELEVATION MI (NSTEMI)
•ST Depression (A)•T wave inversion with or without ST depression (B)•Q wave and ST elevation will never happen
To confirm a NSTEMI, do Troponin test:•If positive - NSTEMI•If negative – unstable angina pectoris
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ST SEGMENT
NON ST-ELEVATION MI (NSTEMI)
N-STEMI: acute coronary syndrome (with troponin increase). Arrows indicate ischemic ST segment changes. Without appropriate treatment in many cases STEMI infarction will occur.
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A ST depression is more suggestive of myocardial ischaemia than infarction
1mm ST-segment depressionSymmetrical, tall T waveLong QT- interval
MYOCARDIAL ISCHEMIA
ST SEGMENT
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ST SEGMENT
ST elevation with concave shape, mostly seen in all leads
PERICARDITIS
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ST SEGMENT
DIGOXINDown sloping ST segment depression also known as the "reverse tick" or "reverse check" sign in supratherapeutic digoxin level.
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ST SEGMENT
Now, moving to
LEFT VENTRICULARHYPERTROPHY
RIGHT VENTRICULARHYPERTROPHYAND
So, we have to start looking at the S waves and R waves
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ST SEGMENT
Left ventricular hypertrophy (LVH)
Example:
Sokolow & Lyon Criteria: S (V1) + R(V5 or V6) > 35mmCornell Criteria: S (V3) + R (aVL) > 28 mm (men) or > 20 mm (women)Others: R (aVL) > 13mm
To determine LVH, use one of the following Criteria:
S (V1) + R(V5) = 15 + 25 = 40mmS(V3) + R (aVL)= 15 + 14 =29mmR(aVL) =14 mm LVH!
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Let’s see another example of LVH
ST SEGMENT
Tall R waves in V4 and V5 with down sloping ST segment depression and T wave inversion are suggestive of left ventricular hypertrophy (LVH) with strain pattern. LVH with strain pattern usually occurs in pressure overload of the left ventricle as in systemic hypertension or aortic stenosis.
LVH strain pattern
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ST SEGMENT
Right ventricular hypertrophy (RVH)
Example:
Right axis deviation (QRS axis >100o)V1(R>S), V6 (S>R)
Right ventricular strain T wave inversion
So, it’s RVH!
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LVH RVH
Hypertension (most common cause)Aortic stenosisAortic regurgitation
Pulmonary hypertensionTetralogy of FallotPulmonary valve stenosis
ST SEGMENT
Common Causes of LVH and RVH
Aortic regurgitationMitral regurgitationCoarctation of the aortaHypertrophic cardiomyopathy
Pulmonary valve stenosisVentricular septal defect (VSD)High altitudeCardiac fibrosisCOPDAthletic heart syndrome
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QT- INTERVALQT- INTERVAL
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QT interval decreases when heart rate increases.A general guide to the upper limit of QT interval. For HR = 70 bpm, QT<0.40 sec.
•For every 10 bpm increase above 70 subtract 0.02s.•For every 10 bpm decrease below 70 add 0.02 s
As a general guide the QT interval should be 0.35- 0.45 s,(<2 large square) and should not be more than half of the interval between adjacent R waves (R-R interval)
QT- INTERVAL
:
< 2 large square
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Calculation of QT interval
1.Use lead II. Use lead V5 alternatively if lead II cannot be read.2.Draw a line through the baseline (preferably the PR segment)3.Draw a tangent against the steepest part of the end of the T wave. If the T wave has two positive deflections, the taller deflection should be chosen. If the T wave is biphasic, the end of the taller deflection should be chosen.4.The QT interval starts at the beginning of the QRS interval and ends where the tangent and baseline cross.5.If the QRS duration exceeds 120ms the amount surpassing ,120ms should be deducted from the QT interval (i.e. QT=QT-(QRS width-120ms) )
To calculate the heart rate-corrected QT interval QTc. Bazett's formula is used
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QT = 0.04 x 10 small square= 0.4s
RR = 0.04 x 18 small square= 0.72s 18 small square
If abnormally prolonged or shortened, there is a risk of developing ventricular arrhythmias
The QT interval is prolonged in congenital long QT syndrome, but QT prolongation can also occur as a consequence of
•Medication (anti-arrhythmics, tricyclic antidepressants, phenothiazedes)•Electrolyte imbalances•Ischemia.
QT prolongation is often treated with beta blockers.
10 small square
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LQT is a rare inborn heart condition in which repolarization of the heart is delayed following a heartbeat. Example: Jervell and Lange-Nielsen Syndrome or Romano-Ward Syndrome
LONG QT SYNDROME
T-WAVE
Normal T waveAsymmetrical, the first half having more gradual slope than the second half>1/8 and < 2/3 of the amplitude of corresponding R waveAmplitude rarely exceeds 10mmAbnormal T waves are symmetrical, tall, peaked, biphasic, or inverted.
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U-WAVE
The U wave is a wave on an electrocardiogram that is not always seen. It is typically small, and, by definition, follows the T wave. U waves are thought to represent repolarization of the papillary muscles or Purkinje fibers
Normal U waves are small, round and symmetrical and positive in lead II. It is the same direction as T wave in that lead.
Prominent U waves are most often seen in hypokalemia, but may be present in hypercalcemia, thyrotoxicosis, or exposure to digitalis,epinephrine, and Class 1A and 3 antiarrhythmics, as well as in congenital long QT syndrome, and in the setting of intracranial hemorrhage.An inverted U wave may represent myocardial ischemia or left ventricular volume overload
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OTHER ECG SIGNSOTHER ECG SIGNS
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Narrow and tall peaked T wave (A) is an early signPR interval becomes longerP wave loses its amplitude and may disappearQRS complex widens (B)When hyperkalemia is very severe, the widened QRS complexes merge with their
HYPERKALAEMIA
When hyperkalemia is very severe, the widened QRS complexes merge with their corresponding T waves and the resultant ECG looks like a series of sine waves (C).If untreated, the heart arrests in asystole
T wave becomes flattened together with appearance of a prominent U wave.The ST segment may become depressed and the T wave inverted.these additional changes are not related to the degree of hypokalemia.
HYPOKALAEMIA
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Usually, signs are not obviousHypercalcemia is associated with short QT interval (A) and
HYPERCALCEMIA/HYPOCALCEMIA
Hypercalcemia is associated with short QT interval (A) and Hypocalcemia with long QT interval (B).Interval shortening or lengthening is mainly in the ST segment.
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PULMONARY EMBOLISM
Tachycardia and incomplete RBBB differentiated PE from no PE.SIQIIITIII = deep S wave in lead I, pathological Q wave in lead III, and inverted T wave in lead III.The ECG is often abnormal in PE, but findings are not sensitive, not specificAny cause of acute cor pulmonale can cause the S1Q3T3 finding on the ECG.
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