ECG Analysis Sequence

Rate
Rhythm/Configuration
Axis
Hypertrophy
Infarction
 Rate
Normal heart rate 60-100/
min
< 60 called bradycardia
>100 called tachycardia
How To Calculate Heart Rate ?
 300
HR=
No. of Large box btw R-R

1500
HR=
No. of Small box btw R-R
 P WAVE

Normal:
• Height < 2.5 mm in lead II
• Width < 0.11 s in lead II
P WAVE ABNORMALITY
P WAVE ABNORMALITIES

Right atrial hypertrophy:

• A P wave in lead II taller then 2.5 mm

(2.5 small squares)
• The P wave is usually pointed
P WAVE ABNORMALITIES

Left atrial abnormality (dilatation

or hypertrophy):
• M shaped P wave in lead II
• Prominent terminal negative component to
P wave in lead V1
 P WAVE ABNORMALITIES
• Premature Atrial Complex (PAC):
An abnormal P wave (arrowed in figure below)

• Hyperkalemia: Small or absent P

wave

• Arrhythmias
 Premature atrial complex (PAC)
 Atrial flutter
 Atrial fibrillation

 PR INTERVAL

Normal PR interval:

• 0.12 to 0.20 s
PR INTERVAL ABNORMALITIES
Shorter PR interval:

• Wolf-Parkinson-White syndrome
- Short PR interval, less than 3 small squares
(120 ms)
- Slurred upstroke to the QRS indicating pre-
excitation (delta wave)
- Broad QRS
PR INTERVAL ABNORMALITIES

Long PR interval
• AV blocks
 QRS COMPLEX
• QRS Axis
• Normal duration of complex is < 0.12 s (3 small
squares)
• NO pathological Q waves
• NO left or right ventricular hypertrophy
 AXIS
-At any point during depolarization and
repolarization electrical potential are being
propagated in different directions.
- Most of these cancel each other out and
only the net force is recorded. This net is
called AXIS or cardiac VECTOR
- Mean QRS axis: the magnitude and
direction of mean cardiac vector.
How To Check Axis in ECG
AXIS - LEFT AXIS DEVIATION
· Left anterior hemiblock
· Left ventricular hypertrophy
· inferior myocardial infarction
· Emphysema
· Hyperkalemia
· Wolff-Parkinson-White syndrome - right sided
accessory pathway
 AXIS - RIGHT AXIS DEVIATION
• Lead I -ve and aVF +ve = RIGHT AXIS DEVIATION
• Causes:
- Normal finding in children and tall thin adults
- Right ventricular hypertrophy
- Chronic lung disease even without pulmonary
hypertension
- Anterolateral myocardial infarction
- Left posterior hemiblock
 WIDE QRS COMPLEX
Right Bundle Branch Block:
• Wide QRS, more than 120 ms (3 small squares)
• Secondary R wave in lead V1 (RSR)
• Other features include slurred S wave in lateral leads
and T wave changes in the septal leads
WIDE QRS COMPLEX
 WIDE QRS COMPLEX
Left Bundle Branch Block:
• Wide QRS, more than 120 ms (3 small squares)
• M shape QRS
WIDE QRS COMPLEX
 WIDE QRS
• Hyperkalemia
• Ventricular rhythm
 RIGHT VENTRICULAR
HYPERTROPHY (RVH)

• Right axis deviation

• Deep S waves in the lateral leads
• A dominant R wave in lead V1
 Hypertrophy
Left ventricular hypertrophy – LVH
- Left axis deviation
– Exaggerated amplitude (height and depth)
– V1 – very deep S in V1
– V5 – very tall R wave
– Diagnosis = V1 (S) + V5 (R ) > 35 mm
 LVH
• Increased amplitude in height and depth
 QT INTERVAL
• Calculate the corrected QT interval
- QTc = QT / RR = 0.42
- Normal = 0.42 s
 LONG QT INTERVAL

Causes:
• Myocardial infarction, myocarditis, diffuse
myocardial disease
• Hypocalcemia, Hypercalcemia (Short QT),
hypothyrodism
• Subarachnoid hemorrhage, intracerebral
hemorrhage
• Drugs (e.g. Sotalol, Amiodarone)
• Heredity
 ST SEGMENT

Normal ST segment:
• No elevation or depression
 ST ELEVATION

Causes of elevation include:

• Acute MI (eg. Anterior, Inferior, Lateral).
• LBBB
• Acute pericarditis
• Normal variants (e.g. athletic heart)
 ACUTE MI
• ST elevation in leads where MI occurs
• Look for reciprocal changes
(e.g. Ant MI look for ST depression in inferior leads )

Anatomical Site Lead with Abnormal EKG complexes Coronary Artery most often responsible
Inferior II, III, aVf RCA
Antero Septal V1-V2 LAD
Antero Apical V3-V4 LAD (distal)
Antero Lateral V5-V6, I, aVL CFX
Posterior V1-V2 (Tall R, Not Q) RCA
LOCATING THE DAMAGE
 Classic Triad of MI
Ischemia
– Reduced blood supply
– Inverted symmetrical T waves OR ST
segment depression
– Check chest leads
Injury (acute or recent infarct)
– ST segment elevation
– Earliest EKG sign of an infarct
Infarction
– Presence of Q wave
– 1 mm wide or 1/3 QRS complex
 ST DEPRESSION

Causes of depression include:

• Myocardial ischemia
• Digoxin Effect
• Ventricular Hypertrophy
• Acute Posterior MI
• LBBB
 T WAVES

• Repolarization of the ventricles is signaled by

the T wave
 TALL T WAVES

Causes:
• Hyperkalemia
• Hyperacute MI
• LBBB
 SMALL, FLATTENED OR
INVERTED T WAVES
Causes are plenty:
• Ischemia, age, race, hyperventilation, anxiety
• LVH, drugs, pericarditis, I-V conduction delay (RBBB),
• Electrolyte disturbances
• The most important thing to consider is INVERTED T waves
associated with Ischemia
 COMMON ARRHYTHMIAS
Location Bradyarrythmia Tacharrythmia
SA node Sinus Bradycardia Sinus tachycardia
Sick Sinus Syndrome
Atria Atrial Premature Beats
Atrial Flutter
Atrial Fibrillation
Paroxysmal SVT

AV node Conduction Blocks (1,2 and 3)

Ventricles Ventricular escape rhytm Ventricular premature Beats

VT
Ventricular Fibrillation
 SINUS BRADYCARDIA

• Less than 60 bpm

• If profound, could have decreased cardiac output
 SINUS TACHYCARDIA

• Greater than 100 bpm

•  Myocardial oxygen demand and may  coronary
artery perfusion resulting in angina in CAD
• Decreased cardiac output could be exhibited
SSS (SICK SINUS SYNDROME)

• Deceased cardiac output, related to

periods of excessive bradycardia, AV
block and/or tachycardia

• Treatment:
- Pacemaker
- Anti coagulation therapy
 ATRIAL PREMATURE BEAT

• Can be in a healthy heart or with CAD

• They are well tolerated because cardiac output is not altered
 ATRIAL FLUTTER

• Saw toothed pattern; 200-350bpm atrial rate

• Can convert to atrial fibrillation
 ATRIAL FIBRILLATION

• Chaotic atrial dysrhythmia; atrial rate can be 350+ bpm

• Higher ventricular response = cardiac output

 PAROXYSMAL ATRIAL TACHYCARDIA
OR SUPRAVENTRICULAR TACHYCARDIA

• High ventricular rate

• Inadequate ventricular filling time, decreased cardiac output, and
inadequate myocardial perfusion time
Conduction block
(Heart Block)
1ST DEGREE AV BLOCK

• PR greater than 120 msec

• No hemodynamic complications
• Could progress to higher AV blocks
 2ND DEGREE AV BLOCK
MOBITZ TYPE 1
(WENCKEBACH)

• PR interval progressively lengthens with each beat until it is

completely blocked
• If bradycardic, could have decreased cardiac output
 2ND DEGREE AV BLOCK
MOBITZ TYPE 2

• Rare, occurs with large ant MI

• PR interval fixed and p waves occur in a regular ratio to QRS
(atrial rate is regular) until conduction is blocked .
• 2:1 or 3:1 block
 3RD DEGREE AV BLOCK
(COMPLETE)

• Atria and ventricles are independent of each other;

no relationship present
• Symptoms could include lightheadedness or syncope from
decreased rate
 Ventricular premature
beats(VPB)

Premature beats that originate in an ectopic

ventricular focus have bizarrely shaped
prolonged QRS complexes .
The P wave is usually buried in the QRS of the
extrasystole.
The ventricular premature beats are followed by
a compensatory pause that is often longer
than the pause after an atrial extrasystole.
Ventricular premature
beats(VPB)

Ventricular
Tachycardia
VENTRICULAR TACHYCARDIA
(VT)

• Wide QRS, AV dissociation, QRS complex does not

resemble typical bundle branch block
• Irritable ventricle
• Sustained VT is an emergency rhythm and could
convert to ventricular fibrillation
 VENTRICULAR FIBRILLATION

• Ventricular muscle contract in a totally irregular and

ineffective way.
• The fibrillating ventricles look like a quivering "bag of
worms."
• It can be produced by an electric shock or an extrasystole
during a critical interval, the vulnerable period.
• No effective cardiac output or coronary perfusion
• Associated with severe myocardial ischemia.
• Life-threatening - death occurs within 4 min.
A form of ventricular
tachycardia in which
the QRS morphology
varies
Hyperkalemia and Hypokalemia

• Hyperkalemia
• QRS complex:
• QRS widening
• Decreased ST segment duration
• Tall & slender T waves.

Hypokalemia
• ST segment depression & inverted T waves
• Prominent U-wave