ECG and Arrhythmias

Dec, 1st 2014

Doctor Mohammad Jarrah
References:
- Lecture and Slides
- ECG Made Easy
- First Aid Cases for the USMLE Step 1

- Davidson Principles of Medicine

- Mini-OSCE Archive

ECG stands for electrocardiogram; its a record of the hearts electrical activity. its a
very important tool that can provide evidences to support a specific diagnosis.
Remember that most abnormalities in the ECG are amenable to reason.
The Basics:
The quality of an ECG is determined by the presence of PATIENTS NAME,
DATE/TIME, the 12 LEADS and a RYTHEM STRIP at the bottom.
The paper moves in a speed of 25mm/s (horizontal).
?If faster (50mm/s) itll give a false impression of slow HR

And a caliberation of 1cm or 10mm/mV (vertical).

?if >1mm/mv gives a false impression of Left Ventriuclar Hypertrophy

1 small square (Ssq) = 1 mm, 1 large square (Lsq) = 5 Ssq = 5 mm.

P: Atria Depolarization (<2.5 mm vertical)

QRS: Ventricular Depolarization
T: Ventricular Repolarization
U: Repolarization of the papillary muscles
follows the T wave. (Normal or Abnormal)
PR interval: 120-220 ms (3-5 small squares)
>220: Block, <120: accessory pathway
QRS complex: 120 ms (3 small squares)
1 min = 60 sec = 60* (5 large squares) = 300 large square

Heart Rate= 300 (Lsq)/ R-R interval

= 1500 (Ssq)/ R-R interval
= # of R per 15 (Lsq) * 20
= (60-100 bpm) normally.
Rhythm:
- Sinus rhythm if each QRS is preceded by P
- Regular rhythm if the distance between
the R is constant.
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Normal ECG
Positive deflection: If a wave of depolarization passing through the heart is moving
toward a surface electrode
Negative deflection: If a wave of depolarization passing through the heart is moving
away from the electrode.
Biphasic wave: If a wave of depolarization passing through the heart is moving
perpendicularly to the electrode.

The 12-Lead ECG

6 limb leads:
I between right arm and left arm.
II between right arm and left leg.
III between left arm and left leg.
aVR: right arm, aVL: left arm, aVF: left leg
I, II, aVL: Left lateral surface.
III, aVF: Inferior surface.
aVR: Right surface.

In a normal cardiac axis (about 60 degrees):

Lead II and aVF have the highest positive deflection.
I and II are normally both positively deflected.
Lead II is usually the long rhythm strip, with the most obvious P wave.

6 chest leads:
V1 and V2: Parasternal at 4th intercostals space.
V3 is in between V2 and V4.
V4, V5 and V6 at the 5th intercostal space:
V4: Midclavicular line
V5: Anterior axillary line
V6: Middle axillary line.
V1, V2, V3, V4: Anteriospetal surface.
V5,V6: Lateral surface
In a normal cardiac axis (about 60 degrees):
- V1: Small R, Deep S
- V2: R increases, S decreases
- V3/V4: R=S
- V5/V6: Large R, S disappears in normal
people
If the R is poorly enlarging (poor
progression R wave sign of ischemia)

The Cardiac Axis: Normally, between -30 and +90

Right Axis Deviation/RAD (>+90):

Right ventricular hypertrophy
Left Axis Deviation/LAD (<-30):
Left ventricular hypertrophy, LBBB.
Indeterminate Axis (No Mans Land):
extreme LAD or extreme RAD, Dextrocardia.

-ve Lead I
+ve Lead II
+ve Lead I
-ve Lead II
-ve Lead I, II & III
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Normal ECG Record:

12 leads with a rhythm strip (II)

Good Voltage (2 Lsq or 1cm vertical)
HR = 300/5 = 60 bpm
Regular Sinus Rhythm: P wave precedes each QRS with good relation between them
PR interval is between 3-5 Ssq, P voltage is less than 2.5 Ssq
QRS complex is less than 3 Ssq
QT isnt prolonged (<450 ms)
Normal axis (+ve lead I,II and III)
Negative T wave in V1 is normal
V1V6: R increases and S decreases (disappears in V6)

ECG Record with some abnormalities:

12 leads with a rhythm strip (II)

Good Voltage (2 Lsq or 1cm vertical)
HR > 60 bpm
Regular Sinus Rhythm: P wave precedes each QRS with good relation between them
PR interval is between 3-5 Ssq, P voltage is less than 2.5 Ssq
QRS complex is slightly widened is some leads
Left axis deviation (+ve Lead I and ve Lead II)
Poor progression R wave Ischemia
S wave in V6 ? Abnormality
The abnormally looking complex in aVF is just an artefact (not significant)
Abnormalities due to machine or human error:
Paper speed 12.5 mm/s false rapid heart rate

Patient is shivering
Remember: ECG must be individualized:
Male vs Female, Old vs Young, Chest Pain vs Normal
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 The Abnormalities of the waves, complexes and intervals:

P wave abnormalities
Absence
Not Sinus
P Pulmonale:
Right Atrial dilatation/hypertrophy due
Pointy; >2.5 Ssq vertical in Lead II
to cor pulmonale/COPD/...

P Mitral:
Bifid in Lead II

Too short (<3 Ssq)

Too long (>1Lsq)

Left Atrial dilatation/hypertrophy due to

Mitral stenosis (MS) or sometimes MR

PR Interval Abnormalities
- Wolf Parkinson White syndrome
(WPW): accessory pathway
associated with Delta wave.
- Could be normal in rapid heart
rate.
Heart block/AV block
(1st, 2nd and 3rd degrees)

Spot on Arrhythmias:
Preexcitation syndromes (WPW Syndrome):
Preexcitation is a condition characterized by an accessory pathway of conduction,
which allows the heart to depolarize in an atypical sequence.
In Wolfe-Parkinson-White (WPW) syndrome, theres a direct atrioventricular
connection allows the ventricles to begin depolarization while the standard action
potential is still traveling through the AV node.
ECG Characteristics of WPW:
1. Short PR interval 2. QRS prolongation
3. Delta Wave
4. Followed by tachycardia
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In fact, the PR interval isnt shortened, but it looks so due to the emergence of the
delta wave.
Heart Block (AV block):
1st degree Heart block:
- Prolongation of the
PR interval, which is
constant
- All P waves are
conducted
2nd degree Heart block
(Mobitz 1)/Wenckebach:
- Progressive
prolongation of the
PR interval until a P
wave is not
conducted.
- As the PR interval
prolongs, the RR
interval actually
shortens
2nd degree Heart block
(Mobitz 2):
Constant PR interval with
intermittent failure to
conduct
Third degree Heart block
(Complete):
No relationship between
P waves and QRS
complexes, Relatively
constant PP intervals and
RR intervals and Greater
number of P waves than
QRS complexes

QRS complex Abnormalities

Generally, if QRS > 0.12 ms Bundle Branch Block (Rt vs Lt)
Accepted Q waves: V1, aVR and III
Pathological Q waves: >25% of
subsequent complex and unusual
location on leads previous infarction.

Sum of the S wave (-ve deflection) in V1

and the biggest R wave in V5 or V6
>35mm (> 5Lsq) Left Ventricular
Hypertrophy (LVH)

If LVH is presented with ST depression

and T inversion on the left leads indicates
LVH induced infarction (blood supply isnt
enough for the hypertrophied muscle
tissue (LVH with Strain)

LVH with Strain, Normal sinus rhythm

Spot on LBBB and RBBB:

Common causes

ECG changes

RBBB
- Normal variant
- Right ventricular
hypertrophy or strain
- ASD
QRS > 3 Ssq
RSR (M shaped QRS complex)
in V1, V2 and deep S in V6.
- May present with RAD
(usually) or LAD (Atrial
septal defect, severe
conducting problem)

LBBB
- CAD
- HTN
- Aortic valve disease
- Cardiomyopathy
QRS > 3 Ssq
RSR (M shaped QRS complex)
in V5, V6, I and deep S in V1
- Usually associated with
LAD

Appearance

Mnemonic

MaRRoW:
M first letter = M in V1

WiLLiaM:
M last letter = M in V6

RBBB with LAD:

Bifascicular rhythm

ST segment Abnormalities
These are usually in territories eg. anterior/lateral/inferior etc. and will be present in
contiguous leads (III,aVF or I,aVL,V5,V6 ...)
ST depression:
- Downsloping or horizontal =
abnormal
- Ischaemia (coronary stenosis):
Chest pain association
- If lateral (V4-V6), consider LVH
with strain or digoxin toxicity
ST elevation
- Infarction (coronary occlusion)
- Pericarditis (widespread)
- Prinzmetal spasm
- Post ventricular aneurysm
- Early embolization

Normal rhythm (P wave in II) and axis, ST elevation is V2-V6, and minimally in aVL, Q
wave also present: Acute MI in the proximal Left Anterior Descending Artery.
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Sinus rhythm
ST depression Lead I, aVL, ST elevation V5, V6 Lateral MI (acute over chronic)
ST elevation in III and aVF Inferior MI
reciprocal ST depression in V1, V2 Posterior MI
InferioPosterioLateral MI
Super-dominant Right coronary artery, proximal occlusion.
ask for Right ventricular leads
Right Ventricular Infarction Cardiogenic Shock Hypotension IV fluids

Pericarditis: Sinus tachycardia with Diffuse ST elevation in all leads except:

V1: Normal or depression, aVR: ST depression
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T wave Abnormalities
Peaked hyperkalaemia or normal young man

Inverted/biphasic ischaemia, previous infarct

Small hypokalaemia

What is the rate, rhythm and axis for these patients, and is there any other abnormalities?

Not sinus (ectopic) and irregular rhythm, rate = 120, right axis deviation?, LVH due to
deep S and huge R, T inversion can be seen laterally.
LVH Right atrial abnormality and fibrillation

P wave present, Sinus tachycardia and LVH (whats the rate?)

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P wave present, Sinus bradychardia (whats the rate?)

Recall that the NORMAL SINUS RHYTHM shows Regular narrow-complex rhythm
Rate 60-100 bpm, Each QRS complex is proceeded by a P wave
P wave is upright in lead II & downgoing in lead aVR

Bradycardia, and obvious delta wave in V1 WPW Syndrome

ST elevation in inferior leads and No relation between P and QRS
complete Heart Block
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QT interval Abnormalities
QT interval must be corrected because
Long QT (>450ms) can be genetic
its affected by the HR:
(long QT syndrome) or secondary
due to drugs (amiodarone, sotalol)
Associated with risk of sudden
death due to Torsades de Pointes
(check page 16)

Atrial and Ventricular Arrythmias?

Supraventricular means SA, AV or Atrial origin.

Most Important Arrythmias to be familiar with:
SVT (Supraventricular Tachycardia):
Narrow QRS, Rate >150, regular RR complexes, P wave may be superimposed on T
wave or hidden inside the QRS complex:

Atrial Flutter:
Biphasic sawtooth flutter waves at a rate of >250/min
Flutter waves have constant amplitude, duration, and morphology through the
cardiac cycle.
There is usually either a 2:1 or 4:1 block at the AV node,
resulting in ventricular rates of either 150 or 75 bpm
Adenosine is used to unmask an unclear record (SVT or Flutter?) by showing
the saw-tooth appearance.
14

Atrial Fibrillation
Atrial fibrillation is caused by numerous wavelets of depolarization spreading
throughout the atria simultaneously, leading to an absence of coordinated atrial
contraction. AF is important because it can lead to: Hemodynamic compromise,
Systemic embolization and other Symptoms
On ECG:
Absent P waves, Presence of fine fibrillatory waves which vary in amplitude and
morphology, Irregularly irregular ventricular response.

Ventricular Tachychardia: (usually follows MI)

- Broad bizzare QRS complex - Regular RR waves
- Rate >120 (less than the SVT)
- P waves are present, fused with T or on top of ascending QRS complexes
- Treat with lignocaine or DC shock.
Some times a normal QRS is present within the tachycardia: Capture beat.

15

Torsade de Pointe: usually with prolonged QT interval

The QRS complexes spin around the baseline, changing their axis and amplitude

Ectopic Beats
Abnormal early beat whether atrial or ventricular within a normal ECG
In ventricular extrasystole/ectopic beat : QRS would look broad and bizarre, not preceeded
by P and followed by opposing ST-T changes and by a compnesatory pause.
In Atrial extrasystole/ectopic beat: QRS would look normal, abnormally looking P wave and
with a compnesatory pause.

Unknown Arrhythmia (not discussed)?

1. Is the rate slow (<60 bpm) or fast (>100 bpm)?
Slow Suggests sinus bradycardia, sinus arrest, or conduction block
Fast Suggets increased/abnormal automaticity or reentry
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2. Is the rhythm irregular?

Irregular Suggests atrial fibrillation, 2nd degree AV block, multifocal atrial
tachycardia, or atrial flutter with variable AV block
3. Is the QRS complex narrow or wide?
Narrow Rhythm must originate from the AV node or above
Wide Rhythm may originate from anywhere
4. Are there P waves?
Absent P waves Suggests atrial fibrillation, ventricular tachycardia, or rhythms
originating from the AV node
5. What is the relationship between the P waves and QRS complexes?
More P waves than QRS complexes Suggests 2nd or 3rd degree AV block
More QRS complexes than P waves Suggests an accelerated junctional or
ventricular rhythm
6. Is the onset/termination of the rhythm abrupt or gradual?
Abrupt Suggests reentrant rhythm
Gradual Suggests altered automaticity

When the variations in PP interval occur in phase with respiration, this is considered
to be a normal variant, called sinus arrhythmia:

What is the Sick Sinus Syndrome (SSS)?

Characterized by a collection of symptoms and ECG findings due to chronic
dysfunction of the sinoatrial (SA) node:
Chronic and severe sinus bradycardia
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 Sinus pauses
Sinus arrhythmia
Complete sinus arrest
Progressive development of atrial arrhythmias (a-flutter, a-fib, atrial
tachycardia)
Patients are usually elderly and present with lightheadedness and/or syncope,
but it can also manifest as angina, dyspnea, and palpitations.

Tachycardia-Bradycharida Variant: (needs pacemaker and medication for the AV)

Etiologies:
Sinus node firbosis , Atherosclerosis of the SA artery, Congenital heart disease,
Excessive vagal tone, Familial, Pericarditis, Hypothyrodism.
Multifocal Atrial Tachycardia:

Discrete P waves with at least 3 different morphologies. Atrial rate > 100 bpm.
The PP, PR, and RR intervals all vary.
Its very common with COPD and Lung fibrosis patients.

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Abnormalities due to electrolyte disturbance:

Hyperkalemia: (peaked T)

Hypokalemia: (U wave)

Hypercalcemia: (QT Shortening)

Hypocalcemia: (QT Elongation)

Interpret this ECG case, before checking its answer beneath it:

RBBB

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First Aid Cases?

20

Past-Years Mini-OSCE Question:

A 68 year old male presents with hx of frequent palpitations. What is your
diagnosis?

Answer: AF

Note:
Arrythmias were discussed in 10 minutes out of 2 hours, this sheet provide the most
important ones according to what the doctor came through and what Davidson
emphasized on.
Make an effort to differentiate Normal from Abnormal ECG, and diagnose MI, Angina,
Bundle Branch Blocks, AV Blocks, Tachycardia, Bradycardia, Axis deviation, Atrial and
Ventricular hypertrophy, and Abnormal/ectopic/SV rhythms in general.

Good Luck.
Melad

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Reminders

REMINDERS
WHAT TO LOOK FOR
1. The rhythm and conduction:
sinus rhythm or some early arrhythmias
evidence of first, second or third degeree
block
evidence of bundle branch block.
2. P wave abnormalities:
peaked, tall right atrial hypertrophy
notched, broad left atrial hypertrophy.
3. The cardiac axis:
right axis deviation QRS complex
predominantly downward in lead I
left axis deviation QRS complex
predominantly downward in leads II and III.
4. The QRS complex:
width:
if wide, ventricular origin, bundle branch
block or the WPW syndrome
height:
tall R waves in lead V1 in right ventricular
hypertrophy
tall R waves in lead V6 in left ventricular
hypertrophy
transition
point:

R and S waves are equal in the chest

leads over the interventricular septum
(normally lead V3 or V4)
clockwise rotation (persistent S wave in
lead V6) indicates chronic lung disease.

Q waves:
? septal
? infarction.
5. The ST segment:
raised in acute myocardial infarction and
in pericarditis
depressed in ischaemia and with digoxin.
6. T waves:
peaked in hyperkalaemia
flat, prolonged, in hypokalaemia
inverted:
normal in some leads
ischaemia
infarction
left or right ventricular hypertrophy
pulmonary embolism
bundle branch block.
7. U waves:
can be normal
hypokalaemia.

175

Now test yourself

REMINDERS
CONDUCTION PROBLEMS
First degree block
One P wave per QRS complex.
PR interval greater than 200 ms.
Second degree block
Wenckebach (Mobitz type 1): progressive
PR lengthening then a nonconducted P wave,
and then repetition of the cycle.
Mobitz type 2: occasional nonconducted
beats.
2:1 (or 3:1) block: two (or three) P waves per
QRS complex, with a normal P wave rate.
Third degree (complete) block
No relationship between P waves and QRS
complexes.
Usually, wide QRS complexes.
Usual QRS complex rate less than 50/min.
Sometimes, narrow QRS complexes, rate
5060/min.
Right bundle branch block
QRS complex duration greater than 120 ms.
RSR1 pattern.
Usually, dominant R1 wave in lead V1.
Inverted T waves in lead V1, and sometimes
in leads V2V3.
Deep and wide S waves in lead V6.

176

Left anterior hemiblock

Marked left axis deviation deep S waves
in leads II and III, usually with a slightly
wide QRS complex.
Left bundle branch block
QRS complex duration greater than 120 ms.
M pattern in lead V6, and sometimes in
leads V4V5.
No septal Q waves.
Inverted T waves in leads I, VL, V5V6 and,
sometimes, V4.
Bifascicular block
Left anterior hemiblock and right bundle
branch block (see above).

Reminders

REMINDERS
CAUSES OF AXIS DEVIATION
Right axis deviation
Normal variant tall thin people.
Right ventricular hypertrophy.
Lateral myocardial infarction (peri-infarction
block).
Dextrocardia or right/left arm lead switch.
The WolffParkinsonWhite (WPW) syndrome.
Left posterior fascicular block.

Left axis deviation

Left anterior hemiblock.
The WPW syndrome.
Inferior myocardial infarction (peri-infarction
block).
Ventricular tachycardia.

REMINDERS
POSSIBLE IMPLICATIONS OF ECG PATTERNS
P:QRS apparently not 1:1
If you cannot see one P wave per QRS complex,
consider the following:

P:QRS more than 1:1

If you can see more P waves than QRS
complexes, consider the following:

If the P wave is actually present but not easily

If the P wave rate is 300/min, the rhythm is

visible, look particularly at leads II and V1.

If the QRS complexes are irregular, the rhythm
is probably atrial fibrillation, and what seem to
be P waves actually are not.
If the QRS complex rate is rapid and there are
no P waves, a wide QRS complex indicates
ventricular tachycardia, and a narrow QRS
complex indicates atrioventricular nodal
(junctional or AV nodal) re-entry tachycardia.
If the QRS complex rate is low, it is probably
an escape rhythm.

atrial flutter.
If the P wave rate is 150200/min and there
are two P waves per QRS complex, the
rhythm is atrial tachycardia with block.
If the P wave rate is normal (i.e. 60100/min)
and there is 2:1 conduction, the rhythm is
sinus with second degree block.
If the PR interval appears to be different with
each beat, complete (third degree) heart
block is probably present.
continued

177

Now test yourself

REMINDERS
POSSIBLE IMPLICATIONS OF ECG PATTERNS continued
Wide QRS complexes (greater than 120 ms)
Wide QRS complexes are characteristic of:

Sinus rhythm with bundle branch block

Sinus rhythm with the WPW syndrome
Ventricular extrasystoles
Ventricular tachycardia
Complete heart block.

Q waves
Small (septal) Q waves are normal in leads
I, VL and V6.
A Q wave in lead III but not in VF is a normal
variant.
Q waves probably indicate infarction if
present in more than one lead, are longer
than 40 ms in duration and are deeper
than 2 mm.
Q waves in lead III but not in VF, plus right
axis deviation, may indicate pulmonary
embolism.
The leads showing Q waves indicate the site
of an infarction.

178

ST segment depression
Digoxin: ST segment slopes downwards.
Ischaemia: flat ST segment depression.
T wave inversion
Normal in leads III, VR and V1; and in V2V3
in black people.
Ventricular rhythms.
Bundle branch block.
Myocardial infarction.
Right or left ventricular hypertrophy.
The WPW syndrome.