ECG

Cardiac cycle. Basic cardiac cycle (P-QRS-T) repeats itself again and again.

\4..~.. - i.S4i:'.-=t'J sec 0 0.04 sec,.--......

I .- -I- - --'--

0.20 sec S mm

1 mm ('~ --_ ..... ,. --....;

10 rnm 0.20 sec

BASIC ECG COBPLEX

EeG paper. ECG paper is a graphic divided into millimeter squares. 'lime IS

measured on the horizontal axis. Each small millimeter box equals 0.04 sec, andeach larger (5 mm) box equals 0.2 sec with a paper speed of 25 mm/ sec. the

amplitude of any wave is measured on the vertical axis in millimeters.'-; .• , .• : •••• I .: 'I: ., '" ~ 1 ~

,. •••• I' • ~... ., ., I ,.. I

" :::. j::' .: .i: "\:.' I!

Al: I: .. j::: I

. \....J.... __

I:l .: A A.:i r'. .

,, I

I ' ,~ " ,T;, ,

'p' l. ~ 'uIX' ;5-1, fI"'f'fi ~

: .. , ~"'f' -! :;'-'4! Ii I t I ! i'~' I

I j ~,- 1 •• ~ 1f·f· t

: ' ". ! 1,·\ I '; II \1,,J. I I. I , 1" 1'\" t• i" ,i I ,

-1-

, . P·R I P·R I:'. :0.16 ::;; .,. ,. 0.121

. ~_..L..__ ", 1

Measurement of tbe.P-R interval.

IH·fi IL'l TIll ,Hft ~~+.~+-tth:: :lti ::,~,~flJi; RS

IT ift I 1:; 1tl:r 1,J~.F -I. ,~j'q .c\=tt :d:;, :~:rq.j: +;: 'Ti±i:b± rt n ~~r I :i:' ';:+ iy1---hoelectnc .:_ ~: r~.T- ~. ·.ti-:1 :,tt' ~~Ir;;;-i::I ,.: i. '1: ~!.\;/it .I:.1+ .urr.: ,: :.i ilt~ 1: !'l:'i-\.. . T.-1. I~h'tt~ .:' L1t llt'f'ft-r +1-1+ -t ,. .j rrr 1'11" .;

H • iH'1 11i t- i+ I; t . .'

Positive and Negative Complexes. P Wave HereIs Positive (Upright), and T Wave Is Negative(Downwards). QRS Complex Is Biphasic(Partly Positive, Partly Negative) S-T SegmentIs Isoelectric (Neither Positive nor Negative) rfI

P wave represents atrial depolanzation. P-R mtervalrepresents time from initial stimulation of atria toinitial stimulation of ventricles. QRS representsventricular depolarization .S-T segment, T wave, andU wave are produced by ventricular repolarization,

r'" ~--~:' T:~ Jr ,1A I \ "', ~'1\.;: ~,~ j

", i I' I ,',:: ... ! I QRS

.!: QRS: ' , ,; ; I : 0,12 j ,,"

; -~;JO,08. ::~ l~. I . ~~ ...:...:....:..

Measurement of QRS width.

SoT

ST

Characteristics of normal S-T segment &Twave .. J junction, marks beginning ofS-Tsegment.

S-T segments. Top, normal S-T segment.middle, abnormal s..T elevation. Bottom.abnormal S-T depression.

, . ...I c

Standardization mark. Before taking an ECG, the machine must be calibrated so that thlistandardization mark, A, is 10 mm tall. Electrocardiographs can also be set at one- half

standardization, B, or 2 times standardization, c.

R R R

1-Jl r -/IvV Tq

0Q Sos

R RR1t R

1\, lLr --i ',•

ss s

QRS nomenclature.

Il=h

'1::'

I:

i'-r- ~!

't

Multiple chest leads give a three- dimensional VIewat cardiac electrical acnvity.

Sample ECG mounted for interpretation showing 12 standard leads.

s

NORMAL CHEST LEAD PATTERNS

A

V,, ~ I I

I ' • ,

, , .,frorl\,"on

zone

A, I.,"'trf-l,aJ\).lion

zone

c ':fl":'::-_ ... --;- •._.I -J

Transitionzone

I

-fth..,. i

I

Normally, the R wave in chest leads becomes relatively taller from lead VI to lenchest leads.

A, Normal R wave progression with transition zone in lead V3

B. Somewhat delayed R wave progression with transition zone in lead V5.

('. Early transition woe in lead \ ' These ,II"( II normal variants.

4

------------ - ~...-_._-- ----------------_ ..._-_ ... _-

Pattern of QRS in limb leads

The normal pattern (the complex ill both I, A VF) =normal axis

RIGHT AXIS DEVIATION LEFT AXIS DEVIATION

II lIi IIIII

R

s

Right axis deviation (RAD)-mean QRS

axis more positive than + lOO°--ean be deter-.mined by simple inspection of leads I, II, and III.With RAD, lead III will show an R wave tallerthan the R wave in lead II.

Left axis deviation (LAD), mean QRSaxis more negative than -30°, can also bedetermined by simple inspection of leads I, II,and 111 With LAD, lead 11 will show an rScomplex, with the S wave of greater amplitudethan the r wave.

IIRIGHT AXIS DEVIATION

III oVa oVl

r

Example of right axis deviation. Note R waves ill leads II and III, with the Rwave in lead III greater than that ill lead II.

LEFT AXIS DEVIATION

Example ofleft axis deviation. Note rs complex ill lead II.

s

__ .0-:-+--_,. __- r--.I :_.;.N_.I II:' . ,

: 11-.,. i: ~: I ; ,-~-..L_'

P wave measurements. Normal Pwave is less than 2.5 mrn tall and less than0.12 sec wide.

Tall narrow P wave indicate nghtatrial enlargement( P pulmoale pattern).

. ,

, 1--'.; 1

Note tall P waves. best seen here in leads II, ill, aVF, and V1. in patient

with nght atrial enlarqernant (P pulmonale).

LEFT ATR 1AL ENLARGEMENT (AB;-~OKMALITY)

P Mitrale Biphasic P waV$ in lead V1

•.. t·,

~~I. t~··t..l' ' ; ~;

Left atrial enlargement may produce.

A. wide, humped P waves In one or

more extremity leads (P mltrale

partern) and j or, B, Wide, bipnasrc P

WCives in lead V1.A B

Example of broad, humped P waves In pauent with left

atuat enlargement (P rnitrale pattern)

6._ ~. '· M~'~ ~ '_~·_~ ".oJ

ri

p

Example of wide, biphasrc (initiallypositive. then negative) P wave incase of left atrial enlargement.

RIGHT VENTRlCULAR HYPERTROPHY

" 'I.' .,\",:,. I;

,:' ~. " ....~"'-.... _...lit ••••

I;: l', .. ~."

.""'I"!'l ~ - --....I ; •••

. ::: :--:-. r-:-: ~.~ ... _.'I

•.• j, .'

" ".'~~

.. :":'"

."".' ./;~.. !" !..·ttn

, • Ii'

".11'; ," '.11

[I' 'I •. :w...:,t.i.; .,

~;~:::: ,~:: :::i .. ::: I'" .I;:; .: ..:::.::::'::.JI ..... ",'

I.:: '::;

:::~!!:I••• , '1"

,,, n: ::0111.1 :!::;II u: 1 : I:

Note tall R wave in lead V1 (with inverted T wave caused by rightventricular strain).Also note right axis deviation (R wave in lead III taller

than R wave in lead II). Patient had tetralogy of Fallot.

7

RIGHT VENTRICULAR HYPERTROPHY

".

RVstrain

Sometimes with RVH lead V1 shows tall R wave as part of qR

complex.

Note peaked P waves (leads II, III, and V1) because of right atrialenlargement. Also note prolonged P-R interval (O.24 sec),

indicating first-degree AV block.

8

LEFT VENTRICULAR HYPERTROPHY

II III

l! II

aV,• i

s=22mm

Ir-' 1 '

~ I I

ij ~ I.I : 1",.1: i

v,I

I!

: I. :.. '.\

I !

." II I I . !

I Iii i: I II I

Patient with severe hypertension with left ventricular hypertrophy withstrain pattern. Note tall voltage in chest leads, with strain pattern in leads I,

aVL, and V4, to V6. Also note tall voltage in lead aVL, (R = 16 mrn), Inaddition, note pattern of left atrial enlargement, with biphasic P wave in lead

VI and broad, notched P wave in lead II (P mitrale).

9

+ Questions.1. Answer these questions about the following E&G

a) What IS the approximate heart rate?

b) Is sinus rhythm present?c) Where is the transition zone in the chest leads?

d) Cite three signs of LVH. I

III

. , ..

. A :j ,.t\: ~--::,If '~f r~(,L.I 1'" 11

I • ~. t '.. . i j:, • I' . t I

i ! '

, ; ·f·I I .

• t... ..,.~'t .....~, -4-

I .1_

i tt • 1_

all. 0\1

. ..•. I j f I ; i •;.."r" . i-+-r-+-+-

.' • t· ..•. • 1 +- .. 4-- JI , ' 1.

-r"+' --+t .

v,

I' .

_+i--,'y I I

\, I

10

II

\

2. In the following ECC:a. What is the heart rate?b. Name two abnormal findings.

II

+ Answers:

1. a) About 100 beats/min.b) No. Notice retrograde P waves, positive in lead aVR and negative inlead II, owing to AVjunctional rhythm.c) Around lead V4.d) Tall voltage in chest leads (SVl + RV6> 35 mm); tall voltage inlead aVL. (R wave> 13 mm); left ventricular strain pattern in leadsI, aVL, V5, and V6.

2. a) About 75 beats/min.b) The P-R interval is prolonged (about 0.22 sec) because of first-degree AV block. Also, the P wave in lead II is abnormally wide andnotched (notice the two humps) as a result of left atrial enlargement.

I I

ECG SEQUENCE WITH ANTERIOR WALL INFARCTION

III aVo oV, oV, v, v • \I.

-h-~~ ~ ~ {'- f\-hl.f-v. .A.--r rl-J-v. Jr yvvv +vii

I-/-Jr- ~[ri+:-~,r,r_l_Sequential QRS and ST-T changes seen wit'" anterior wall infarction

Note reciprocal ST-T changes in inferior leads (11111.and AVF).

A. Acute phase' S-T elevationsand new Q waves.

B. Evolving phase: deep T wave

inversions.

C. Resolving phase.

ECG SEQUENCE WITH INFERIOR WALl INFARCTION

'" "'I,

A Acute phase S· T elevations

and new Q waves

B Evolving phase. deep T wavemversions

C Resolving phase

~ ~ +vo.L--. I

-1--1 "1--1I i

I1iII

II

Sequential QRS and 5T -T changes with infenor wall infarction Note reciprocalST-T changes in antenor leads.

\I

II\

A

c oS-T segment elevations seen with acute infarction may have variable

shapes, as shown in A to D.

II

A

'B

Chest leads from patient with acute anterior wall infarction. A, Note tallpositive T waves (hyperacute T waves) seen in leads V2 to V5 in earliestphase of infarction. B, Recorded several hours later, shows marked S-Tsegment elevation in same leads (current of injury pattern) with abnormal Qwaves in leads V1and V2.

IIII : ' I l ~ ~ I l. \ ; \ j i ; ; I. I ~..~..1

. .' I;! 1."\ r i ~ ! I J I : ! I !f,' .. I ·:1', I "I. : I:. I I :.;J~V'-r-J~l.,.A ~L.. ~. ~ i

: • I : :: :::. I j I ! ."V -,....., --~

• : ' , ;' j j . :;;oV, oV, oV,

I II'" I, I ;! 1 ~ I j \ \ :+-h II - ~ I : - 1

I ,. I t I • .·1 j 1 ' • I .,

.~. • Iii ~ u,::; A./X I :: t.A.", ~.A.1---Ji ; I : " A :, ,A :1 .1'"1 . 1 I ~~~.~-;-- ;-r-1.-\-"'l1"' l i "~lo....;---..i~

. ' ; i. I' I I I . I' i,;1 Ii,' "\ I' 'I ; i • : 'i:!,' I I' I I I l ' . I , '

. . ..• : j :. ! I '!:" j. I' .i ' I' I' ,. ~ : . " ,, I ' ~! 'I I,' . I I

V V, .. , . v,~J ~. :- : ~-l ~,'--' 1 l\ ; , I~,

I ~ ; ~ ~" I, 1 'i -;' ,_.

. : ,. -I - ,..

I : -1 _I I • I •

I I I I• r i

Hyperacute T waves with anterior wall infarction, Patient was complaining

of severe chest pain. Note very tall, hyperacute T waves in chest leads.

There is also slight S-T segment elevation in lead aVF with reciprocal S-T

depressions in leads II, III, and aVF. Note premature atrial contraction (PAC)

in lead V4.

's

III oV, aV,,- r:- .. _._-" I ,I,:' d "Ii ,

;

".' " .:....

1fT!

,il i:t iii: ":It .'

I!! :l!i

III ,Uilh: 1

••- l- T

Anterior wall infarction. Note as complexes in leads V1 and V2 indicating

anteroseptal infarction. Also note characteristic notching (arrow, V2) of QS

complex often seen with infarcts. In addition, ECG shows diffuse rscherruc

T wave inversions in leads I, aV1, and V3 toV5. indicating generalized

anterior wall ischemia.

!III

\

i\\

II!

h m• \ j I I, I -t l :t I. I I ' '1-+ . "\ + ' ..; , ' • [' : .• t ~ t I r I '1 t- -. 1 t -, 1" j" t.i- t.. ~ 1.

...", I' I' I I! -, I, L' ~ .. . "t- I - •.•.. t • " ..;, t .1'" 1 ,\ ~\~1 ~~~ .,..--~~~ q.~-rl+¥::' -r-\ ;--+-,' ri+ I • 'f' , , 1'/. , ' '(

i •. t , j I l' ~ : 1 I I ~+i -, t: ..t . . I •

; , ' I "-j t' ti-j-h- .•....ill j I If .. ' J I

, ,• -t

oV.

i •

v , v.; t- j ,. -t I--h' ,t • I" •

,'L'i-~'-.jL; ". ,··I,J··If. I ,

t l-j ..- j: : 1 • . 1 ~ I .: ""'T!--i-+ -I- ", I

", . -:).~~~.-1- I' i.: 1T: ~ i i ,-~:

I I ! t' 'Lv,~''+~: ~. : : 1 : ' t ; ~1

T t i' , -t i-j 1 1 1 1 I : ,I t-- t--, ' I 1 1 ii'. -..Jt...t ~ t ! lAL \ ,"':'1\

..:T -I iTrrrrl,·TL:''~f ! ' ,,..L L..!, , .1,_ 1-.1

Evolving anterior wall infarction. Patient sustained anterior wall infarct 1week earlier. Note abnormal Q waves (leads I, aV1, and V2, to V5) withslight S-T segment elevations and deep T wave inversions. Left axisdeviation resulting from left anterior hemi block is present as well.

14

I \I - III ~- ..,.-"

I ~ __.._--..- .- .~~ rr -=-~=-.--_.:= =:.. ~.i ~.. +.--, ..••.- .. - ... - . r-l~.. .,."" ~ I- - f--. .•. .. :~ f-- -" t-.. -i- +

I, .,--- '.. '.. -' A . IJ. I A' j:p

I ._ :"--' .... 1"""". --:d'

~,]~=~---.._'~.~;-) ~;'H~l='~+~'~.='S7U-:- ·E-;i~J~OV~I ! I ,~~OV'rl t '-i I-I I .... OV:, ..~:..,I~.. - -.,.:.~.~.++\

I f--- 't - ..-'l'- roo .. , ':1"'--'11--1_ -'-.. I --- _._....I ""'._.._.'" . i,.. -1- -t-r-i I ... - --:- ' oo. . ... _ ... oo r- .oo,-- -O-='I'r -j- ~ I

l.~~: ..'~'...---J ,,_._~,-Ji~,g f']::-'~:~lT:V1.t1: :.. ., . J, v. OO" ••• " '--1- _II' '""".V.~: .1 . ..' ::.. '-+.:: _1'_ .,.,.\~.ft-I-:- .1+-:.",' '-",,- :-n -LL.. " ,I ,. '1" ,I: - ':::: '.. •••I"" 'T:~~~~ .. i

,=~ :::1::': :,; ~ t' ~~~;t,'--.--':"l~:] --: ;I'" _.!'; .~:~ !·~S, +-1"", - -:r..,.,.·J' ,-:' 'oo' ._- - )-';ctj:-:; "',11

•••.• ,'~ ~ ,i •..uJ-"'" • :tl .... = ..01"",,:.,,1... V. ~....,..~-r~~~-+..rtf.·- .:..=-- - ~

:'I,,-:n'''''.: I!i ".,~ ["".. !

If:, =a,~t~+c-_~.:I _., I... :)*",:± ,-J \ I I -.. +- --_.-

, L_ _ .. ' ,-_.-t.--::-.t-.r-:tc:;;r..±d-=t==-

Evolving anterior wall infarction. Infarct occurred I week earlier. Note poo.·R wave progression in leads VI to V5 along wjth Q waves III leads I and aV I.T waves are slightly inverted in these leads. Right axis deviation 111 this case IS

the result ofloss of lateral wall forces, with (J waves II! I ,,' d aV I.

V'/i'-C-~ _.~_.

Ii

r".-, ~':i'\......\ I. .. 1i--j' r-r l-: '.:;A_T~,'7or.'. ,I-: ,·1, ., ,~'IIrII~:\i

L:' "('I, ,.! ,,11' I

~~., ', ...•

: \ \

" . 'Iii,I: ",_ ~71~ I

" "1\ .:: •.~,.,,Il

'r-I~ .'~:;_. j. I" •

. ' "I:" '.:

:;i tH::'~1it;:"\~ , .,1T 'I I'" .u: d .11

v.i~t!:j;1 /!\;

,'I ," -'-III ! I.;, :I '" \•. r.:r.I:

" J."

" r:.: ~, .1'1·.~·~~~

't

Ii

Ll El: j!: ,: :tr ,tT, I~!., :'1, ,;1: ,I, I 01 ',i ::71:\ I :~

:r;': ".i rm', ' 'I '" •,I··' '.

~;i ' ,!~I::\i': . ,..' ,tI "1

JI;: ! Ii:! .. I:'.\ ,': ,", :<r t •

" ' 1 I I '_"'iii

If i';Im:~." :I: ": ";'f T=,~r.-M~ ~':~ I~ •• • I .,

U~ ~~,~litJ:

Posterior infarction. Note tall R waves in VI and V2. In addition there IS

evidence of prior inferior Ml (Q waves 111 II, Ill. aVF) and probably lateralinfarction (T wave inversions 111 V4 to V6).

IS i-f J

\I II! OVa

I'

J1!u

oV ~

.II

tu

.1 ,Old inferior wall infarct. Note pronuncnt Q waves ill lonl-. II. II/, ami <1\ j. 1:',11I

patient with infarct I vear previouslv. ST-T chanaes have t"'l'llll;llh re vcrt cd 10

uurmal.

Subendocardial infarction. Patient with severe che ••, pam who subsequentlydeveloped cardiac enzyme elevations. 1\01(' marked S-T depressions best seen III chestIl'ads \'2 to \ S. Panern ., consistent with subendocardial infarction. NOlI.' prematureventricular conrractiou (1'\ C) in I"',ld I. Sligh I reciprocal S-T elevation is seen in le.ida\'R and lead III.

16

------_.----------- _._---.,' - - -"_. -- - -------------_ .._ ..------

Subendocardial infarction (ant. wall):

i i:,'- ,

>.1.

/-II ,~..

±~. H .J-

-t .,1-4. _ ..i:-t

::~.. -- ~ _;r~:j'- -r-"-----i : ::ti.J.'J

- ,-.;....;.

- . , +"-..• ,., - ..;;~ .L-•....• . .~

~I •

\j. :

V2 . V3 '14

• T wave is inverted in I, aVL, V2~ V6 •• S-T segment depressed in V3, V4 subendocardial• Finding V2~V6.

'/-':;'

11

, -_ .._. --_.-- ---------

Anterior infarction:- r--r I -!. .] rTl-','-l "Tr I "'j. I -'! ; .... \ ... i' 1 • : : ! - I

, , I : 1- . ! : i I I;! - , - I .- - :! , I I ~... ~

, 1-.-j_. !.! -, - I -: ~ -! Ii ,I·.. '

i. I. !~ Iri:..: ! J'_....:__1- ... _'1_. ILlVL '5..~

'-'.,----I . , l-, - i .

I, '

~.~

t--l -!1..1. L..-

\.i

•. 1

II III .,: .',

V1

• Elevated S·T segment is V2, V3. V4-~ transmural.• Finding in V2, V4, V5= anterior wall mfarction• Segment elevated> recent.

18

; . I--t ~. _;_L

I I LJ.I I

L

~ _ •.1..._

---_._---------_._-_ ...-- .. _ ..._-- ------,-~ _.,_._--_ ...~--.._-"-_ .. _._.~." --- ._--- - -'----'._-, _ .• --_. _. _._---

, .. """

Antero-lateral infarction with left aXISdeviation:

i~ Jilt illl l!i; ............... ,. , ~~t •• " ••• '-'t. 'JI'!i: ;~::ilil ::i: :i:~

::;; It:! "lli:I~:~: a'" l:~; ..•.•• .;."'I'I~ ~ ••••••

I ••.• ".

". :i: :!: :..•••••• '1··

!ij' ....:.i:· :::: .:::-°1' •• . ...

•• '0 ••• 1. •.,.. - ...... 1. " •.

"1: .• '::: .....:... . .. 1 ••• '.1

:,,1· .J :~ ...." r ..r+····•••·... ! ...• t •.•••.•••••.

V1

~m!q~~H~n:..'r;' P'l •••..rt: ,;:, :1;: '- .L,. 1-.. .... _,

~~'IC:: t~::!: I.. '0. :•• i. ~ ••• • • • • ~ f---

T :' I '::1FrTTT I I 1 ' ..I ii ~rI;:llt ..-. j-= :=-

~"-T _.1·_· - ~rt: '.__.:_;.._:-~-~-j--l'-" . .:.._L_, ll .:I' J I "I I I'" j....;: I;.;", ll"- -"..·t··' - .. i,~-' ..~. i"~T~ .-- ~+-'~---i' ;:...:I ,i '--~-

Vi.... '. -

: I.,'"'r'0J--, I

..l ..' _I

v

• QS Pattern inVI ~ V5 transmural infarction.• Elevated SoT segment In V3, V4=anterior wall.• Finding m VI, V5, I, and avL =anterior wall infarction.

!:fJ 'r'I'" :!!: ''''~1!;: (':: '! I "I,. ,.' , t , I

ill; ;p. ::;; :;: 'I" ~ ~ l I i: I: :,;: :':l.-+i: ' ...:.._." .::~~:~~2~,~~~~I~A

., r I'j 1 ~. .: •

::.r: .::::,:.1.,.: ': ':" ti- I (~; i .-',~:~:~::~....~!!;..~: r .' '.

';': , Wi ::1: .. .; "I::; ..•......... ;. "r" .. : 'j'~:-t: ut. ;tr :.l;t :d:;: ·11~..... :~ ••. 1':· .~.: !I II .;;

19

i,, ".

~ -.. .'--:...II...... ...._-,--IT-I

I-i i

-- f" I

't

.. ,. ,,-'

l-r-·--'. I ! I.·

I. t j

" I I, r-\ ]r

J

I...: ~!!;. ; I

~~~~;~'f':'j' .."]'r"":'~ ~ •., .,...• [1:,"i'tlr ft::! _ :..II ~"

Notice leads II, ITI, aVL =infenor leadsElevated S·T segment ::.recent transmural inferior wall infarction

J I1

.J

20

I,

- ",";; Ii!; , , I

~~!;a'f' : '1' j'r"":" t •. , "":- r-4. . rt-:' l-~ --; ,

rEr- I::;: I . l._II ~"

Notice leads II, ITI, aVL <infenor leadsElevated S-T segrnenr > recent transmural inferior wall infarction

Development of inferior infarction1,1'-1-11"I I ' I 'I ,"!

I,, I - •

I '

-~!

-1 __ j

" " ,--j!

t

-: -;-,l

I, . J

I --r----, I ! I

1_ - I ,! I i

I 1

20

I ~ Questions:

1. Answer the following questions about the ECG below:a) What is approximate heart rate?

b) Are there any 5- T segment elevations?

c) Are there any abnormal Q waves?

d) What is the diagnosis?.

,R, II

2. Answer the following questions about the ECG below:a) Is sinus rhythm present?b) What is the approximate mean QRS axis?c) Is the R wave progression In the chest leads normal?d) Are the T waves normal?e) What is the diagnosis?

I\

3. With an acute anterior wall infarction. the 5 -T segments In leadsII. m. and aVF are likely to be

4. Persistent 5- T segment elevations several weeks or more after an

infarct may be a sIgn of......... . .

5. A patient with severe chest pain shows per-sistent diffuse 5- T segmentdepressions with abnormal elevations of the ccrdrcc enzymes The mostlikely diagnosis is:

a) Prinzmetal's angina.b) Subendocardial infarctionc) Hyperacute infarction.d) Angina pectoris.

6. What ECG abnormality is shown and what symptom might thispatient have complaining about?

v. v.

: t

II

7.I I

!

;"11 ' . I

+ Answers:1. a) 100 beats/min.

b) Yes. Leads II, III, and aVF (with reciprocal S- T depressions in leadsV2 to V4, I, and aVl).

c) Yes. Best seen in leads m and aVF.d) Acute inferior wall infarction.

2. a) Yes. Positive P wave in leads II, negative in lead aVR.b) About +90°. (Between 80° and 90° is acceptable.)c) No.d) No. Note inverted T waves in leads V2 to V6, I, and aVl.e) (Evolving)anterior wall infarction.

3. Reciprocally depressed.4. Ventricular aneurysm.5. b.6. Marked S- T segment depressions. Patient ha9 severe ischemic

chest pain and had a subendocardial infarct.7. Yes. There is evidence of anterior wall infarction with loss of R wave

progression in chest leads. There is also evidence of inferior wallinfarction with large Q waves in leads III and aVF. Also note tall Rwave in lead aVl. (14 mm) with strain pattern in leads I and aVL.Patient had prior history of hypertension, producing left ventricularhypertrophy.

25

EFFECTS OF HYPERKALEMIA ON ECG

Normal

4 mEq/L 7 mEq/L

p

I J mEq/l10 mEq/t

tIi ts mfql L~LA.

12 mfq/l

Earliest change with Hyperkalaemia IS peaking ("tentmg" I of T wave. Withprogressive increases lD serum potassium (K+). there IS Widening of()RS

complex. loss of P waves. and. finally, ventricular fibrtllauon I hese changes donot necessarily occur with a specific serum K+ level. fur l'\ .tlUple .•• unit" panentsmay have a normal E.<(J with a K+ of 7 mEq/L. othe •.••111..1\ devetop ventrrcular

fibrillanon at 9 mEq/1..II III

III

\I

Note peaked T waves. Wide QRS complex,and prolonged P-R mterval. At other times,junctional rhythm IS present with no Pwaves.

HYPOKALEMIA

I II III oVa oVI oVf

I

i:!l ..': !I" :!:: ", !!;I ':11 "II 'JII :11' I, ,. ,',' " ,'I"Ii 1:1 I" I'll':11 :1:: I::: ".1 "I .." I' i\:1

" ' ,I

~ ' ! :::1 III' "I1 ; : ~

I!: \11: II: I_I "'1I' 1::\>,,1 I"

,I ' .. :1.:ji :;" : 11:::11 I i~!!;ilj I::i il!i " , .. 1111 I .• , 1111;:1: '!II i'il:' I I~ ;;;1 :! :::: :lj::111:" I: " :'1: I'" , , ,II."I I .•I" T: 1 t:i~ c~~ttn~ "! ",II \:1\ ;1 ,I il!! I ,I" I!r ;ii'ili I .. , ", " I !I I",pill II :ill '"

II :~j11 II: ' , "

",I

:1,..

" 'I" '\ I' , ,~~ ',;'\"" ~. ~" .: I", 1 In , ::::~ nn I:;: rm ,,!: :1:, ,1;1 !Il! :i l \, II: Ii;: I_

I\ .. " !1 : I I:::: ,'" ,j"!~'" : I:' !:i' Ii' I I"~ ", ::!'Ifl:11'II t:1 ~ ~ ' m' 1 I " ,;~.,ill I, i:! I I •• I :;11 ,;i; 'I', ::~: {I !h !I: ! ,I Iii: il i::: W' "Iq,' .. :r. '::, :;!qlll I l.• _I ,'I

!:II !~.: ~~I I 'I" t 11 .l.l "',1,1, ,.I •..• I" " I " ,', I" .. ,Ijr. 'I: 11 "

" I '11'1

I1;:1 :" ill ! I II: I::: : ~:! .:1: :1,: T, ~H !I:: I !I~,.1: Ii!, :::, I" iii Y 1)1, Iii; :::! li:!lIil~"," : "I ttr, ',,1"I 1 : .: ~!:j :, : ••• . • I I :' ' '. II, J • , I'. "IJ1 " .. " ,

IV,': :!:I ii: I j'!i i," •• I 'I

I

V,'1""1" ~I'fflii II II

,'~ 'I

~~ IU~*Mnl,: :,~' ,I: I I tn

~Ijl , ':I:

"."'1,1,,, rm !'mIl '/'J,'11

11':;11;"111HnI:'II':,I,1friH II

'I i I 111, I I! I: :IIWI :1/, F

I ~1:IIJ~1t;I, III , !III,I, I' :::111:' II1;, ,:. :" ,:1 .. ;,', '1,111 '1'1'1

y.I!

~I. I

I

I'm

T ,U

Normal T wov. Serum K+ was 2.2 mEq/L. Notice

prominent U waves.

Nonspecific ST·T chong os

\1

Flattening of the T wave (left and middle) or slight T wave inversion (right) areabnormal but relatively nonspecific changes that may be caused by numerous

factors.

IS-

JII III

oV oil,

"j"'"-; -' ..••~-.Jr-r 4 '.!i

II1

II

".I

1 I ; . J t--y--y-~ ~~~r-J. :.r ,/"";,- ·..J,,--~.Jr·

• •• : I t; l- 1; ~ I ~!. ' r".

I • :Jc+,Al. , , J I. " ! I ."7""r:--r- ----,-'--,- __ ".;~~i-;-II \~lt lIft-

.• ...' .••. .•. of ~ • 1, L.

Nonspecific Sl·T changes Note drrtuse I wave fldll~ rung

SubendocardialDigitalis effect Ischemia

.Jftlt~uu It It

HyperkalaemlaII ,

··u·

Acute Infarct

,. ,

Relatively specific ST-T changes. ST-T changes depicted are relatlnly butnot absolutel) specific for abnormahnes show n.

16

Calculation of heart rate

Measurement of heart rarefbeats per minute)by counting number ofiarge(0.2 secjrimeboxes between two successive QRS complexes and dividing 300 by this number. In this

example, heart rate is 300"'3 = 100 beats Imin.

IMeasurement of heart rate per minute by counting number of cardiac cycles in a 6 sec

interval and multiplying by 10. in this example, there are 10 cardiac cycles/6 sec.therefore, heart rate is lOx 10= 100 beats/mill .

•.~~

0·' •Measurement ofQ -T interval. p. Rinterval is interval between twoconsecutive QRS complexes.

(l.,

D~l. o.•..l

Abnormal Q·T prolongation. Note thatQ·T interval (0.6 sec) exceeds one- halfthe R-R interval (1/2 xO.92=O.46sec.).

it

1. Calculate the heart rate in each of the examples

2. Name the major abnormality IFIeach example.

A II

3. A block in the AV node IS most likely t.:a. Prolong the P·R .nterv .11b. Prolong the QRS widthc. Prolong the Q·I interval.d. None ot the above.

4. A block in the left or rIght oundle branch IS most likely toa Prolong tr« t f..' .nterv.ub. Prolong tne ~k~ widthc. Shorten the V- I intervat.d. None ot the above

18

5 Name the component waves of the QRS complexes shown.

1iII

A B c o

ll1-~'1:!:, ., '

_J i

.:

I

ANSWERS:

1. a, 50 beats/ nun.

b.I50 bears/nun.

c. 60 beats/ min.

d. Approximately 160 beats/min (There cW' 10 <..!RS vcle ...in o '1.'1.: )***

2. a. Abnormallv wide QRS complex (0 14 V" ,

b Abnormally long P·R tnl('fval (approx»: j~fl\ e "'. I

( Abnormally iongQ-l II It· I val «.Ff .nur v». .;'< .I:,till'~ U·1 'C:l. l'w fI I,'

Interval measures 06 sec dod the heart fall' I.'> !U\J'!JL:

d

4, bS. a. R

b.QRSL.QS

D.RSRe.QR t-

*** Notice the IrregularIty of the QRS complexes and the absence ofPwaves. The rhythm here IS ctrrcl frbrttlcnon.

19

NORMAL SINUS Rh 1 fHM

II

IEach QRS complex is preo it'd by a P

wave that is negative in lead aVR ano positive in lead II

\' 1 \

Sinus tachycardia.

Sinus bradycardia.

50

Phasic sinus arrnythrrua Norrnatly melt:: i::' sugnr increase in hean rate witt

inspirauon ana ::'JJgI.lldecrease Will. .xpuauon.

Nonphasic sinus arrhythmia. Monitor lead shows markedly Irregular rhythm Each

QRS complex IS preceded by P wave with constant P-R interval. Marked nonphasic

smus arrhythmia in this case resulted from viral mvocardms IT waves are blpl1d::.1. LD

this tracing j

Sinus pause in panent WIth "sick smus syndrome" Monitor lead shows markedsinus bradycardia with long sinus pause Patient had sinus node disease and required a

pacemaker

Junctionaj escape beat. Monitor StrIP shows SInUSpause WIth runcnonal escape beat.

SI

Premature ventricular contraction, PVC, PVC is recognized because it comes ht'lUIC

the nex~ normal beat is expected and has a wide, aberrant shdpe (Als» note lung I'R

inrcrval in the normal ,l!1US beats indicating firstdegree r\ V block

A

1'"'I+;t7:f ~t-;'~'F:~

B

PVC\ ,,)mp,llt:'d I~)PACs Note wide, J.bt'iLIl11 S~.iPt' III fl\'1. A \ »rnpared II'

l1<ifl\)\\ PAl B

Premature ventricular contractionNote that the same PVC (marked X) 1l:'~OJlkJ

~.t " . l

Monitor lead.

,t

FVCs. Two PVCs (marked V) 10 a row a.c called "paired Pv'Cs " I've, hn,"r, )W "R on Til phenomenon.

PAROXYSMAL ATRIAL TACHYCARDIA (PATj

PAT is a run of three or more consecutive PACs. ThJS stnp shows F:\T wul: . ~::'

of about 167 beats/rum. Note marked regula my of rhythm. No P w.r.:-. ,1:1.' \~:>:h\t"

PAROXYSMAL ATRIAL TACHYCARDlt\

PAT with rate of about 200 be ,us , r ; .,'

PAT

u

Carotid Sinus massage

Paroxysma! ·1tna;l.iChvuuJJ.l: !'Xi, ':t',ti','" with C:ll,,~;d '.,111\1', PUSq,},l' I'h\' tlr~l14 bedls In ih:', rhvthrn ~,t:-1P"lhY"'- }:"T wuh r,Ht' of about J 50 beats. mill

Carotid 'lnt'" mJ)~ag~ :c':ultt'J Hl abr upt terrr.mauon of the tachycardi., with,Ippearan,c or 1'1,'(':'1.\1xinus rh dhr.l

55

II

I r+.

PAROXYSMAL VENTRlCULAR TACHYCARDIAj1'\ 1'\\ 1;'\ PH~H n.'; lilt ;i!i\iiF Y1Q u l!BuHiW} '1t,l.in :It: 'to' ,:1, L i :!EI:,~;'!lii ; !i'l',\ "PHI!'1i ~ lii!,!' 'l1\lUltiJ It lfii 'i1}R!! I!h,'l!ll jUo', ;1 :Ilil 'Ii IX '1 ,Tfl1 ," !~~lJ\1ll111,~ ll~i j,11:1.'; '" :1

ill,' ~'~, I I" l:I!!T":' l; :w l~'!I;ltRmf,.,~:: :if;:~t~f :M'm,II!'I ' lit'· ,.~ffTj j'l '1, ':.' ,:: • olj 1 ~ I I ' ill' 1;' I I 'III II' 1:111 j' I' 1'1 il r:1 'I' 1'1 ,; I I I ' j 4':. !flt I' t':· H:iI, ' ":f:t.,, !1 It! fin 11 I'd 11; J f I; "01 l; n II: "'I'~ ,!.II 11

;',:; .:,; :!l1 'If iii. 'q It '111'1 t li1J f n!ll1tH~j' I! Wf tid H JJ:':: ,:,: ;:J','w; 11: I, . 'tin · 'illJ mm jj: i,l i.,. :1'., il,l' HI' ~ t r j. t, I. i. 1

i' ::i ~1l:.;: '\' I J" I'i,. " 'r~! p:: ~fi.i I ,: . , 1.1 l' I,: '!Ir:' "I,!;! IV! ,I, !, !i' ·i" ,f ~g un •

:~: i;!' "I ; ,: ' 'n I' '" ,I " t d' 1 f f lli! 11 , I j

r..: [\" r: I jill"j'll ; l:TitllI , II ~ n ,1(\\\11jti. J','" •.• 1 II. ""11 WIH 1 II J It ,Ill '1i1"'JlI, J 1

#j!'lili... I' g' pi tf,'!J"1 . " I,' :,' I ••,,~ . ifr 'I ' •• I It' Ii' Ii!!i, :, II 11: ::: ' • • , : f· H: I'J.:. : " ,,"j'f: : i J}L,i;~. I! ~, t I " :'1 1 'it 1'! 1

, '[ . 'I J.

I iI, f . ii,' . f l' 1 : t I '1;, •

l .nmtl1Hllll 1 ,

Monitor lead shows bursts of ventricular tachycardia.

VENTRlCULAR TACHYCARDIA TERMINATED RY DC SHOCK

AI\I

\

I\

I 11

\' ~t

i T,

,1

I ,I j

,"

,I I"

: 1 : ..1

'ii, i:~'itI ' t

B'd

II

A. Long run of ventricular tachycardia. B, Normal SInUSrhythm restored afterDC shock (cardioversion).

II

Ventricular tachycardia terminated by thump on chest (thump version)

54rf, •.•...

Atrial flutter with variable ventricular rate.

55

't

••

rf

ATRIAL FIBKlLLA I iUN

II

' ••1••••• 1..1,1.., IlJldllb:hUl of 1,.•,,·1,," 11~·\.11l'.' of hili ,II ,I."

...• ~ .1 •• ' \, llill' .il.If VB •.•· \lc' I· ."'''':111.11

Note irregular undulation of basel me because ot fibnllau» v waves (t wa ves). 'then' ,1ft>

no rrue P waves. Veruncular (Qj{~) Jdll' I:> '/1('gU(,H

RAPID ATR I AI. FIBRIL! /\ rf( 1:\J

Note coarse flbnl I atorv WilV'?S and rapid ventruula: !"\~Jl!li\' !',,;:Cl: n.a1 hyperthyrordism. (The commonly used term "rapui atnar nbnltauon" IS actually d mISO,HIWI"mel' the word "rapid refers to [he veruncular rate, not lhe .u: ;,J! (.ilt' Ih« \dllle IS {rut'

tor the term "slow atrial fibnll.iu.«. I

ATRIAl FIBRILLATIoN

Fibnllatory waves may be hard to find with rapid atrial tibnllation. A la, tlycardiaIS present WIth ventncular rate of about 140 beats Imin (14 R wave cycles 0 sec) The

ventricular fate is irregular. No P waves are seen. The rhvrhrn here IS atrIal tibnllauor.alrhc ...•f.h no :'kar tibnll.Hi::, '""<1\0 "iI. Pt .\ i, .11 lni;, 1,lll

56

ATRIAL FIBRILLATION, :".. ,

,.. :

II .t

\'I'r~ il n·).:1I1.lIvrutriculur r,lll' is pn'\I'II{ ~II dl'ar I' wa\ I" ,liT \t'I'II 1111\th'lI Ill'rl',

a, ill Fi!: )1·Ii, i, alrbl fiJ,rillatioli with rapid \ ('lItn('lIlar ral ••

Very irregular ventricular rate is present. No clear P waves are seen. Rhythm here IS

atrial fibrillation with rapid ventricular rate,

VENTRICULAR TACHYCARDiA

- '- -, ...~---,j-.----1- - '-1111'1'-r\'-i'-\-+-++'\ 't"l-t-f-t-'j'"..-'- .-f- u .- --i -'1. -'1, ,-1'1 ' .~- i ,J, --" r-j---" ·\·-t~-'-'-- --h~'w' ,-''-~(-A

tl-~_\. I-Wd' ,-- tf!'ff-• ' !." , I'

II -~-- \- :.: .; .. i ';'..,'.'."""ir--\"+- ;'" '--, L '.. '--,',,' r~- -) - .. - -!.,,' _.. -- ' ' 'T '. ' .. -" _. \.

_...- ~l\,,iJ .....J \--I'r-+9"· -l'I!-\ \.1 t''',-l' ---, ~- ...-.., -,--I'-I-lt fL, ." \ t I .jji ,I, , , ,i Iii i " ' __I I I I i.

Ventricular tachycardia is, by definition, three Or more consecutive PVCs, ECG shows.

two short bursts of ventricular tachycardia.,--, -" .• '_'0 ., r'. "'''-'

I .: : r:i: .. ,' .•. , .. i:': ::< \jH \i;; 1~;1 iL' ~j!l ~~;l !,. I: ;;j I I' .._.

'\ ; ~;! '''' :'" ;! d. 1!H ~IPn~!I1~;~jill ;;~~1::1 .t )i .t.: :'1 :q! '. L< .~:

A "':,,,::,;: ,I!' ~ ',::, :,:: ,;,: :::: ',' ,i" ~,~; lliL:~:li:;;:; ,::,!~ ~ :;: ,::' ,;:: :i,! ,:;:;,:;~ .~::: ,iI: I;': TIl, :!!i !,!~ilL ... If! HI: !!:i till iI ,n :~l 1:'1 liiH aii ;,iJ :!!f ii!i ilii i4:~;ii!11i!tli Ii'!

:i'j 1:,: :!:I,!rl nil ,:H lii! :1ii ;'1: ,,!! !!;::m iI· il!· iii !pi lliH!IJIII iii' n IIiii '!lllHiHii1 ili' ill! ."',,:

B

'i;; 'it. m~ii ~'l .,

In, m: ill ii!' 1::11iFI!iI! mil

II !>;; 1iU t!i :' , ":!l! iul li'l I...

I I

1lli" '.

f ... I

Ventricular premature contractions. A, Ventricular bigeminy. Each normal sinus

beat is followed by a premature ventricular contraction (marked X). B, Ventricular

trigeminy. A premature ventricular contraction occurs after every two sinus beats.

57 rf

[=tJII

Ij

jI

\I,

Iiiii

!,I!i

I

i

FULLY COMPEN~AlUKY PAUSl:f i '\ ~~C. 'I r t1,! I: . 'i·1Ili'; II r-H

r . ': I i I Ii: I ! i·

, ,,~I, \P:!~'; p "p 1"'1.

"' .••• "\~ ["I;'t'!"~",:~ .i"!'-"':' : •••••r 'v, ,'Ii' ,,;:t ~, ~ I:W; I' .,

,it, l.' Ill' I , t" I I':V 111' . I

'II' ; 'J.. :i':- I··, I, I '

IfL- I

I...•

" ~ r.II1,-1,

520msec

Some Pv'Cs cause a tully compensator" pause sucn I.tldl the uuervai between the

vwo sinus beats that surround the PVC (}{} anu R4 HI uus "'d~t')!:> exactly two urnes

the normal interval between sinus bC,HS :Rl and R2 In trus Case) Nonce that the P

waves come on nme, except that the third P \.'v.lyt·l~ Hlll'Il'-l~lcu by IIIl' P\C and

therefore does not conduct normally through rhe A V -iuncuon Tile next (!l -urth) P

wave also comes on tune The fact thai ine SIIlU) ll11dt' l\J:H:t;un 1,\: p,Kt: uvspue the

PVC: results 10 the lullv rornperisa« lTV prtlJ:>e

MULTIFt,)( At. PVl.._'

II

PVCs here have different shapes In same lead, Imlll<iUllg uuuu tUt <11ongin

S8

't

I

III

iI!iIII

\,,!I

;

!

,!

VENTRICULAR FIBRILLATION (VF)

1 1

Ventricular fibrillation may produce coarse waves or fme waves. Immediate

defibrillation should be perfcrmed

B

FIRST-DEGREE AV BLOCK

,:1..A

First-degree A V block, P-R interval is uniformly prolonged above 0.2 sec WIth eachbeat. A and B are from different patients.

WENCKEBACH (MOBITZ TYPE I) SECOND-DEGREEAVBLOCK

I

PII

With Wenck:ebach block, P-R int val lengthens progressively with successive beatsuntil one P wave is not conducted at all, Cycle then repeats Itself.

59

WENCKEBACH tMOBITZ TYPE 1) SECOND-Uh.d<U AV BLOCK

'·R '·R P '·i P·I P P·I P·R P P·R P·R P P·INotice nrogressive mcrease in P-R interval, with tlurd P wave In each sequerv-: norfollowed by QRS complex, Wenckebach block produces charac tenstically irregular

rhythm with grouping of QRS C01l11' ,.,',

MOBITZ TYPe 11Sr.CONU·D.l:.1 .KEI \ V iH.Ul:K

W •.th Mobitz type II A v block there is a series ot nun .unducted I' waves tollowed

by a P wave that ts conducted In this diagrammatn example .~ ! t. ,I block I' present

wrth three P waves tOI each VI{:> .;"n:;'IO

Complete heart block IS characterized by independent atrial (P) and ventncular(QRS) activity. The atrial rate IS always faster than the ventr n ular rate The P-Rintervals are completely variable. Some P waves tall on the T wave. distorung the

shape ofthe T wave Other P waves may fall in the (JR2. ,-UIlIP,l\ .1nJ may he "lust"Note that QRS complexes are normal Width, mdicaung that the ventricles are being

paced trom the A Vjunction

THIRD-DEGREE (COMPLETE) AV tiLUL K

Another example ot complete heart block. showuu; slow .druvenu ',1.11 i nvthrnand taster. uidependent dlfldi i hvthm

40

't

RIGHT BUNDLE BRAN('}T nT OCKI

TIT,.'1::1 IIl:I!

I I Ii I r: j

! I 'liI. i I "I

1

I II !,I I . i ' ~Itl HJf.liil I jil, U 1111111

II III oVa,jiIPII'.' i I,.I . , . 1

'. I

oVL,'I 'IiI I' P-, t, n

I I 1+ I ,, . "Iti 111 I

I i

-II

I ~

lI'

~u~ f" f' II[i Iii

;1 ': '~;III~~Example ofRBBB. Note wide rSR complex in lead VI and qRS complex III lead

V6.Inverted T waves in right precordial leads (VI to V3) are common with RBBB andare called "secondary T wave Inversion, "

LEFT BUNDLE BRANCH BLCk K

:-j' ",- r-~t~-Itl' '~I~I TI·i: \ I r .. lj tr I! '~j"\l; 11\1 j

'. , ;. f\ 'I!"- +"j. 1'1 ._._.il'llml'·!· jill .' ! !-- '-.,1. -f~ Ic;.;-.~. '. Y:~A. :·,.;i. .. 'dki ...I·-+·-+-:.i·~,· -:..J i

"~T-~:'~l: '1·1. II, r~-·: r+1······-_···f:F.········I'·"r ~1 +~+I[·-r'-¥·- -.1\'1 r! tt'l,"j: L: I.J... 1::t:t·:.I=h-l+~:·::::.:·::·I·~\. t·:r··~li·· ""1'"1 j ,

.v··~LFLI-- -'"r=-~2'~~~tl~T*triH'-If'1.·qit;

tl':'jJj-~~<: .:i;: -]~":I j~ '..'b;" ;, '__ 1.1IV -l \ V" .•.. ""'1\I '~. .1= -" .. ,.'. - ... ,·r .. "" . -,. - -+-1- "'1' .. .:: -;- +- ~ -'- _ - -- -'. .. 'i l,+~.; f- . -1-_

V· '.- •....... ;, .r: ·':-1.... ,." -f - .. -=: =- -.= ~ ~::.. :" - :,',', 'I ",. '.:' .

I V V.- ,- _.. .1 .. _ J 1-"\';'" " -. .... 7'i. -; ~/ ... - :., -'Ib tho :~-~~ ,'" '~'n'\~' ._-I-,- . :::.. :: .: k-- -+-It\. ~ .:... t= ,./--,--'; ,'\.--,-~...'..-Hi ',; .-. - '+'fF ..._.~~.~.. ~.::~~~~.~I~~A\ -.:.~,__ : .~=~:: ::'llfl: ~~:,:~~:.--~ .r- ...~~ :

~ ··1-.. ...- ._ .• [ . -. 1-· 'H l.: . ;...,! • .; : .i.1 ,. :.+_·t'· ,. . --j--. +. ~'.=...:_~: '1"-'.~~ ~~I~r ..! ;':".1 . _--,-h t--. '" .- ..-b- _.t· ... -.... .1-•. ,_ . ..L~:' ..'f--.. -- 1F-1'; . i j:' .

'V V ' , v ,., '...

•..Ll-~=--r T,,;!-,; ..~--!~ ".:l"f-:.....-.. i .... ':~ ~ -:::: ~:. t~~t~'~~ijJ.-::ttJi1t"..I..· ···t··· - !; t I I:. . _ L. __'_~;,I .-1'-011-"" . ~" - ' .. : J 'rtr ~tt"-'-:1' ,.. . . r' ~t:-:-::: ~ii' In.:..:.. t: ..·..-Vi;-71 ..~~~· $f= :r:-: .. ~::~t--'=· : F. i.":, ~\~~lI:\'J'q,ztt:::,:.=:" .:~ ~~::~ ~:: :::.:!~:::::.::...; -j-.:t::= ~::r·::.: ::~:.-!:..rr . I::: .; 1:=.:~.:~'j~ ~:=::l ..•,•.•......•....•• ::: .. ,;. ••. '-- 'r-t-r- TI.I, ·.rt.tt ....· ...: ' .1; ·i .. ,. ~I

Example of LBBB. Note characteristic wide QS complex III lead VI and wide R wave 10

lead V6 with slight notching at the peak. Note inverted T waves 10 leads V5 to V6, whichare also characteristic ofLBBB (secondary T wave inversions).

r ;., 41rf

BeG appendix

II AVjunctional beats IIaVR II

A

.- .-1 -

-.

- -. , , .. ,

.- ,- --

-

.~~ ·~U~I. ,

• \ .• I••

. f- ". -_. - 'jlli

, " -.. .... -

- . 1-_." f ' -

B

I I-

. ~. .-.

.

t -.

I

'I I I

.. -,- +i -t-L-r-ft t •..t""':TTl:' ....;. ....•,-

-.' .

c

This Fig.: A V junotional beats produce retrograde P waves that areupright in lead aVR and negative in lead II, just opposite of pattern seenwith sinus rhythm. The junctional P wave may precede the QRS complexA; follow the QRS complex. B; or occur simultaneously with the QRScomplex, in which case no P wave will lie visible. C

To summarize, AV junctional heats can be (recognizedon the ECG by one of the following three patterns:1. Retrograde P waves (positive in lead aVR, negative

in lead II) preceding the QRS complex.2. Retrograde P waves following the QRS complex.3. Absent P waves, so that the baseline between QRS

complexes is fiat.

41

HOW TO INTERPRET AN EeG

In Parts I and II we described the-fundamentals of the normal ECGandlht'

major abnormal patterns and arrhythmias. Part III is a collection of testquestions to help you review these topics. We will conclude Part II wuh J lJi'LI

summary of how to systematically approach any ECG.

ECG INTERPRETATIGNAccurate interpretation of ECGs requires, above all, rltoroughness andc.u ,Therefore, it is essential to develop a systematic method of reading ECGs I lid ,~

applied in every case. There are 13 points that should be analyzed m every EeL;Standardization: Make sure the electrocardiograph has been properlycalibrated so that the standardization mark is 10 mm tall (1 mv = 10 mm).

xx In special cases. the ECGmay be intentionally recorded at 1/2

standardization (1 mv = 5 mm) or 2x standardization (1 mv = 20 mm)Heart rate: Calculate the heart rate. If the rate is faster than 100 beats/min,

a tachycardia is present. A rate slower than 60 beats/min means a bradycardia IS

present.

Rhythm: Decide whether normal sinus rhythm (NSR) is present or whethersome arrhythmia is present.

P-R interval: The normal P-R interval (measured from the beginning of the Pwave to the beginning of the QRS complex) is 0.12 to 0.2 second. A consistentlyprolonged P-R interval means first-degree AV block is present. A short P-Rinterval (with wide QRS complex and delta wave) is seen with the Wol((-

Parkinson-White syndrome. A short PR interval with a normal width QRS mayrepresent Lawn-Ganong-Levine type pre excitation.

P wave size: Normally, the P wave is less than 2.5 mm tall and 3 rnm wide in allleads. Tall peaked P waves are a sign of right atrial enlargement (P pulmonale).Wide P waves are seen with left atrial abnormality.

QRS width: Normally, the QRS width is 0.1 sec or less in all leads.

Q-T interval: A prolonged Q-T interval may be a clue to electrolyte disturbances(hypocalcaemia, hypokalemia), drug effects (quinidine, procainamide), ormyocardial isrhernia. Shortened Q-T intervals are seen with hypercalcemia anddigitalis effect.

QRS voltage: Look for signs of left or right ventricular hypertrophy. Rememberthat thin-chested people and young adults frequently show tall voltage without leftventricular hypertrophy. Do not forget about low voltage which may result frompericardial effusion, Myxoedema, emphysema, obesity, or myocardial disease.

I·

Mean QRS electrical axis: Estimate the mean QRS axis in the frontal plane.Decide by mspecnon whether the axis ISnormal (between -30° and +100°) orwhether left or right axis deviation is present.

R wave progressIOn m chest leads: Inspect leads VI to V6 to see if thenormal increase in R waves is seen as you move across the chest. Poor R waveprogression may be a SIgn of myocardial infarcnonsbut It may also be seen withleft ventricular hypertrophy, chronic lung disease. left bundle branch block, andother conditions in the absence of inrarcuon. ".

Abnormal Q wave: Abnormal Q waves m leads 11, Ill. and aVF may indicatetransmural infenor wall infarction. Abnormal Q waves in the anterior leads (I, a VI ,and VI to V6) may indicate transmural antenor wall intarcnon .

S-T segment: look tor abnormal SoT segment elevations or S·T depression,

T wave and U wave: Inspect the T waves. Norrnallv lht' I wave IS alwayspositive (up-nght) in leads with a posiuve QRS complexThe T wave IS normally positive in leads V3 to v6 in adults. It ISnormallynegative in lead aVR and positive in lead n. The normal polanty of the T wavesin the other extrermty leads depends on the QRS electrical aXIS.

Also look for prominent U waves, which may be a SlgIl of hypokalemia or drugeffect (as With quinidine).

ECG for interpretation:1- Standardization: Note normal (10 mm) standardization markrecorded at end of leads I, VI, and V6. Standardization markneed be recorded only once when taking ECG.

44

2. Heart rate: 88 beats/min.

3. Rhythm: Normal sinus.

4. P-R interval: 0.16 sec.

5. P waves: Normal size.

6. QRS width: 0.08 sec (normal).

7. Q- T interval: 0.36 sec (normal for rate).8. QRS voltage: Normal.

9. Mean QRS axis: About -300 (biphasic QRS complex in lead IIwith positive QRS complex in lead I).

10. R wave progression in chest leads: Normal.11. Abnormal Q waves: Pathologic Q waves in leads n, m, andaVF.

12, S- T segments: Isoelectric.13. T waves and u waves: Ischemic T wave inversions in leads n,nI, aVf, and V6.Impression: ECGconsistent with inferolateral wall myocardialinfarction of indeterminate age.Comment: You cannot determine the age of an infarct from the ECG.The ECGchanges here:(q waves and T wave inversions) could have been caused by aninfarct that occurred the day before or the year before.

After you have analyzed these 13 points, you should formulate an overallinterpretation. For example, an ECG might show sinus tachycardia, first-degreeA V block, and Q waves and T wave inversions consistent with an evolvinganterior wall myocardial infarction. Part III contains other examples for practice.We would like to emphasize that every ECG abnormality you identify shouldsummon up a list of differential diagnostic possibilities. The ECC is a clinicaltool, and you should search for a clinical explanation for any ECC abnormalityyou find. For example, if the ECG shows sinus tachycardia, then the nextquestion to ask is what caused this arrhythmia? Is the sinus tachycardia a resultof anxiety, congestive heart failure, shock, Sympathornyrnetic drugs, or othercauses? If you find ventricular tachycardia, what are the diagnostic possibilities?Is the ventricular ectopy caused by myocardial infarction or some potentiallyreversible cause, such as acidosis, hypoxia, digitalis toxicity pr otherdrugs, hypokalemia, or hypotension? If you see signs of left atrial enlargement orleft ventricular hypertrophy, what is the cause: valvular heart disease,hypertensive heart disease, ischemic heart disease, or cardiomyopathy? In thisway, the interpretation of an ECG becomes an integral part of diagnosis .and patient care. Finally, we will conclude this section with a brief discussion ofsome important ECG artifacts.

45

ECG artifacts:The ECG, like any other electronic recording, ISsubject to numerous artifactsthat may interfere WIth accurate interpretation Some or the most common ofthese ECG artitaets are described here.60 cycle (Hertz.) mterterence: Interference from alternating current generatorsproduct's the characteristic pattern shown in Fig. below Note the fine-tooth comb60 cps (Hz) artifacts. By switching the electrocardiograph plug to a different outletor hy turning off other electrical appliances in the mom, 6Ucycle mterference canusu~y be eliminated. J

Muscle tremor: Involuntary muscle tremor can product' undulations in the baselinethat may be mistaken for atrial fibnllauon or flutter

Wandenng ba8chne: Upward or downward movement ot the baseline may producespunous SoT segment elevations or depressions

Poor electrode contact or patIent movement. Pour electrode •.ontact or pauerumovement can produce arnractual deflections m the baselme I WhIChmay obscurethe underlying pattern or be mistaken for abnormal beats

Improper standardlzanon: The electrocardiograph. as mentioned, should be stan-dardized before each tracmg so that d I mv pulse produces d square wave 10 mmhigh, Failure to properly standardize will result m complexes that are either spu-riously low or high. Furthermore, most electrocardiographs are equipped with halfstandardization and double standardization setnngs. Inadvertent recordmg of anECG on either of these settmgs will also result mspunously low or high voltage

A

"j .. ,. i../·.t ..·.hl·; \..'.'J"~~ 1.1' I I ~t -1-'1: .~~.~.~~i.-. I I· --r.".j l I • -j'--' ./.. -~ I·~I' ! , ; ! 'I]'" g. .:..::'.J~i.tl~+.~.~~ ....-'.\:".','Ii i. ~:'\''':Ifl-F.. I II' I ,.'" ··I·r" - . '1"1, ··, .. +·1I I I ", '1--"'1 .~..

B

A, Muscle tremor artifact produces wave baselme resembling atrial flutter. B, Samepattern Without artifact showmg normal P waves

46

! : : : 'i' , :I~I I IIii :1 :!i: I:I I:I !J : :I0 I I : ; : : : : .'

" .."

! 1I;~:!( ,'I! ! '/1 : : l.:;:1 J" 0' : 0,

; ; : L: ,I F : ,.. .. ;..

':1 ?i ,'I: i : .."

.. ,"

t ;I l. ..

/'1 ; ; : : " : : : !: : ; : :" " .. " :

oJ!"I : ii:j I : ~ ie~ i, : i : I" : : .. .. ,i"• ""'" I ; : I : : : .. : : : , ...:...;

I"S. : : .: :J; IJ ..,~ J II-..

. , : :t~ I- ..

I : ".. : ,

0 q : : : I : ; :I 0, ! .,, : ..

" J I.""C t-:-: ...,- t, : : : ! ; i: : : :

....: : :1 :

..,,.t-- [-. rot : Ii 0' : : :I : "~~. : :: : : :I : ; : : "

: ;: , .. :0" : .. :

,Wandering baseline resulting from patient movement.

:n~o :In~'nlltV~ittJ I 11Jtt~1lj~~ i : II '#( . Vii

t ' 1,} ~

Patient movement artifact produced deflections simulating Pv'Cs.60-cyc1e artifact is also present.

++ Remember:

The following 13 points should he evaluated in ever)' ECC;:1. Standardization2. Heart rate3. Rhythm4. P-R interval5. P wave size6. QRS width7. Q- T interval8. QRS voltage9. Mean QRS axis10. R wave progression in chest leads11. Abnormal Q waves12. S- T segment13. T wave and U wave

Any ECGabnormality should be related to the clinical status of thepatient.The ECGcan also be affected by numerous artifacts, including 60 cps(Hz) interference, patient movement, poor electrode contact, muscletremor, and so on.

lAHMED RAMZY 47

Test questions

_.~4."_._ ...

~.~.'=.:-::.;...'. v~ ~r .,., II . ..... ..V. I

~.' .~. ': .. ~- ~-~"' ~._- HI .. - 1:· -L'~ r- If- .

. ' " 'v . r ----1J . _.. . ...._ • ~ !

VL

1) A 40-year-old woman is referred to the Out-patient Department because ofincreasing breathlessness. What does this ECG show. what physical signs might youexpect. and what mIght be the underlYing problem? What mIght you do? CommentQRS or chamber enlargement,

-...-, -_ ....• ""l ~

._,.---~."._ ••.•. - .•..•--r .•- • ~ .• .-:--

II .....__~:-_..~_~L.._ ..:...vL-::-:=.~:';. ." ."~.':2~c.:-=..~·,:,,=·:!!..-~.::.:-.:.~·....------ ..--. ,"7':-"-' .- .._,.-' ._.,...- _.----------_ ....---...•....- --

--- ,-_. -.-.- .

2) This ECG came from a 40-year-old woman who complained of palpations. which were

present i\

rhythm.

rhe recording was made. What abnormality does It show? Comment on

48

II

\I

-.-····...r-_'__ .,._.._...__,~._...

:.~~.:"j-- ~~:~·~!;·T~-:~r:~··::~~_"~~:~·~·-!3:~:~.~,~.~:~~::.-:~~·~r:;:·~:~··:~~:·,:·~··v.' ;.:":.~.~..;-_:.'.~~~:,.:_~:~'~:..~..~.J~;.~~.:.=.:~;:':;-..~'~~.:~.·,,~w"'71-:··~-_··_·-.··r ...- ..:._.

3) A 50-year-old man is admitted to hospital as an emergency, having had chest paincharacteristic of a myocardial infarction for 4 hours. Apart from the featuresassociated with pain there are no abnormal physical findings. What does this ECGshowand what would you do? Comment on $- T segment.

l·· ..~ ...•.....,... , t' . , .•. )jR .. ~-.... "1"- n¥i ..·· '"•.........,..,....'V.•............•...'.•...•........~. . . ~ .. •,•..••...•. ,. ':""'t, _ .•..•, ...•.

:..n ..,',."..u"J~.

. -..- '

• 1

. .. ._ :..- ......•...__ .....•--_ .....•_. _ -.'_ .._.__ - - : I••_ •.•'""'!'- •••"~--_._--;...-~--:._._._.- .,_ •

" : , _ - ..- '.'...............•..•..... . .•-:' •.....•..•,.. •. -_ _._ ..•.... _.•.... _ .•_ ..'·0 _ ,_ .

4) This ECGwas recorded from a 75-year-old woman who complained of attacks ofdizziness. It shows one abnormality: what is its significance? Comment on P-Rinterval.

49

...;. ~N.· • i.:~ U\A.Jvw

III

-. . ._. _.. .-!.-. _.~._._..---.--:-.----. - ..- _·__·_;-:-'-····_--···--···f-,····-+-

•. ~.. ~ .••. 00+-- ••. ..•• .• • •.•.• ~ .~.. . . .. -,.-: . ·1' ,-'r .'''': I

.- _ .••••• -._ •.••-- ''''''f--''' •• - •.- _.. . •.•••.• -_. '.o • j". <... t· . < ."- - ---_._" .._~.._._._-- ..--,_.:-__ ....•-.- .- .....;- .....- ~. ,

5) A 75-year-old woman complained of central chest discomfort on climbing hills,together with dizziness; on one occosron she had "fcmred'' while climbing stairs.What abnormality does this ECG show and what physical signs would you look for?Comment on QRS.

----._. -_._--. _._-- ---.-. ----,---

. '\J\./'2,"--- - ._.-.-. - .... .5..

.•..I

" . \11 .. -.-.- ...,tt·

..•.- ,6) This ECG was recorded from a 60-year-old man being treated as an out-patient for

severe congestive cardiac failure. What might be the dIagnOSIs of the underlying

heart condition and what would you do? Comment on fate & rhythm.

so

III'\

I\

I !

-------~.7 . I._:_~~...:...._ •• ~ , I. I 1 : .!. .'- __ ~ ~..1 .,......:..,~~-1.-'-'-'-

. ,

-..-.~...JlhJ---t. I-,' ~~., A-' -,(-,~.~'_._., ·1·-:-- . - . T" ,r;""-- . - ... " ...'.-.-.-.-

. ......,.....,.._- '-I ,-: oJ-; ]'1 --J-,-rl...,-l-C-·--~-r:r-q:::;:p~..,-,,_ ..~. ,~I_IL':..__,-•...•._.,_.I • j ..•.._~-:..,... :...._..:_~..L.~... .:.._ :. i. :_. __; .• "i_._--.: ... _ ..._....J-_L..L~_•...,L~ .._..4_~ ._._.; 1_ ••• : j. .••• ~,_ •

7) A 60-year-old man, who 3 years earlier had had a myocardial infarction followed by mildangina, was admitted to hospital with central chest pain that had be.sn present for 1 hourand had .not responded to sublingual nitrates. What does his ECG show, and what would

you do? Comment on QRS & S- T segment.- -_.__ ...- --. '-.--_._._---...··_,·--:0·-:;-.~-·..·~~~T,r·-fi'~~

. . ... : '. ,--to,.;' VA', ,.

.' "~';~: ~i·-:-!_t·~-----::-T.r-r-f : '. '; -; .., v "'. v: I

1 4·

-r..., ...··· .._-

V2-~-.~~- --_:-.=.-:: _~~;v~~::L~:.~,~~·'~~.:.--..,-- . '.~-··r~r·;-..~j.-~'~::-.~-.:..~:-

. i .j ,; I ","' ., ••. - •••• ,••-,._-_ ...•....__ .- - .. .- .. _.. .. .- - ~.~~-:-.:-..-~~~.~~:=-.~~-=-~=~~~_.:=:~-_:=-~==-:-~-=~~::.~=-=-~.:.._.=~=-._:-~: ..~._'--~~~-:~~=-," .. !., ;--,_ _..

,- .,'--~-:::_;II:::_~;::~;~~==:_:VF._::,:=:~::-~::::;y.~;~k;:~!:::::~~iJtH~~i--,----- - ..-i---_._- ._-_'_·I·,...:.- ·.__ -:~- __

, I'"-'-'-r- -.__ . ·..·-..·---~-- ..i'-;_-M- ;_;_; __ -;--. ..- •..- .-- j- i"~'-- .--- ---' : ,....o.

8) A 15-year-old boy was referred to the Out-patient Department because of a heartmurmur. He had no symptoms. What does this ECG show and what physical signswould you look for? Comment on QRS.

5 I

~.I

~2' --_._.---L.L--.--: ...v;--~-:-r~ ,•.....-..-.;..;------:--._._~------

. 1 •• ~.••• _4._ ~~'1.J.-~:-:-T:.·.-~--_.·I., I•__._",_.,.. 0.. 'p'

9) This ECG was recorded in a Coronary Care Unit from a patient admitted 2 hourspreviously with an acute anterior myocardial infarction. The patient was cold andclammy, he was confused. and his blood pressure was unrecordable. What does theECG show and what would you do? Comment on complex.

I· VA

II VL

1lII

. VF ..

. -.--,--

10) A 50-year-old man is admitted to hospital as an emergency, having had chest pornfor 4 hours. The pain is characteristic of a myocardial infarction. Apart from signsdue to pain, the examination is normal. What does this ECGshow and what wouldyou do? Comment on S- T segment.

SI

'" .'N .•.•. ·•__ •••• &- ••••••_ ••N._ .• ' __ """ ...•.•. _._.: .•__ .: .•.•• _" •.--.--------_. __ .•._ ..._---_ ...--- _ ...._ .•.~_.._ ..--_ •.-.-.--.--- ...._.__ ._~-----.~_.-..•......... ---_.-:--:"' ..-..~-"'-.•--;--_ •....-, -----' _.' ..•._- ._.-._-_ _ .....•_ ;-.......• _ ..-_ ......•..-•..•..........._ ....•.- ; _ _ _ - .. ' - , .. ... ..::.:.~::·~·~·::.:·~·;:~ll:.:~~:~:.~.:;:j.::~::~..::.~:.:VL.··.:.: ..~. : •......:..: ..: .: ::..' :V~..",:..~.:~; v~._., .._.._ ,.. ---_ •.._ •...._ ..._ ...._ ..-...._..--_ ..... .--,' ..._-- .._. -_ ..,..... -_._ ... "--'-- .. " . .

-:-:-r'-. ---.---.--:-~--;-_ ..__:_:0"_."" _.....•...:--.;'-.- -.- ..------.-.--."1--:-.~..~-.-_.-.-_ _-_ _._~.~-_____ ••.•••• _ •.••••••••••••• _._ •• _. __ ••••••.••••••• _._ •••••.••• - •.••.••• :e •••• ' •.•..••••••.•. '." ••• -•••••.•••.•.•••.•.. __ .;.. •••••••.•••• •••• ••.••. ••. _ __ .•••••••. _ ... , .. .... . ... ' ., ., .. .... ... ,. . . ..•.•••-. __ ••: ••• "":.__ •.• "-'" •••••••• '!' ••••..•.•••••• _ •••••• _ •••_ •••.. , ••••.•..••••• -. • •

.-:::-:- ~l.~ ..-.__:...:- _..-:-.::.;_.:"~:YF':-.:~~=~~=~~:=:~:.;,v3~~~~<:.~=~::::.:::.~~.::..:~~:::.-=~·:....V~.~.:.:.~.=:~:_=~.~.::".·i·:~:-~·..~:j:~::.;·.·:::il~:~·;.;·.·:...~~~';.'.·-~:···:~;::il···::·;:..·~~~:..:;:-~:·:=~::~;:;:..;..}~::~.~:..::.

11)An 80 years old man being observed in the recovery room following a femoral poplitialbypass operation was noticed to have an abnormal ECG.What dose it show and whatwould-you do? Comment"" 5- T segment.

- .. , -•......-:. - _ ...••....•........... - ,.....•.-.- _ .._._-_. __ .....•.... -'- _ .. .. ... .... - . _.• ~..•..... ·-··· .._·r .._..........•.... _... _ .._ .__ '.....•.__ .•...._ .....

"'- - .:._.- _-.:-- ..__ ............•. -•.........•._ , - _ ..---- ._ ' - .-' •••••••••••••• , ••••• ' .. "! ••• "7' -" •..•....•• :. •.:.- •.• ..•••••.•. - •. ''''; o •• :..,.~ ••• ,". .

• ••• 0· •• 0 , •••••••••••••

~~::~:2=~~:~~~~~~:.-~~~~~g~:·~:~v::~_--v 5---;- -_.".--

......:- _.' -:' - -....•................ ;..... . .. . , , .

•• '" ••••••••••••••.• ~ ••• - ••••••••• '0 •••••• _....... ._ •• _ •• , •••••••••••• _. •••••••••••• ••••• • •••••• : •• ..:_ •••••

=-it~!:~r~~·__:=~~f-ftrt~~_E.f.::~.~.E.~.T__=~~-_~-!3[i~~.1.•.1 ••••.1. I

12) This ECGwas recorded from a fit 22-year-old male medical student. He wasworried - should he have been? CD/MItlnt Dn QRS voltogtl.

55

~ .- : _... -- "i .'."!".!.....

13) This ECGwas recorded from a 30-year-old woman who complained of palpitations.Does it help make a diagnosis? Comment on rated rhythm.

~~---- ---

VR v, - _..~r.....--- ._... --._------_._-----

II___.:..-.'---.::v;--=:=-. ---

--....--.... .._---._. ----- - .•.....__ ._.__ •.

.._ .. .- ..---.---;-' _,..L.- -~....,...' ....,...... --. - --- ··r .....·--· -----_.---_ .._---------- - ..-- - - ..•._- ...... _--_.--.~

14) A 60 years old woman is seen in the out-patient department complaining ofbreathlessness. There are no abnormal physical findings. What dose this ECGshow.what might be the underlying problem, and how would you treat her? (Rate & Rhythm)

S4

..... i: ~... _:.... - VR .... ,V-i . :. .;• 't' :.. .•••••.•• ;.~; •• ,: -;' , ..•• : .•• ,._~ .• : .;

• '.- .' r'o ••••

. : I

l~ :'~::.::.~·~·--~~·.i:~.,..~S~:.·;.! _ >~2.... . . .. '._ .. -:--. -_ _-~ _ ,..' .......•..... " .~ , .

. ..' .: ~-.! . .,

v·5

., ." .....!. .

lU ....~.:"L:~-:LJ-.]'~._.~~: _ !.J ..! .. : .. :..y.~.._ .. .:.;..:..' .. . , .•••••• ••••• ••••.• ••',_ ••• ':. o'

j. ,- .

~Vo..............

·0"· ;.. . . - ': 'j' ': 0... . . I •

. .••.•••..•.....•- ':'.." ..•.- ... ,.-•.,••' ......•.•;••':. !'."_ .•.•......,•..;.•.•...••....•~..'.'_ ...:•.~..•,... " - ... _..~..:::-:'..:::.:';.'~.~~'.'.."'..':.~-:.::..H ':~.'.'.:''':...:.....: .... .• •••• j .•• ': •••.• _. "oj, •.••• ";':' •• '•••.• ~ •. ,

15) A 25-year-old man, knownto have an atrial septal defect, was admitted to hospitalas an emergency because of palpitations. His heart rate was 170 per minute, hisblood pressure was 140/80 and there were no signs of heart failure. What is thecardiac rhythm and what would you do? Comment on rote & rhythm.

VR

. - .. '

. 11' - .. - . V~.' .. Vr. .

.•...- .... .

.m~:·:··· .. VF: .... :..:·.: ..·· .... .v" .....

16) This ECG was recorded from a 55 years old man who was admitted to hospital as anemergency with sever central chest pain that had been present for about an hour. He'waspale, cold and clammy; his blood pressure was 100/80 but there were no signs ofheart failure. What dose this ECG show? Dose anything about it surprise you?Comment on 5- T segment tf P-R intervtll.

SS

1 - . - ··VP..···

•••• -._ ••• •• ••• __ •••••• __ ••••••••. _ •• __ ••••••• _ •••••• _._. __ ••• __ •••••••• " _." ~~r

•••• _ •• - ••••• < ._._---""'!'..._•.._._---_.--_ ..._--- .._..._--- ----_._...• -._ ..•........._.--_.--- •...._.

" ....._.- ..- --- --,---_ ..._-_ .. -_ .•.__ . ---_ ..- _ ..- ._•...__ •..•._.__ ..,- .

17) This ECG was recorded from a 50-year-old man who had had severechest pain for 1 hour. What does it show and what would you do?Comment on S-t segment.

18) This ECG was recorded as a part of the routine pre-operativeassessment of a 65 years old man who had no cardiovascularsymptoms, and whose heart was clinically normal. What dose It show?Is any action necessary? Comment on QJS.

S6

- ..•. _ .._ _.•.- --" _."••• __ ••••• -. - .0 - • _ •• _. _"" ••• __ ._-;- ••• .~_. __ -:.~-. __ --.--- •.•• : _:_ • .,.. ••• _

...: ..:•.::.::.~~~~::~.~~~.~~~.~.V~~~-~·~~~-::·~i~~:-;.-~L.:._~!.'_~~=;_..~'ST=~~~1'-" .• ' -••. f" .-!' ._- ••

.-or --r- - -·0·- _ •• " _'.--_ .....•...... ------- -.._--,--------... . . . --, -'-_......---'_. ._'-r-"'- ~_,,_....,_--_~-~~:

_. . :--r-;----,- ~ ~. -r_,_-_--~-.:----.~__'..•..__

:-::~L:: ~:~::~~::~~~:::-~:::~:::Ll~-c;f~.:~::_·:.·~_·~·:::..~.:+.t~:.-2_~.~.~.-:.;..~_..:_:.:_~.::---_ ..-- ..•._-_ .•.._._-_._ ....._-_ .•......_.- .._--------"-' •...•_----.:.-'-'.- -_._---'"...••.'-'.... ~

19) A 60-year-old man who complains of ankle swelling is found to have a regular pulse,a blood pressure of 115/70, an enlarged heart, and signs of congestive cardiacfailure. This is his ECG. What does it show? He is untreated so how would you

manage him? Comment on rate and rhyt~m. '/, 'J.,.I .. - .V R - ".- _. -. .

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20) An 85-year-old man is seen in the Out-patient Department complaining of typicalangina and of occasional dizziness when wa~king up hills. This was his ECG. What isthe diagnosis and what would you do? Comment on QRS-(Chamber enlargement).

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21) A 60-year-old man had complained of occasional episodes of palpitations forseveral years. Between attacks he was well, there were no physical abnormalities,and his ECGwas normal. Eventually this ECGwas recorded during one of hisattacks. What is the arrhythmia and what would you do? Comment Rate &Rhythm .

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.....- _ -. __ .._- ~ .22) This ECGwas recorded from a 60-year-old womanWith rheumatic heart disease.

She had been in heart failure, but this had been treated and she was no longerbreathless. What does the ECGshow and what question might you ask her?Comment on rate & rhythm. 58

Answers1) The ECG shows:

• Sinus rhythm.• Peaked P wave, best seen in lead II.• Right axis deviation.• DominationR waves in lead VI.• Deep S waves in lead V6.• Inverted Twaves in leads II, ITI, VF,V1-V3.• DiOSnosis:right ventricular hypertrophy.

2) The ECG shows:• Sinus rhythm• Atrial extra systole identified by early beats with broad and

abnormal P waves (best seen in V2 andV3).• Extra systole is followed by a compensatory pause.• Normal axis.• There is an RSR pattern In lead m, but the QRS complex is

narrow.• The ST segment and T waves are normal. J• Diagnosis: sinus rhythm+ atrial extra systole.

3) The ECG shows:• Sinus rhythm.• Normal axis.• Small Q waves in lead mbut not elsewhere.• Elevated ST segment in leads IT, m,VFwith upright T waves.• T wave inversion in lead VL.• Suggestion of ST segment depression in leads V2-V3.• Diagnosis: recent inferior wall infarction.

4) The ECG shows:• Sinus rhythm.• Prolonged PRintervals, of 280 ms (best Seen in VI, V2).• Normal axis.• Normal QRS complex.• Normal ST segments and T waves.• Diagnosis: sinus rhythm +1st degree heart block.

5) The ECG shows:• Sinus rhythm.• Wide QRS, -ve QRS Vl- V2, notched complex in V5, V6.• Diagnosis: L888.

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6) The ECGshows:• Atrial fibrillation.• Ventricular rate 75-200 per min.• Normal axis.• Normal QRS.• Downsloping ST segment depression, especially in V5 and V6 leads.• Diagnosis: AF + digitalis effect.

7) The ECGshows:• Sinus rhythm.o Normal axis.• Q waves m leads II. III, VF• Normal QRS complexes rn the anterior leads.• Marked ST segment elevation in leads VI-V6.• Diagnosis: old mf. Infarction+ recent anterior wall.

8) The ECGshows:• Sinus rhythm.• Normal axis.• Broad QRS complexes (duration 140ms).• RSRpattern in lead I.• Wide and slurred S waves rn lead V5.o Normal ST segment and T waves.• Diagnosis: sinus rhythm + BBB.

9) The ECGshows:• Broad-complex tachycardia, rate about 250 per min.• Regular QRS complexes.• QRS duration 200 ms.• Indeterminate axis and QRS configurations.o Diagnosis: ventricular tachycardia.

10) The ECGshows:• Sinus rhythm.• Left axis deviation.• Q waves in leads II, II, and VF.• Elevated ST segments in leads II, III, VF with biphasic T waves.• Downsloping ST segments in lead VL.• Normal QRS complexes, ST segment and T waves in the chest

leads.• Diagnosis: recent info wall infarction.

60

11) The ECG shows:• Sinus rhythm.• Normal axis.• Normal QRS.• Marked (about 8mm) horizontal 5 T segment depression in leads

V2-V4and down sloping ST segment depression in the lateralleads.

• Diagnosis: sever antero-Iateral ischemia.

12) The ECG shows:• Sinus rhythm.• Normal axis.• Tall R waves (28 mm in lead V6, 32mm in lead V5).• Loss of R waves in lead V3.• Normal ST segments and T waves,• Diagnosis: left ventricular hypertrophy

13) The ECG shows:• Sinus rhythm, heart rate 110 per minute.• Normal nxrs.• Small Q waves in lead III.• Otherwise. normal QRS complexes and T waves.• Diagnosis: SinUStachycardia.

14) The ECG shows:

• Atrial flutter.• 4:1 block.• Normal axis.• Normal QRS complexes.• Sloping ST segment depression, best seen in leads V5, V6.• Diagnosis: A. flutter.

15) The ECG shows:• Broad-complex tachycardia, rate 170 per minute.• No clear P waves but possibly some P waves visible in lead YR.• Normal axis.• Right bundle branch block pattern.• Horizontal ST Segment depression in V4, V5.• Diagnosis: supraventricular tcchycerdio- right BBB.

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61

16) The ECQ shows:• Sinus rhythm, rate 55 per minute.• First degree block (PRinterval 350 ms).• Normal axis.• Small Q waves in leads II. III, VF.• Raised ST segments in leads II, III, VF.• Depressed ST segments and inverted T waves In leads I, VL• Slight ST Segment depression in the chest leads.• Diagnosis: recent inferior wall infarction + 1

st degree heart block.

17) The ECQshows:• Sinus rhythm with ventricular extra systole.• Normal axis.• Q waves in leads V3-V5.• Raised ST segment in leads I, VL,VI, and V6.• Depressed ST segment in leads III, VF.• Diagnosis: recent antero lateral infurctton- ventrrculcr extra systole.

18) The ECQ shows:• Sinus rhythm.• 1st degree heart block.• Normal axis.• Right BBB.• Diagnosis: sinus rhythm + 1st degree heart block + Rt. BBB.

19) The ECQ shows:• Atrial flutter with 4: 1 block.• Normal axis.• Slight QRS widening.• T waves are difficult to identify but at least in VLare inverted.• Diagnosis: atrial flutter.

20) The ECQ shows:• Sinus rhythm.• Normal axis .• Tall R waves and deep S waves in the chest leads.• Inverted T waves in leads I, II, VL,V3-V6.• Diagnosis: left ventricular hypertrophy with stram pattern.

61

16) The ECQ shows:• Sinus rhythm, rate 55 per minute.• First degree block (PRinterval 350 ms).• Normal axis.• Small Q waves in leads II. III,VF.• Raised ST segments in leads II, III, VF.• Depressed ST segments and inverted T woves m leads I, VL• Slight ST Segment depression in the chest leads.• Diagnosis: recent inferior wall infcrction « 1

st degree heart block.

17) The ECQ shows:• Sinus rhythm with ventricular extra systole.• Normal axis.• Q waves in leads V3-V5.• Raised ST segment in leads I, VL, V1, and V6.• Depressed ST segment in leads III, VF.• Diagnosis: recent antero lateral tnfcrcnon- ventricular extra systole.

18) The ECQ shows:• Sinus rhythm.• 1st degree heart block.• Normal axis.• Right BBB.• Diagnosis: sinus rhythm + 1st degree heart block + Rt. BBB.

19) The ECQ shows:• Atrial flutter with 4: 1 block.• Normal axis.• Slight QRS widening.• T wavesare difficult to identify but at least in VL are inverted.• Diagnosis: atrial flutter.

20) The ECQ shows:• Sinus rhythm.• Normal axis.• Tall R wavesand deep S waves in the chest leads.• Inverted T waves in leads I, II, VL, V3-V6.• Diagnosis: left ventricular hypertrophy with strain pattern.

21) The ECQ shows:• Regular broad complex tachycardia.• QRS complex duration of 160 ms.• Left axis deviation indeterminate QRS complex configuration, but

the complex point downwards In all the chest leads, with QSpattern in lead V6.

• Diagnosis: ventricular tachycardia.

22) The ECQ shows:• Atrial fibrillation with a ventricular rate of 60-65 per min.• Normal axis.• Normal QRS complex.• Prominent U wave in lead V2.• Downsloping ST Segments, best seen in leads V5-V6.• Diagnosis: AF + digitalis effect.

•Ramnja_ramzy2001@hotmail.com

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WITH MY JEST WISHES,

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