Rudiments of ECG

Bartosz J. Sapilak, MD, PhD

Katedra i Zakład Medycyny Rodzinnej AM we Wrocławiu
Kierownik: Prof. dr hab. Andrzej Steciwko
 ECG – what it is?
 ECG records bioelectrical activity of a heart muscle which is the sum
of all potentials of individual heart cells.

 Potentials are changing due to depolarization and repolarization of

cell membranes.

 Potentials are changing in range of a few mV.

ECG – what it is?
 Higher potential changes  higher/deeper waves seen

 Two types of record:

– 25mm/s
– 50 mm/s
ECG – what it is?

Bifasic wave

Negtive wave

Electical vector Positive wave

ECG – what it is?
Leads

red black green yelow

ECG set

25 mm/s 1mm = 40ms

50 mm/s 1mm = 20ms

Amplitude is usually 1cm = 1mV

frequency= 300/small 5mm squeres (25 mm/s)

300/big 10mm squeres (50 mm/s)
Electrical axis of the heart
Electrical axis of the heart

Cabrera’s wheel
Electrical axis of the heart
Electrical axis of the heart
Electrical axis of the heart
Electrical axis of the heart
Electrical axis of the heart
Waves, segmens and intervals
Waves, segmens and intervals
Waves, segmens and intervals

 P wave – propagation of stimulation in atria < 120ms

 PQ interval - A-V conduction time , 120-200ms

 QRS complex - conduction time in ventricles, 80-100ms

 ST segment, T and U waves – ventricular repolarisation

P wave
P wave
 upright, excludeing aVR

 present before every QRS complex

 lower than 2,5 mm

 < 120 ms
P wave

Lead sinus also should be

sinus sinus
I + + +
II + + +
III + + +
avR - - -
avL + - -
avF + + -
V1 +/- +/- +/-
P wave
P wave
 1. Check if any P wave is not present?

– hidden

– possible stimulation from lower part of stimuloconducting system

– If not present at all: AF, hyperkalemia, sick sinus syndrome, A-V block
P wave
 2. Check if P wave is not inverted?

– wrong electrodes placement

– dextrocardia

– backward atria stimulation

P wave
 3. Check if P wave is not to high?

– right atrium enlargement (P pulmonale)

 4. Check if P wave is not widened or bifasic?

– left atrium enlargement (P mitrale)

PQ interval
PQ interval
 P wave + PR segment = PR/PQ/ interval, 120-200 ms

 1. Check if PR interval is < 120 ms ?

– A-V junction rythm

– pre-excitation syndrome - WPW, LGL
PR interval
 2. Check if PR interval is > 200ms ?

– A-V I0 block
– hypokalemia
– ischaemic heart disease
– acute reumatoid myocarditis
– drugs: digoxin, chinidin, β-bloker, Ca-bloker
PR interval
 3. Check if PR interval is variable?

– A-V II0 Mobitz block

– A-V II0 Wenckebach block
– A-V II0 block 2 : 1
– A-V III0 block
Q wave
Q wave
 usually shouldn’t be seen

 small q can be present in lead:

I, II, aVL, V5, V6 (septum depolarization)

 sometimes q is present in lead III

– If don’t disappear on inspiration + SIQIIITIII + tachycardia = pulmonary

tromboembolia
Q wave
 Patological Q wave:

– > 10 mm

– > 25% załamka R

– width > 40 ms
Q wave
 1. Is patological Q wave present?

– cardiac infarct
– LVH (I, II, aVL, V5, V6)
– Hiss bundle block
– pulmonary tromboembolia
QRS complex
QRS complex
 Shape varies in leads:

– R is increases from V1 to V6
– r < S w V1 - V2
– R > s w V5 - V6
– the biggest R < 25 mm
– the deepest S < 25 mm
QRS complex
 1. Check if R or S waves are not to high?

– improper calibration of ECG

– LVH
– RAH
– posterior MI
– WPW syndrome
– dekstrocardia
– BBB
QRS complex
 2. If QRS amplitude is not to to small?

– improper calibration of ECG

– obesity
– pulmonary emphysema
– pericardial exudate
QRS complex
 3. If QRS amplitude is not to wide?

– BBB

– ventricular dysrrythmia

– hyperkalemia
QRS complex
 4. If QRS morphology is correct?

– BBB

– WPW syndrome

– MI
ST segment
 Should be in isoelectric line

 1. If ST segment is not elevated?

– AMI
– RV aneurysm
– Prinzmetal angin
– pericarditis
– physiological
ST segment
 2. If ST segment is not depleted?

– Ischaemia
– posterorir AMI
– LVH with strain
– digoxin, chinidyn
T wave
T wave
 No higher than 50% of QRS complex
 Negative in aVR, sometimes in III, V1 i V2

 1. If T wave is not to high?

– hiperkaliemia (tent shapeT)
– AMI
T wave
 2. If T wave is not to low?

– hipokaliemia (U wave)
– pericarditis
– hypothyreosis
T wave
 3. If T wave is not inverted?

– norm (afroamericans, young patients)

– ischemia
– MI
– LVH with strain
– digitalis overdose
U wave
 best seen in V2 - V4, aVL

 1. If U wave is not to high?

– hypokaliemy
– hypercalcemy
– hyperthyreosis
QT segment
QT segment
 Time from QRS begining till enf of T wave (excludeing U wave) – best
seen in aVL

 Corrigated QTc= QT/square root of RR

 Correct QTc = 350 - 430 ms (HR 60/min)

QT segment
 1. Is QTc to short?

– hyperkalcemia
– digitalis overdose
– hyperthermia
QT segment
 2. If QTc is not to long?
– hypokalcemy
– AMI
– antiarrytmic drugs
– congenital

– hypothermia
– brain damage
– cardiomiopathy
Cardiac rhythm
 Anatomical point

 Frequency

 Sequence

 ex.: Regular sinus rhythm, HR about 75/min, atrial stimulation

conducted to ventricles in 1:1 ratio, correct PR segment …
Sinus rhythm

 HR 60 - 100/min

 P wave positive in II lead

 P wave negativein aVR lead

 P present after each QRS complex

Bradycardia

 sinus bradycardia

 sick sinus node syndrome

 block AV II i III degree

 ventricular or nodal rhythm

 asystolie

 drugs
Bradycardia

 HR< 60/min (dangerous when< 40/min)

 QRS present after each P wave

Bradycardia
 sleep, sportsmen
 drugs
 hypothyreosis
 dyselectrolitaemia
 uraemia
 intracranial hypertension
 sick sinus node
 cholestasis
Tachycardia
 narrow QRS
– sinus tachycardia
– atrial tachycardia
– atrial fluttery
– AF
– A-V re-entry tachycardia

 wide QRS
– supraventricular with abberation
– ventricular tachycardia
– accelerated idiowentricular rhythm
– torsade de pointes
Sinus tachycardia
 HR > 90/min (seldom > 180/min)

– positive P in II lead
– negative P in aVR lead
– P present after each QRS complex
Sinus tachycardia
 pain, excercise
 drugs
 IHD, AMI
 cardiac insuficiency
 pulmonary embolism
 hypovolemia
 anaemia
 hyperthyreosis
AT
 HR > 100/min
 atrial rhythm usually 120 - 250/min
 improper shape of P wave

 digoksin
 IHD
 rheumatic heart disease
 cardiomiopathy

 sick sinus node syndrome

Atrial fluttery
 atrial rhythm 250 - 350/min
 improper shape of P wave – „teeth of the saw”
 A-V block 2:1 (or higher)
 HR 75 - 150/min
Atrial fibryllation
 No P wave – f wave
 (atrial rhythm 400 - 600/min)
 irregular HR

– 5 - 10 % of adults
– persistent/ paroxysmal
AF
 hypertension
 IHD
 hyperthyreosis

 sick sinus node syndrome

 alkohol
 mitral valve disease
 cardiomiopathy
VT
• QRS > 120/min (usually 150-250/min)
• widened QRS
VT
 AMI
 IHD
 cardiomiopathy
 mitral cusp prolapse
 myocarditis
 electrolites
 drugs
VF
Ventricular asystole
B

A
Ischaemia
AMI
AMI
Healed infarct
Blocks
Io - prolonged impuls conduction,
conduction rate 1:1
(a-v I0 - PR interval > 120ms)

II0 – impulses are partially blocked

(Wenckebach, Mobitz, 2:1)

III0 – impulses are not conducted

Blok II0
Blok III0
Block II 0

Mobitz I (Wenckebach)

Mobitz II
Block II 0

Block a-v 2:1

Blok III0
RBBB
 widened SI, II, V5, V6 > 40ms, or lasting longer than R wave
 widened QRS > 120ms (complited)
 notched R’ w V1, 2 , delayed intrinsicoid deflection > 50ms

 often in healthy ones

 ICD, cardiomiopathy, pulmonary embolism, ventricular septal defect,

Ebstein anomaly
RBBB
LBBB
 QRS > 120ms
 widened, notched R in leads V5, V6, I i aVL
 no Q wave present
 Delayed intrinsicoid deflection > 60ms in V5, V6
 rS complex in V1-V3 leads
LBBB
LBBB
 usually pathological

– ICD
– cardiomiopathy
– LVH
– fibrosis of intraventricular conduction system
Other blocks
 LAH (LAFB)
– left axis deviation (-450 do -900)
– qR configuration in aVL lead
– delayed intrinsicoid deflection in aVL > 45ms

 LPH (LPFB)
– dekstrogram (+900 do +1800)
– konfiguracja rS w odprowadzeniach I i aVL
– obecny zał. q w odprowadzeniach III i aVF
LAH
Pre-excitation syndrome
 Lown-Ganong-Levine (LGL)
– PQ interval < 120ms,
– no delta wave

 Wolf-Parkinson-White (WPW)
– Delta wave present
– PQ interval < 120ms
Pre-excitation syndrome
Pre-excitation syndrome
LVH

 Sokolow index (S V1+R V5 >35 mm),

 deepest S + highest R V1–V6 >45 mm,

 R V5-V6 >26 mm,

 S V1 >24 mm,
LVH

 RI + SIII >25 mm,

 R III >20 mm,

 S aVR >14 mm,

 R aVL >10 mm (sometimes > 7,5 mm),

LVH

 Cornell criteria (R aVL + S V3)

– > 27 mm (male)

– > 19 mm (female)

 Cornell product – Cornell criteria * QRS time

– > 2647 mm*ms (male)

– >1713 mm*ms (female)

RVH
 right axis deviation + 110o
 R V1 > 7 mm
 deep S in V5 – V6
 ST depletion, negative T wave, (asymetric or negative/positive in V1 i
V2)
 delayed intrinsicoid deflection >0,035 ms in V1, V2
 RBBB

 pulmonary hypertension
 pulmonary stenosis
Pericarditis
 common ST elevation V1 - V6, I, aVL, II, III, aVF

 mirror ST denivetation in aVR and V1

 typical saddle ST shape

 no q wave present
Pericarditis
AMI
 sometimes correct ECG present
 sometimes without pain

 STEMI
 NSTEMI
 recent LBBB

 syndromes simillar to aortic wall dissection

AMI
 Localisation:

 V1 - V4 - anterial
 I, aVL, V5 - V6 - lateral
 I, aVL, V1 - V6 - antero-lateral
 V1 - V3 - antero-septal
 II, III, aVF - inferior
 I, aVL, V5 - V6, II, III, aVF - infero-lateral
AMI

 If AMI of inferior wall present always look for AMI of RV

– ST elevation in V1R –V6R

– best seen in V4R

 do not ordinate NTG

 liquids i.v.
LV aneurysm
 6 months after anterior wall AMI persistent SR elevation in V1-V5
Digoxin
Cardiac stimulator
Thank you