ELECTROCARDIOGRAM

Prepared: July , 2006

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 Objectives
At the end of the course, participants will
be able to:
 Define Measurement of Axis

 Discuss causes of Axis Deviation.

 Differentiate between Chamber

Enlargement & Hypertrophy.
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 MEASUREMENT OF AXIS
 Localizes the mean QRS vector to quadrant on the
hexaxial reference system be combining the net vectors
from lead I and AVF.

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 Look only at lead I and AVF
 If the net deflection of the QRS complex in
both leads is positive + the axis falls within
the normal limit.

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 If the vector of lead I (QRS deflection) is
positive and the vector of lead AVF is
negative, the net deflection will fall between
those two poles. This is the left axis quadrant
and represents a Left Axis Deviation.

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 If the vector of lead I is negative while the
vector of lead AVF is positive, the net
deflection will fall between the negative
pole of lead I and the positive pole of lead
AVF. This is in the right axis quadrant and
Right Axis Deflection.

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 If the deflections of the QRS complexes in
both leads I and AVF are negative –the net
deflection will fall between the negative poles
of those leads. This is known as Axis
Indeterminate or Extreme Right Axis.

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 Causes of Axis Deviation
Right Axis Deviation

May occur in a normal slender person

 Right ventricular hypertrophy
 Pulmonary conditions:
 Pulmonary hypertension
 COPD
 Emphysema / bronchitis
 Pulmonary embolism
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Conductions defects:
 Left posterior fascicular block
 Wolff-Parkinson-White (WPW) Syndrome
 Right ventricular (outflow) pacing
 Congenital dextrocardia

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Acute myocardial infarction (MI):
 Anterior
 Anterior-lateral
Valvular lesions:
 Mitral stenosis
 Tricuspid insufficiency
 Pulmonary stenosis
 Pulmonary insufficiency

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 Left Axis Deviation
May occur in a normal obese person
 Left ventricular hypertrophy
Pulmonary conditions:
 Emphysema
Conduction defects:
 WPW syndrome
 Right ventricular (apical) pacing
 Left bundle branch block

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 Congenital ventricular-septal defect
 Acute MI:
 Inferior
 Elevated diaphragm:
 Pregnancy
 Abdominal masses
 Systemic hypertension
 Coarctation of the aorta

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 Hypertrophy
Hypertrophy
 An increase in the thickness of the chamber
wall.

Enlargement
 Increase both in chamber size or volume
(dilation).

Atrial enlargement
 The P waves is usually biphasic (both +ve and
–ve). 17
Causes of chamber Enlargement and
Hypertrophy
•CHAMBER •CAUSED BY PRESSURE •CAUSED BY VOLUME
(SYSTOLIC) OVERLOAD (DIASTOLIC) OVERLOAD

•Right Atrial •Pulmonary •Left to Right Shunts

•Enlargement (RAE) •Hypertension •Tricuspid Regurgitation
•Tricuspid stenosis

•Left Atrial •Systemic Hypertension •Left Ventricular Failure,

•Enlargement (LAE) •Mitral stenosis •Mitral Regurgitation

•Right Ventricular •Pulmonary Hypertension •Left to Right Shunts

•Hypertrophy (RVH) •Pulmonic stenosis •Tricuspid Regurgitation

•Left Ventricular •Systemic hypertension •Left ventricular Failure

•Hypertrophy •Left Ventricular Outflow •mitral and / or Aortic
obstruction regurgitation
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 Enlargement and Hypertrophy
•RIGHT ATRIL ENLARGEMENT
Height of the P waves in
lead II is >2.5mm. (tall and
peaked).
The initial positive
deflection of p wave in lead
V1 is >1.5mm than the
negative deflection.
•RIGHT VENTRICULAR
HYPERTROPHY
Dominant S wave in V5
or V6 >7mm OR dominant
R wave in V1 >7mm
•LEFT ARTIAL ENLARGEMENT
Terminal portion of a
diphasic wave in VI is large
and wide.
Limb lead II notched P
wave “M shaped” wider than
0.10 sec.
•LEFT ENTRIVULAR
HYPERTROPHY
Amplitude of R wave in V5
or V6 plus S wave in V1 is ≥3519
RAH

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LAH

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LVH

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RVH

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 References
Porterfield, M.L. (2000). ECG interpretation
made incredibly easy, Spring House
Corporation,Pennsylvania
Lipman, B. C. (2000).ECG Pocket Guide,
Chicago
Nagell, Kaye D. , Nagell, R. (2003). A case-based
approach to ECG interpretation
Chung, S. N. (2006).Text book of clinical
electrocardiography. Jaypee Publishers, New
Delhi. 26