20 IMPORTANT ECGs
NOOR ATIKAH SAINI080201033
Ecg 1
h/o: 60 years old man with 4 hours crushing chest pain
This ECG shows :• Rate = 60/min• Rhythm = sinus rhythm• Axis = normal• P wave = normal• QRS complex = normal• T wave = normal• ST segment = elevated in the anterior leads V1-V6, I and aVL = reciprocal ST depression in the inferior leads ( leads II,III, aVF)• PR interval = normal• QT interval = normal
Diagnosis = Acute Anterolateral Myocardial Infarction
Ecg 2 :
H/o: A 56 years old man with chest pain and vomiting for 90 minutes
This ECG shows :• Rate = 50/min• Rhythm = sinus• Axis = normal• P wave = normal• QRS complex = normal• T wave = normal• ST segment = elevated in the inferior leads II, III, aVF. reciprocal ST depression in the anterior leads ( V1-V4).• PR interval = normal• QT interval = normal
Diagnosis = Acute Inferior Myocardial Infarction
Ecg 3 :
H/o: A 78 years old lady with chest pain and collapse, BP 60/40
This ECG shows :• Rate = 50/min• Rhythm = sinus• Axis = normal• P wave = normal• QRS complex = tall R wave in leads V1-V3• T wave = tall upwright T wave in leads V1-V3• ST segment = depression in anterior leads V1- V3• PR interval = normal• QT interval = normal
Diagnosis = Acute Posterior Myocardial Infarction
Summary :1. Features of MI based on its site of infarction:
Changes of ECG
Anterolateral MI
Inferior MI Posterior MI
ST segment
•ST elevetion in leads V1-6, I and aVL
•With ST depression in leads II,III,aVF
•ST elevation in the leads II, III and aVF
•With ST depression in leads V1-V4
ST elevation in leads V1-3
R wave - - Tall R wave in leads V1-V3
T wave - - Tall T wave in leads V1-3
Progression of Ischaemia to Injury to Infarction
ECG changes:• Ischaemia = only T wave abnormalities • Injury = T waves + ST segments abnormalities • Infarction = T waves + ST segments + QRS complexes abnormalities
Ecg 4 :
H/o: A 64 years old man with breathlessness and a raised JVP
This ECG shows:• Rate = 120 beats/min• Rhythm = sinus• Axis = normal• P wave = normal • QRS complex = normal• T wave = small or inverted• ST segment = widespread • PR interval = normal• QT interval = normalOther features = alternating high and low voltages of all the ECG waveforms Diagnosis = Electrical alternans of pericardial effusionThe classic example is a pericardial effusion with the heart "swinging" in it
and changing its location and proximity to the chest wall (where the electrodes are) from beat to beat.
electrical alternans/low voltage alternans:=>alternate-beat variation in the direction, amplitude, and duration of any
component of the ECG waveform (ie, P, PR, QRS, R-R, ST, T, U).
Causes :1. Physical : hypothermia2. Infections : myocarditis, pericardial TB3. Neoplasm : pericardial mesothelioma4. Metabolic disorders : obesity, heart amyloidosis,haemochromatosis
cardiomyopathy5. Structural disorders : pericardial effusion, cardiac temponade,
hydro/hemopericardium,pneumothorax6. Poisoning : chronic alchoholism
60 year old male with chronic kidney disease on mantainance hemodialysis is brought to emergency with breathlessness and volume overload
Findings:-sinus rhythm-small or absent P wave-long PR interval-shortened ST segment -normal axis-broad QRS complexes-tall tented T waves
Hyperkalemia Definition:plasma potassium level of
5.5mM Changes in hyperkalemia:1.mild-prolongation of PR and QRS interval.2.moderate-loss of Pwave and progressive
widening of QRS complex3.severe-sine wave sinoaventricular rhythm
Management:-IV administration of glucose along with
insulin to encourage shift of potasium from EC to IC compartment
-50ml of 50% glucose plus 10 unit of soluble insulin as bolus
-500ml 20% glucose plus 10 unit of soluble insulin as infusion over 6 – 12 hours
-10ml of 10% calcium gluconate IV slowly over 2-5 min to stabilise myocardial cell
-50 – 100ml of 8.4% sodium bicarbonate IV-nebulisation of beta agonist( salbutamol)-if these measure fail hemodialysis is
indicated
Case 2A 22 year old lady with prolonged vomitting
Findings:-sinus bradycardia-long PR interval-normal axis-small T wave-Presence of U wave (repolarization of
papillary muscles or purkinje fibres) -ST segment deviation-prolonged QT interval
ECG changes of hypokalemia-increased amplitude and width of Pwave-prolongation of PR interval-T wave flattening and inversion-ST depression-prominent U wave-apparent long QT interval due to fusion of T
and U waves
Hypokalemia-causes:1.Low PTH level:parathyroid agenesis,
destruction, reduced function2.High PTH level:vit D deficiency, drugs, PTH
resistance syndrome, acute pancreatitis-features1.Asymptomatic2.Paresthesia of fingers ,toes,circumoral
regions3.severe:seizure, carpopedal spasm,
bronchospasm, laryngospasm
Case 3A 65 year old women with congestive cardiac failure and on treatment come with the ECG.
Findings:-Abnormal rhythm-inverted T wave-downward sloping ST segment- reversed tick
sign -depressed ST – J point-shortened QT interval
Digitalis effects-digitalis is a drug used in CCF and to slow
the ventricular rate in atrial tachyarrhythmias
-digitalis effects is due to early recovery and repolarisation of myocardial cells.
1.coved ST segment depression 2.flattened T wave 3.decreased QT interval
Digitalis toxicity-due to excessive amount of digitalis >2ng/ml-features: 1.general symptoms-weakness, anorexia,
nausea, vomitting, visual effects and mental changes.
2.arrhythmias and conduction disturbance-ventricular arrhythmia,bidirectional ventricular tachycardia,AV junctional rhythm,sinus bradycardia
-treatment: 1.prevention-baseline ECG, serum electrolyte,
BUN and creatinine. 2.definitive treatment depend on arrhythmia minor-discontinuation of digitalis and
careful observation serious-suppression with IV drugs lidocaine -pacemaker in patient with
complete heart block -digitalis binding antibody IV
(digoxin immune Fab)-lethal dose
Case 4A 40 year old male, asymptomatic came with the ECG
Findings :-sinus rhythm-inverted P wave in lead I-increased PR interval-right axis deviation-QRS complexes get progressively smaller
from V1 to V6 with small R wave
Dextrocardia It is the condition in which the cardiac
apex is in the right side of the chest D/D-accidental reversal of the left and right arm
electrodes-situs inversus : congenital condition in
which major visceral organs are reversed from their normal position
CASE #1• A 27 year old female, Mrs. Terry,
a known case of α₁-antitrypsin deficiency, complained of fever, increased breathlessness and wheezing since 3 days.
COPD
• Rhythm : sinus rhythm• Axis : right axis deviation• P wave : P pulmonale ( >2.5mm in lead II)
D/D for P pulmonaleValvular disease
• Tricuspid stenosis
• Tricuspid regurgitation
Pulmonary hypertension
• COPD• Pulmonary
embolism• ILD• Sleep apnoea• LV systolic
dysfunction
Congenital heart disease
• Ebstein’s anomaly
EBSTEIN’S ANOMALY-congenital condition often associated with WPW syndrome
ECG findings- ‘Himalayan’ P wave- prolong PR interval
ECG 240 year old female with history of chronic breathlessness
• Rhythm : irregularly irregular• Axis : right axis deviation• P wave : diminished
MITRAL STENOSIS
LA enlargement???
CASE #3• An 83-year-old man who is
apparently asymptomatic came to OPD.He is regularly seen by your colleague. Since your colleague is on leave,this patient asked your review on his current heart condition.
ECG #3
• Rhythm : sinus rhythm• Axis : left axis deviation• P wave : biphasic (2nd half of wave is –ve)• QRS complex : deep S wave, tall R wave
DIAGNOSING LVH ON ECG• Limb Leads (Low sensitivity, high specificity)
– R wave lead I + S wave lead III > 25 mm– R wave aVL > 11mm– R wave aVF > 20mm– S wave in aVR > 14mm
......
• Precordial Leads (High sensitivity, low specificity)
– R wave V5 or V6 > 26mm– R wave V5 or V6 + S wave in V1 > 35mm– Largest R wave + largest S wave in precordial leads
> 45mm
........
• The Sokolow-Lyon criteriumR in V5 / V6 + S in V1 > 35mm
• The Cornell criteriumR in aVL and S in V3 >28 mm in menR in aVL and S in V3 >20 mm in women
ECG #4
CASE #4• A 60-year-old female, known
case of IHD, presented with palpitations in the OPD. On examination, her measured systolic BP is 80.
Torsades de Pointes
TORSADES DE POINTES(Polymorphic ventricular tachycardia)
• Acute management1)Electrolyte2)Drugs3)Heart rate4)MgSo₄5)IV isoprenaline
• Long-term management1)β-blockers2)Left cardiac sympathetic
denervation3)Pacemaker
ECGNUR SHUHAIZA BINTI SUPIAN
080201039
CASE 1A 23 years old male with h/o episodes of palpitation
ECG FINDINGS: Normal rate Sinus rhythm Normal axis Short PR interval Slurred upstroke of QRS complex, best seen
in I, V4, V5 Widened QRS complex due to ‘delta’ wave
WPW SYNDROME
WOLFF-PARKINSON-WHITE SYNDROME
one of several disorders of the conduction system of the heart that are commonly referred to as pre-excitation syndromes.
majority of individuals with WPW remain asymptomatic throughout their entire lives
risk of sudden cardiac death associated with the syndrome.
caused by the presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles
Electrical signals travelling down this abnormal pathway (known as the bundle of Kent) may stimulate the ventricles to contract prematurely, resulting in a unique type of supraventricular tachycardia referred to as an atrio-ventricular reciprocating tachycardia.
CASE 2A 50 years old male with h/o chest pain for 24 hours
Sinus rhythm with ventricular bigeminy Normal rate and axis Bigeminy : every sinus beat is followed by a
ventricular premature beat No preceding P wave The coupling interval is usually constant Usually followed by compensatory pause
VENTRICULAR BIGEMINY
Compensatory pause:The R-R interval between the beats directly preceding and following the VPB is exactly twice that of regular R-R interval
Common cause for ventricular bigeminy: May occur in normal individual Ischemic heart disease Digoxin toxicity Left ventricular dysfunction
CASE 3A 40 years old female, bedridden for 48 hours, come with c/o breathlessness
Sinus tachycardia Normal rate Normal axis Prominent S wave in Lead I Small Q wave, inverted T wave in Lead III
S1 Q3 T3 PATTERN
ACUTE PULMONARY EMBOLISM
CASE 4A 60 years old male, recently diagnosed with myocardial infarction
Rate increased (>100/min) Sinus rhythm Independent P wave Broad QRS complexes (>0.16s) beat to beat variability of the QRS
morphology
VENTRICULAR TACHYCARDIA
Fusion beat:When one impulse originating from ventricle and a second supraventricular impulse simultaneously activate the ventricular myocardium
Capture beat:Normal conduction momentarily “captured” control of ventricular activation from VT focus
Brugada Criteria: Lack of an RS complex in the precordial leads
Whether the longest interval in any precordial lead from the beginning of the R wave to the deepest part of the S wave when an RS complex is present is greater than 100 ms
Whether atrioventricular dissociation is present
Whether both leads V1 and V6 fulfilled classic criteria for ventricular tachycardia.
Immediate cardioversion in synchronised mode
IV Amiodarone : given as bolus followed by continuous infusion
IV Lidocaine
TREATMENT OF VT:
AV BLOCKS
• FIRST DEGREE- All impulses conducted, but delay present
(prolonged PR interval)In coronary artery disease, drug toxicity(digoxin, CCB’s, β blockers) electrolyte disturbances(hyperkalemia) acute rheumatic carditis, congenital heart diseases(ASD, Ebstein’s anomaly)
• SECOND DEGREE- Impulse completely fails to pass through the AV
node Mobitz type ll Wenkebach phenomenon/Mobitz type l Causes- o Physiological- atheletes, vagotonic individualso Acute rheumatic carditiso MI (eg inf wall, right ventricular)o Acute diphtheric myocarditiso Drugs- digitaliso Idiopathic fibrosis of the conduction system
(Lenegre’s disease)
• THIRD DEGREE- Atrial contraction is normal, but no beats are
conducted to the ventricles Causes- o Drugs-o Acute MIo Acute rheumatic carditiso Congenital heart disease(ASD, VSD)
HOW TO DIAGNOSE
• LOOK FOR-R-R INTERVAL
P WAVES
P-R INTERVAL
R-R INTERVAL
REGULAR IRREGULARP-R INTERVAL 2ND DEGREE
SAME VARIABLE P-R INTERVAL
1ST DEGREE 3RD DEGREE CHANGES FIXED MOBITZ TYPE I TYPE II
CASE I
• 70 year old male, complains of exercise intolerance
• RATE- normal• RHYTHM- regular( dual rhythm)• AXIS- normal• P WAVE• QRS COMPLEX• T WAVE• PR INTERVAL• QRS INTERVAL
CASE II
• 90 year old male, presented with syncope
Rhythm : sinus rhythmAxis : normalP wave : QRS complex : widersR’ pattern (M shaped) in V1, V2
•T wave : inversion in V1, V2 •wide, slurred S wave in L I and V5, V6 ST segment : depression in V1, V2PR interval :QT interval :
CAUSES
• acute myocardial infarction,• acute pulmonary embolism,• chronic cor pulmonale• Congenital heart disease(ASD, VSD, Ebstein’s
anomaly)• Myocarditis• Cardiac contusion
CASE III
• 90 year old male presented with sudden onset of chest pain and was diagnosed to have myocardial infarction
•Rhythm : sinus rhythm•Axis : normal•P wave : •QRS complex :wide small r waves followed by deep, wide and slurred S waves in V1, V3;•broad, notched or slurred (M shaped) R wave in L I, aVL, V5, V6;absence of q waves in L I, aVL, V5, V6;•T wave : inversion•ST segment :depression in L I, aVL, V5, V6 •PR interval :•QT interval :
CAUSES
• Always pathological• acute myocardial infarction,• hypertensive heart disease • dilated cardiomyopathy• Aortic valve disease• Drugs (quinidine).
CASE IV
• 90 year old male with a past history of MI, which was complicated by LBBB. He is currently asymptomatic
WHERE IS THE PACEMAKER ?• Atrial pacing spikes- short vertical lines
preceding the P waves and best seen in lead III• Ventricular pacing spikes- precede the QRS
complex and best seen in lead V2 , V3, V4 & V5
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