Basic Ecg Course

8/6/2019 Basic Ecg Course

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BASIC ECGBASIC ECG

INTERPRETATIONINTERPRETATION


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ECGECG

electrocardiogramelectrocardiogram ((ECGECG ororEKGEKG,,abbreviated from the Germanabbreviated from the German

ElektrokardiogrammElektrokardiogramm)) electroelectro, becauseitis relatedtoelectrical, becauseitis relatedtoelectrical

activityactivity

cardiocardio,, GreekGreek for heart,for heart, gramgram, a Greek root meaning"to write"., a Greek root meaning"to write".


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IndicationsIndications

Todetermine cardiac rateTodetermine cardiac rate

To accuratelydefine cardiac rhythmTo accuratelydefine cardiac rhythm

Todiagnoseoldor new MITodiagnoseoldor new MI Toidentifyintracardiac conductionToidentifyintracardiac conduction

disturbancesdisturbances

To aidin thediagnosis ofischemic heartTo aidin thediagnosis ofischemic heartdiseaseelectrolytes abnormalities anddiseaseelectrolytes abnormalities andpacemakermalfunctionpacemakermalfunction


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PROPER LEADS PLACEMENTPROPER LEADS PLACEMENT


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Lead V1 is placedin the fourth intercostal space to therightof the sternum

Lead V2 is placedin the fourth intercostal space to theleftof the sternum

Lead V3 is placeddirectly between leads V2 and V4 Lead V4 is placedin the fifth intercostal spacein the

midclavicularline(even if theapex beatis displaced) Lead V5 is placed horizontally with V4 in the anterior

axillaryline

Lead V6 is placed horizontally with V4 and V5 in themidaxillaryline

.

.


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MeasurementMeasurement


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Six components of ECGSix components of ECG

InterpretationInterpretation RateRate

RhythmRhythm

AxisAxis HypertrophyHypertrophy

Ischemia andinfarctionIschemia andinfarction

Miscellaneous findings (including normalMiscellaneous findings (including normalvariants)variants)

Mnemonic: RRAHIMMnemonic: RRAHIM


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RateRate

Formula:Formula:

HRHR == 15001500# of small square# of small square

== 300300

# of big boxes# of big boxes


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RateRate


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RateRate

ShortcutShortcut

If R to R intervalis > 5 big squares:If R to R intervalis > 5 big squares:

BradycardiaBradycardiaIf R to R interval between 3If R to R interval between 35 big5 bigsquares:squares:

NormalrateNormalrateif R to R intervalis < 3 big squares:if R to R intervalis < 3 big squares:

TachycardiaTachycardia


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AxisAxis


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AxisAxis

Lead ILead I Lead AVFLead AVF

NormalNormal ++ ++

Left axisLeft axis

deviationdeviation++ --

Right axisRight axis

deviationdeviation

-- ++

IndeterminateIndeterminate

axisaxis-- --


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Differential Diagnosis of Right andDifferential Diagnosis of Right andLeft Axis DeviationLeft Axis Deviation

LADLAD RADRAD

Normalvariant( short &Normalvariant( short &

fatindividualsfatindividuals

LVHLVH

Inferior wallinfarctionInferior wallinfarction

LBBBLBBB

LAHBLAHB

WPWSWPWS

Normalvariant( thin, tallNormalvariant( thin, tall

individuals)individuals)

RVHRVH

Lateral wallinfarctionLateral wallinfarction

Pulmonary EmbolismPulmonary Embolism

LPHBLPHB


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AxisAxis

causes of a Northwest axis (no man'scauses of a Northwest axis (no man'sland)land)

emphysemaemphysema hyperkalaemiahyperkalaemia

lead transpositionlead transposition

artificial cardiac pacingartificial cardiac pacing ventricular tachycardiaventricular tachycardia


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RhythmRhythm

Commom Rhythm Interpretations:Commom Rhythm Interpretations:1.1. Sinus rhythmSinus rhythm2.2. Arrhythmias ( AF, AtrialFlutter, SVT)Arrhythmias ( AF, AtrialFlutter, SVT)

3.3. Heart BlocksHeart Blocks-- firstdegree AV Blockfirstdegree AV Block-- Seconddegree AV Block ( Mobits Type 1 andSeconddegree AV Block ( Mobits Type 1 and22

-- Thirddegree AV BlockThirddegree AV Block-- LBBB and RBBBLBBB and RBBB

4. Ventricular arrhythmias ( PVC, VT , VF)4. Ventricular arrhythmias ( PVC, VT , VF)


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Sinus rhythmSinus rhythm P waveis presentP waveis present Each QRS is preceded by a P waveEach QRS is preceded by a P wave HR 60HR 60 -- 100100


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Sinus arrhythmiaSinus arrhythmia

PP--P intervalvary bymore than 10%P intervalvary bymore than 10%


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AtrialFibrillationAtrialFibrillation P waves are absentP waves are absent Irregular RIrregular R--R intervalR interval


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AtrialFlutterAtrialFlutter sawtooth patternsawtooth pattern absenceof P waveabsenceof P wave


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Premature Atrial contractionPremature Atrial contraction

P wave thatdiffers in morphologyP wave thatdiffers in morphology


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Premature Ventricular ContractionPremature Ventricular Contraction

bizzarelooking QRS complexbizzarelooking QRS complex


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HypertrophyHypertrophy

1.1. Atrial HypertropyAtrial Hypertropy

-- P wavemore than 3 small square wideP wavemore than 3 small square wide

A.A. RAHRAH-- largediphasic P wave with tallinitiallargediphasic P wave with tallinitialcomponent.component.

B. LAHB. LAH-- largediphasic P wave with widelargediphasic P wave with wideterminal component.terminal component.


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HypertrophyHypertrophy

Left ventricular hypertrophy (LVH)Left ventricular hypertrophy (LVH)There are many different criteria for LVH.There are many different criteria for LVH.

Sokolow + LyonSokolow + Lyon (Am Heart J, 1949;37:161)(Am Heart J, 1949;37:161) SV1+ R V5 or V6 > 35 mmSV1+ R V5 or V6 > 35 mm

Cornell criteriaCornell criteria (Circulation, 1987;3: 565(Circulation, 1987;3: 565--72)72) SV3 + R avl > 28 mm in menSV3 + R avl > 28 mm in men SV3 + R avl > 20 mm in womenSV3 + R avl > 20 mm in women

Framingham criteriaFramingham criteria (Circulation,1990; 81:815(Circulation,1990; 81:815--820)820)

R avl > 11mm, R V4R avl > 11mm, R V4--6 > 25mm6 > 25mm SV1SV1--3 > 25mm, SV1 or V2 +3 > 25mm, SV1 or V2 + R V5 or V6 > 35mm, R I + S III > 25mmR V5 or V6 > 35mm, R I + S III > 25mm

Romhilt + EstesRomhilt + Estes (Am Heart J, 1986:75:752(Am Heart J, 1986:75:752--58)58) Point score systemPoint score system


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Ischemia/InfarctIschemia/Infarct

IschemiaIschemia

-- T waveinversionT waveinversion

-- ST depressionST depression

InfarctionInfarction

-- ST elevationST elevation


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TREADMILL STRESS TESTTREADMILL STRESS TEST

FordiagnosisFordiagnosis

Atypical symptoms or symptoms suggestiveofAtypical symptoms or symptoms suggestiveofIHDIHD

Prognostic assessment and functional capacityPrognostic assessment and functional capacityevaluationevaluation

Blood pressureevaluationBlood pressureevaluation

Evaluation of therapy for arrhytmiasEvaluation of therapy for arrhytmias


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CONTRAINDICATION FOR TETCONTRAINDICATION FOR TET

PhysicaldisabilityPhysicaldisability

Acute non cardiac illnessAcute non cardiac illness

Acute MI ( within 2 days)Acute MI ( within 2 days) Suspected Leftmain coronary arterySuspected Leftmain coronary artery

stenosisstenosis

Uncompensated CHF( Class IIIUncompensated CHF( Class III--IV)IV)


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Uninterpretable ResultUninterpretable Result

Resting ST segmentdepression >1 mmResting ST segmentdepression >1 mm

Digitalis therapyDigitalis therapy

LVH with repolarization changesLVH with repolarization changes CLBBBCLBBB

PrePre-- excitation syndromeexcitation syndrome


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High risk parametersHigh risk parameters

Duration of symptomDuration of symptom--limitinglimitingexercise 120mmHg,or a sustaines dercrease >10 mmHgor a sustaines dercrease >10 mmHgduring progressiveexerciseduring progressiveexercise

ST segmentdepression of >2mmST segmentdepression of >2mm(downsloping type)(downsloping type)


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High risk parametersHigh risk parameters

ST segmentelevation ( AVR excluded)inST segmentelevation ( AVR excluded)ina non Q waveleada non Q wavelead

Reproducible sustaines ( >30 sec)orReproducible sustaines ( >30 sec)orsymptomatic VTsymptomatic VT


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INDICATIONS FORINDICATIONS FOR

TERMINATING A STRESS TESTTERMINATING A STRESS TESTModerate to severe anginaModerate to severe angina

Increasing nervous system symptomsIncreasing nervous system symptoms

Patient unable to continuedue toPatient unable to continuedue toexcessive fatigue, claudication, wheezing,excessive fatigue, claudication, wheezing,ordyspneaordyspnea

Achievemntof predictedmaximal heartAchievemntof predictedmaximal heartrate for agerate for age

Decreasing heartrateDecreasing heartrate


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INDICATIONS FORINDICATIONS FORTERMINATING A STRESS TESTTERMINATING A STRESS TEST

BP systolic >220 mmHg ordiastolic >115BP systolic >220 mmHg ordiastolic >115mmHgmmHg

BP drops by 10mmHg from baselineBP drops by 10mmHg from baselineindicativeofleftventriculardysfunctionindicativeofleftventriculardysfunction

When high risk exercise parameters areWhen high risk exercise parameters arealready present:already present:

--Ischemic ST segmentdepressionIschemic ST segmentdepression >> 3mmin3mminseveralleadsseveralleads


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INDICATIONS FORINDICATIONS FORTERMINATING A STRESS TESTTERMINATING A STRESS TEST

--Ischemic ST segmentelevationIschemic ST segmentelevation >> 1 mmin1 mmina nona non--Q wavw leadQ wavw lead

Unsustainedventricular tachycardiaUnsustainedventricular tachycardia Onsetof supraventricular tachycardia,Onsetof supraventricular tachycardia,

advanced AV block or bradyarrhythmiasadvanced AV block or bradyarrhythmias

Technical problems interfering with ECGTechnical problems interfering with ECGand BP interpretationand BP interpretation

Patient's desire to stop the testPatient's desire to stop the test


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Basic Ecg Course

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