ELECTROCARDIOGRAM

Tachycardic and bradycardial heart

rhythm disorders

Prof.dr. Davor Puljević

Klinika za bolesti srca i krvnih žila, KBC Zagreb

ECG tape: speed and scale
 ANALYSIS OF HEART RHYTHM

Frequency 60-100 / min

Regular rhythm
P QRS, P QRS
P wave - normal vector
Normal PQ interval
Normal QRS complex
Normal Sinus Rhythm Without Aritism: All Criteria!
 12-channel ECG analysis

- Ventricular Rate (QRS)

- Regular or irregular rhythm (QRS)

- QRS width

- Presence of atrial activity (P wave)

- Atrial and ventricular connection

- Morphology of P wave
Heart rate:
RR interval (thicker lines) - 300,150,100,75,60,50
An irregular rhythm or <50 / min
1 small cube = 0.04 sec
5 cubes (thicker line) = 0.2 sec
30 bigger cubes = 6 seconds
Number of RR intervals in 6 seconds x 10 = frequency
 REGULARITY OF RHYTHM

Regular rhythm

Irregular rhythm

Regularly irregular rhythm

QRS COMPLEX WIDTH
Presence of P wave
Atrial and ventricular connection
NORMAL P WAVE VECTOR
 P WAVE MORPHOLOGY
II lead
QT INTERVAL

350(320)-440 (460) ms (60/min)

NORMAL SINUS RHYTHM
DIVISION OF BRADYARRHYTHMIAS
THE SINUS NODE AREA

- sinus bradycardia

- SA block II and III degree

(PAUSES WITHOUT P WAVES AND QRS COMPLEXES)

THE AV NODE AREA

- AV Block I, II Type I and II, III degree

(PAUSES WITH P WAVES BUT WITHOUT QRS COMPLEXES)

VENTRICULAR AREA

- Block of right or left branch

- Fascicular blocks

- combinations (bifasc block, bifasc block with PQ prolongation)

SINUS BRADYCARDIA
SINOATRIAL SA BLOCK OF II DEGREE
SINOATRIAL SA BLOCK OF III DEGREE (SINUS ARREST)
AV BLOCK OF I DEGREE (PQ PROLONGATION)
AV BLOCK OF II DEGREE TYPE I
AV BLOCK OF II DEGREE TYPE II
AV block of II degree 3:1
AV BLOCK OF III DEGREE (TOTAL AV BLOCK)
ASYSTOLE
 TACHYARRHYTHMIAS DIVISION
SUPRAVENTRICULAR TACHYARRHYTHMIAS: VENTRICULAR TACHYARRHYTHMIAS
atrial - ventricular extrasystoles
a) area of sinus node - ventricular tachycardia (VT)
- sinus extrasystoles - classic
- sinus tachycardia - bidirectional
b) from the rest of the atrium - polymorphic
- atrial extrasystoles - with long QT interval (torsade)
- ectopic atrial tachycardia - without long QT interval
- multifocal atrial tachycardia - slow VT (accelerated idioventricular
- paroxysmal atr. Tachycardia with AV block rhythm)
- atrial flutter - ventricular flutter
- atrial fibrillation - ventricular fibrillaton
2) nodal
- nodal (junctional) extrasystoles
- neparoxysmal junctional tachycardia
- AVNRT (atrioventricular nodal reentry tachy.)
- typical (slow-fast)
- atypical (fast-slow)
3) AV reentry with accesory pathway
- WPW syndrome (delta wave in sinus)
orthodromic tachycardia (narow QRS)
antidromic tachycardia (wide QRS)
 SUPRAVENTRICULAR EXSTRASYSTOLES

Sinus ES: premature P wave with completely the same morphology as the sinusoidal P wave

Atrial ES: premature P wave with different morfology compared to sinus P

Junctional (nodal) ES:

-P wave ussually can’t be seen ( in QRS complex)
-P wave can be in front or behind the QRS complex
-If P wave is visible it is retrograde (negative in II lead)
 VENTRICULAR EKSTRASYSTOLES (PVC)

Premature bizarre wide QRS complexes with divergent T wave

Not preceded by P wave
The pause is compensatory (except for interpolated PVCs)
Monomorphic and polymorphic
Bigeminal (every other QRS is PVC, trigeminal = 2 sinuses 1 PVC)
PVC: monomorphic and polymorphic
PVC with R on T phenomenon
PVC pairs
SINUS TACHYCARDIA
 PAROXISMAL TACHYCARDIA (sudden start)

PSVT: AT, AVNRT, AVRT,UA, (AF)

VT: non sustained/sustained
monomorphic/ polymorphic (bidirectional, torsade, polymorphic)
ATRIOVENTRICULAR NODAL REENTRY TACHYCARDIA
PREEXCITATION (WPW SYNDROME)
ORTHODROMIC AND ANTIDROMIC TACHYCARDIA
ATRIAL FLUTTER
ATRIAL FLUTTER
ATRIAL FIBRILLATION
 Atrial fibrillation
(b) with accesory pathway )
VENTRICULAR TACHYCARDIA (tachycardia of
broad QRS complexes)
SHORT POLYMORPHIC VT
 BIDIRECTIONAL VT

Bidirectional ventricular tachycardia. The axis of QRS complex in standard leads

(II lead) alternately alternates.
TORSADES DE POINTES VT
VENTRICULAR FLUTTER
VENTRICULAR FIBRILLATION
Tachycardia with broad QRS complexes:
Ventricular Tachycardia (VT)
Supraventricular Tachycardia with Branch Block (SVT)
Antidromic tachycardia with an aberrant bundle

Sign for ventricular tachycardia:

AV dissociation
Captured (conducted) QRS complexes
Fusion QRS complexes
Negative Concordance precordially
The width of the QRS complex
VT and AV dissociation
VT – negative concordance
ARTEFACTS IN ECG
PACEMAKER (DUAL CHAMBER PACING)
 CONCLUSION

In rhythm analysing of ECG:

- Sistematically answer to six questions

- Carefully analyse all intervals and morphology of QRS,ST and T wave.

Maybe you can recognise P waves in unusual localisation

- Define basic rhythm (normally is sinus rhythm)

- In the same ECG sometimes we have several different arrfhythmias

- With carefully ECG analysing correct rhythm and diagnosis can be

achieved in many cases, but in almost 20 % ECG is not enough for
definite diagnosis

- In that situation we need other diagnostic tools.

 EXAMPLE 1.

Atrial fibrillation with rapid ventricular response

 EXAMPLE 2.

Sinus bradycardia which crosses into VT

 EXAMPLE 3.

Non-sustained VT
 EXAMPLE 4.

Dual chamber pacemaker

 Example 6.

Normal sinu rhythm, ECG within the normal limit

 Example 8.

AV block II degree type I

Example 9.

Atrial fibrillation with LBBB

Example 11.

Long QT and torsade

Example 12.

Artefacts