systematic ecg interpretation

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ECG: Systematic Analysis Dr Nola McPherson CME SCGH 2014

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Systematic ECG Interpretation

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Page 1: Systematic ECG Interpretation

ECG: Systematic Analysis

Dr Nola McPherson CME SCGH 2014

Page 2: Systematic ECG Interpretation

ECG Interpretation Overview

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

5. Q Waves, R waves

6. QRS complex

7. ST segment

8. T wave

9. U wave

10. QT interval

Page 3: Systematic ECG Interpretation

ECG Interpretation Overview

11.Additional waves (D O E)

12.Chamber hypertrophy

13.Other

- T oxicology

- I schaemia

- E lectrolytes

- sudden death ECG

Q B R A D W H

- dextrocardia

- lead reversals

- artefacts

- pacing spikes

Page 4: Systematic ECG Interpretation

Putting it all together…Diagnosis

Differential diagnoses

Life threats

Page 5: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type & recording

Page 6: Systematic ECG Interpretation

ECG TYPE & RECORDING 12 lead vs rhythm strip

Paper rate (N= 25mm/s)

Calibration (5mm wide, 10mm high = 1mV)

Unusual leads

- right

- posterior

Page 7: Systematic ECG Interpretation
Page 8: Systematic ECG Interpretation
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Page 11: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

Page 12: Systematic ECG Interpretation

Rate, Rhythm, AxisRATE

Normal 60-100/min (tachy/bradycardia)

Method: 300/RR(large squares)

OR 1500/RR(small squares)

OR number of QRS x 6 (if 25mm/s)

RHYTHM

Pattern: regular or irregular (reg irreg or irreg irreg)

7 STEP APPROACH

Page 13: Systematic ECG Interpretation

Rate, Rhythm, AxisAXIS

Normal (-30 to +90)

RAD

LAD

NW axis

Page 14: Systematic ECG Interpretation

NORMAL SINUS RHYTHM 12 Lead ECG

Page 15: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

Page 16: Systematic ECG Interpretation

P Wave?present or absent

Amplitude & duration (LAE/RAE/BAE)

<2.5mm amp limb leads, <1.5mm amp chest leads

<3mm duration

Contour monophasic lead II, biphasic lead V1

inverted aVR, upright I, II, V2-6

Page 17: Systematic ECG Interpretation

Left Atrial Enlargement

Page 18: Systematic ECG Interpretation

Left Atrial Enlargement

Page 19: Systematic ECG Interpretation

Right Atrial Enlargement

Page 20: Systematic ECG Interpretation

Right Atrial Enlargement

Page 21: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

Page 22: Systematic ECG Interpretation

PR Interval Duration (N= 120-200ms)

Short (<120ms)

1. Preexcitation Syndrome

eg WPW, Lown - Ganong- Levine (LGL)

2. AV (nodal) junctional Rhythm

Long (>200ms)

1. 1 HB (alone or with other blocks)

Varying (blocks)

Page 23: Systematic ECG Interpretation

Short PR Interval - WPW

Short PR interval (<120ms)

Prolonged QRS (>110ms) + early slurred upstroke (delta wave)

Dominant R in V1-3

ST seg & T wave discordant changes

Page 24: Systematic ECG Interpretation

Short PR Interval - LGL

Page 25: Systematic ECG Interpretation

Short PR – AV (nodal) Junctional Rhythm

Page 26: Systematic ECG Interpretation

Long PR Interval

Page 27: Systematic ECG Interpretation

PR Segment Elevation or Depression

1. pericarditis

2. atrial ischaemia

- Liu’s Criteria

Page 28: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

5. Q Waves, R waves

Page 29: Systematic ECG Interpretation

Q waves NORMAL

<1mm wide, <2mm deep

PATHOLOGICAL

Criteria:

- >40ms (>1mm wide)

- > 2mm deep

- >25% depth of QRS complex

- seen in lead V1- V3

DDX:

1. Myocardial infarction

2. Cardiomyopathies

Hypertrophic

Infiltrative disease

Page 30: Systematic ECG Interpretation

Pathological Q Waves

Page 31: Systematic ECG Interpretation

R wavesNORMAL

Transition point V3-V4

ABNORMAL

Dominant R wave in aVR

Dominant R wave in V1

Poor R wave progression (Ht ≤ 3 mm in V3)

Page 32: Systematic ECG Interpretation

Dominant R Wave in aVRCAUSES

1. Poisoning with Na channel blocking medications

(Criteria: R wave height > 3 mm, R/S ratio > 0.7)

2. Dextrocardia

3. Incorrect lead placement (L & R arms reversed)

Page 33: Systematic ECG Interpretation

Dominant R Wave in V1CAUSES

1. RVH (PE, L to R shunt)

2. RBBB

3. POSTERIOR MI (+ STE in leads V7,8,9)

4. WPW TYPE A

5. Hypertrophic Cardiomyopathy

6. Dextrocardia

7. Normal in children and young adults

Page 34: Systematic ECG Interpretation
Page 35: Systematic ECG Interpretation

Poor R Wave ProgressionCAUSES

1. Prior anteroseptal infarction

2. LVH

3. Dilated cardiomyopathy

4. Transpositioin of leads V1 & V3

5. May be normal

Page 36: Systematic ECG Interpretation
Page 37: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

5. Q Waves, R waves

6. QRS complex

Page 38: Systematic ECG Interpretation

QRS Complex Duration

N = 70-100ms

narrow (Supraventricular)

wide (ventricular or SVT with aberrant

conduction)

Amplitude

High voltage eg LVH

Low voltage

Alternans eg pericardial effusion

Morphology

Notched

RBBB

LBBB

Spot Diagnoses

Brugada Syndrome

WPW Syndrome (delta waves)

Tricyclic poisoning (wide QRS + dom R in aVR

Page 39: Systematic ECG Interpretation
Page 40: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

5. Q Waves, R waves

6. QRS complex

7. ST segment

Page 41: Systematic ECG Interpretation

ST Segment Displacement

Elevation

Depression

ST Depression Morphology

Horizontal

Up sloping

Down sloping

Page 42: Systematic ECG Interpretation

ST Segment Elevation

Page 43: Systematic ECG Interpretation

ST Segment Depression

Page 44: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

5. Q Waves, R waves

6. QRS complex

7. ST segment

8. T wave

Page 45: Systematic ECG Interpretation

T WaveNormal

= < 5mm height in limb leads = < 15mm height in precordial leads = < 2/3 R

= <15 mm ht in precordial leads = < 2/3 R

Page 46: Systematic ECG Interpretation

T Wave Amplitude & Morphology

Peaked eg hyperkalaemia

Flat eg myocardial ischaemia, hypoK

Hyperacute eg early STEM, Prinzmetal angina

Inverted eg ischaemia & infarction, increased ICP

Biphasic eg Myocardial ischaemia, hypoK, Wellens

Page 47: Systematic ECG Interpretation

T Wave Morphology

Page 48: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

5. Q Waves, R waves

6. QRS complex

7. ST segment

8. T wave

9. U wave

Page 49: Systematic ECG Interpretation

U Wave Normal

= 0.5 mm (max 2mm)

= 10% TW (max 25% TW)

Prominent

Inverted

Page 50: Systematic ECG Interpretation

U Wave Prominent

> 1-2mm or > 25% ht TW

CAUSES

Bradycardia

HypoK

HypoCa, HypoMg

Hypothermia

Increased ICP

LVH

Hypertrophic cardiomypy

Digoxin

Inverted

abnormal if in leads with upright T waves

CAUSES

Heart disease

**HIGHLY SPECIFIC FOR HEART DISEASE**

**Predicts >75% stenosis of LAD/LMCA and suggests LV dysfn**

Page 51: Systematic ECG Interpretation

ECG Interpretation Template

1. ECG type &recording

2. Rate, Rhythm, Axis

3. P wave

4. PR interval + segment

5. Q Waves, R waves

6. QRS complex

7. ST segment

8. T wave

9. U wave

10. QT interval

Page 52: Systematic ECG Interpretation

QT Interval Normal QTc

= 390-440ms M/460 ms F

< ½ preceding RR

inversely prop to HR

Measure in lead II or V5-6

Large U waves (>1 mm) fused to T included in measurement

Small, separate U waves excluded in measurement

Long (>440/460 ms)

Short (<350ms)

Page 53: Systematic ECG Interpretation

QT Interval

Page 54: Systematic ECG Interpretation

ECG Interpretation Template

11. Additional waves (D O E)

Page 55: Systematic ECG Interpretation

Additional Waves (D O E) Delta Wave

WPW

= slurred upstroke to QRS

Additional Features:

Short PR interval (<120ms)

Broad QRS (>100ms)

Page 56: Systematic ECG Interpretation

Additional Waves (D O E) Osborn Wave (J waves)

= positive deflection at J point

Most prominent in precordial leads

Causes

Hypothermia

Hyper Ca

Medications

Raised ICP

Normal varient

Page 57: Systematic ECG Interpretation

Additional Waves (D O E) Epsilon Wave

Arrythmogenic RV dysplasia (in 30% patients)

= pos deflection buried in end of QRS

Additional Features

TWI V1-3

Prolonged S Wave upstroke V1-3

Page 58: Systematic ECG Interpretation
Page 59: Systematic ECG Interpretation

ECG Interpretation Template

11.Additional waves (D O E)

12.Chamber hypertrophy

13. Other

- T oxicology

- I schaemia

- E lectrolytes

- sudden death ECG

- dextrocardia

- lead reversals

- artefacts

- pacing spikes

Page 60: Systematic ECG Interpretation

Lethal Causes SyncopeQ BRAD W H

1. QT syndrome (Long/short)

2. Brugada Syndrome

3. RV infarction

4. Arrythmogenic RV Dysplasia

5. Dilated Cardiomyopathy

6. WPW

7. Hypertrophic Cardiomyopathy

Page 61: Systematic ECG Interpretation

Questions & Comments

Page 62: Systematic ECG Interpretation

ReferencesLife in the Fast Lane ECG Library