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 Preface
l The aim of this atlas is to help the
medical students in the understanding the
pathophysiology of the ECG and to buildup their
efficacy in the interpretation of abnormal ECG in
different cardiac and extra-cardiac diseases

(cont.)

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 Preface
l I have no authority for any of these slides but I
had collected them from different websites and
added my notes.
l To open any chapter click on its title in the
content.
l The title of the slide has been hidden for self
assessment. To reveal the title click on the
slide.
Assist. prof. Safaa Ali
FICMS (med.)
College of Medicine / Kufa University
2008
[email protected]

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Contents

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6
Conductive system

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Propagation of cardiac impulse

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Normal ECG

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ECG machine

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 ECG Leads
Limb leads: I, II, III, aVR, aVL, aVF,
Chest leads: V1-V6

l Anterior surface: V1-4.

l Inferior surface: II, III and aVF.
l Lateral surface: I, aVL and V5-6.
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ECG Paper

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ECG Complex

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Generation of normal ECG complex

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 P-wave

Normal values Abnormalities

1. Polarity. 1. Inverted P-wave
up in all leads except l Junctional rhythm.
aVR. 2. Wide P-wave (P- mitrale)
2. Duration. l LAE
< 2.5 mm. 3. Peaked P-wave (P-pulmonale)
3. Amplitude. l RAE

< 2.5 mm. 4. Saw-tooth appearance

l Atrial flutter
5. Absent P wave
l Atrial fibrillation
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Abnormalities of P wave

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 PR interval

Definition: The time Abnormalities

interval between 1. Short PR interval
beginning of P-wave l WPW syndrome
to beginning of QRS
complex. 2. Long PR interval
l First degree heart
Normal PR interval
3-5mm (0.12-0.2 sec) block

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Abnormalities of PR interval

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 QRS complex
Normal values 2. Tall R in V1
l Duration: < 2.5 mm. l RVH.
l Morphology: progression l RBBB.
from Short R and deep S l Posterior MI.
(rS) in V1 to tall R and l WPW syndrome.
short S in V6 with small Q 3. Abnormal Q wave
in V5-6 (qRs).
[ > 25% of R wave]
Abnormalities:
l MI.
1. Wide QRS complex l Hypertrophic
l Bundle branch block. cardiomyopathy.
l Ventricular rhythm. l Normal variant.

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Abnormalities of QRS complex

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Normal Q wave

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Q wave in MI

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Q wave in septal hypertrophy

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 ST- segment

Normally it's isoelectric. 2. ST depression:

[i.e. at same level of l Ischemia.
PR segment] l Ventricular strain.
Abnormalities: l BBB.
l Hypokalemia.
1. ST elevation:
l Digoxin effect.
l Acute MI.
l Prinzmetal angina.
l Acute pericarditis.
l Early repolarization.

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Abnormalities of ST- segment

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 T-wave
Normal values. Abnormalities:
1. Polarity: 1. Peaked T-wave:
l Always up in I,II,V4-5 l Hyper-acute MI.
l Always down in aVR. l Hyperkalemia.
l Variable in III, aVL, aVF, l Normal variant.
V1-3. 2. T- inversion:
l Ischemia.
2. amplitude: < 10mm in the l Myocardial infarction.
chest leads. l Myocarditis
l Ventricular strain
l BBB.
l Hypokalemia.
l Digoxin effect.
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Abnormalities of T wave

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 QT- interval

Definition: Time interval between beginning of

QRS complex to the end of T wave.
Normally: At normal HR: QT ≤ 11mm (0.44 sec)
(or) QTc = QT/ √RR
Abnormalities:
1. Prolonged QT interval: hypocalcemia and
congenital long QT syndrome.
2. Short QT interval: hypercalcemia.
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 Interpretation of ECG

1. standardization: Usually 10 mm for 1 mV

2. Rate:
l With regular rhythm: 300/R-R interval (large squares).
l With irregular rhythm: (no. of QRS complexes in 15
large squares) X 20
3. Rhythm is read according to the following:
l R-R interval. [regular or irregular]
l QRS morphology. [narrow or wide]
l P wave. [normal or abnormal]
l P-R relationship. [fixed or variable]

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 Interpretation of ECG cont.

4. Axis (mean QRS axis): Normally -30 to +100

LAD: LVH, LAFB and Inferior MI.
RAD: Normal, RVH, Lat. MI, LPFB.

5. Analysis of complete ECG complex in each lead.

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Calculation of electrical axis depending on QRS
polarity in leads I and aVF

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Normal axis, LAD and RAD

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Pathogenesis of arrhythmia :
1. Reentry.

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Pathogenesis of arrhythmia :
2. Enhanced automaticity of ectopic focus
in the atria, AV node or Purkinje fibers

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Pathogenesis of arrhythmia :
3. Multiple enhanced foci

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 Pro-arrhythmogenic conditions

l WPW syndrome. (pre-excitation syndrome)

l Long QT syndrome.
l Brugada’s syndrome: Autosomal dominant
disease associated with increase risk of
ventricular arrhythmia and sudden death.

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WPW syndrome and long QT syndrome

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 Brugada’s syndrome
(RBBB pattern with ST elevation in V1-V3)

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 WPW
(type A, left side pathway, tall R wave in V1-3)

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Long QT syndrome

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 Atrial ectopic
(premature complex with abnormal P wave and
normal QRS complex)

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Atrial bigeminy

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 Junctional ectopic
(premature complex with inverted P wave and
normal QRS complex)

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 Ventricular ectopic
(premature complex with absent P wave and
wide QRS complex)

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 Ventricular ectopic
(without compensatory pause)

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 Ventricular bigeminy
(ventricular ectopic every other sinus complex)

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 Ventricular trigeminy
(ventricular ectopic every two sinus complexes)

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R on T event

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 R on T phenomena
(ventricular ectopic on the preceding T wave)

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 Multifocal Ventricular ectopics
( variable morphologies of the ventricular
ectopics)

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 Ventricular Couplet
( two successive ventricular ectopics)

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 Ventricular parasystole
(no fixed relationship to the preceding sinus complex)

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 Sinus tachycardia
(tachycardia with normal P wave and normal QRS complex)

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 Sinus arrhythmia
(variable RR intervals with otherwise normal ECG)

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Paroxysmal supraventricular tachycardia
(regular tachycardia with normal QRS complex
and absent P wave)

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PSVT

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 PSVT
(with retrograde P- wave)

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 Atrial fibrillation (fine)
(irregular tachycardia with normal QRS complex
and absent P wave)

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Atrial fibrillation (coarse)

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 AF + LBBB
(irregular tachycardia with wide QRS complex and
absent P wave)

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 Atrial flutter
(irregular tachycardia with normal QRS complex and
saw-tooth appearance of P wave)

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Atrial flutter

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 Ectopic atrial tachycardia
(regular tachycardia with normal QRS complex and
abnormal P wave)

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 Multifocal atrial tachycardia
(irregular tachycardia with normal QRS complex and
variable morphologies of P wave and variable PR intervals)

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Multifocal atrial tachycardia

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 Wandering pacemaker
(bradycardia with variable morphologies
of P wave and variable PR intervals)

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Wandering pacemaker

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Accelerated junctional rhythm
(normal rate with normal QRS complex
and inverted P wave)

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 Accelerated junctional rhythm
(normal rate with normal QRS complex
and absent P wave)

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 Non-sustained VT
(short run of more than two successive ventricular
ectopics)

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 Ventricular tachycardia (VT)
(regular tachycardia with wide QRS complex
and absent P wave)

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VT

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ECG criteria that favor VT

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 VT
(regular tachycardia with LBBB pattern, wide R wave in V5-6)

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 VT
(regular tachycardia with RBBB pattern, R wave in V1-2)

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 SVT + WPW syndrome
(regular tachycardia with wide QRS complex
and absent P wave)

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AF + LBBB

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 VT
(with capture beat)

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 VT
(with fusion beat)

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Twisting VT (Torsades de pointes)

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Ventricular Flutter

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Ventricular fibrillation

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Sinus bradycardia

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Sinus arrhythmia

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 Junctional rhythm
(regular bradycardia with normal QRS complex and
inverted P wave)

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 Sinus arrest
(variable time of cardiac arrest)

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 Sinus arrest
(variable time of cardiac arrest)

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 Sino-atrial exit block
(the time of cardiac arrest is double the time
of sinus RR interval)

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SA exit block

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 Sick sinus syndrome
(tachycardia- bradycardia syndrome)

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 First degree heart block
(regular bradycardia with normal QRS complex
and fixed prolonged PR interval)

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 Second degree heart block
Mobitz type I (Wenckebach block)
(irregular rhythm with normal QRS complex and progressive prolongation

of PR interval then failure of conduction to the ventricle)

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 Second degree heart block
Mobitz type II
(irregular rhythm with normal QRS complex and fixed normal PR
interval, but frequent failure of conduction to the ventricle,
P wave without QRS complex)

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 Complete heart block (high block)
(regular bradycardia with normal QRS complex and
complete A-V dissociation)

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Complete heart block (low block)
(regular bradycardia with wide QRS complex
and complete A-V dissociation)

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Bundle system and sites of block

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Bundle branch block

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 Left Bundle branch block (LBBB)
(wide QRS complex and notched R wave in V5-6 with
ST changes and wide S wave in V1-2)

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 Right Bundle branch block (RBBB)
(wide QRS complex and RsR pattern in V1-2 with
ST changes, and wide S wave in V5-6)

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 Incomplete RBBB
(RBBB pattern with normal duration of QRS complex)

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Intermittent RBBB

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Left anterior fascicular block (LAFB)
(left axis deviation)

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Bifascicular block (RBBB+LAFB)
(RBBB pattern with LAD)

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 Trifascicular block
(RBBB pattern with LAD and first degree heart block)

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Trifasicular block

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 ECG changes in IHD

l Signs of ischemia:
Reversible ST depression, ST elevation or T
inversion.
l Signs of MI:
1. Hyperacute T wave.
2. ST elevation (STEMI)
3. Q wave (Q or transmural infarction)
4. T inversion.

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ST segment and T wave changes in
ischemia and MI

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Evolution of ECG changes in MI

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Non-Q infarction

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Q wave infarction

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Localization of MI
1. anterior MI

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Localization of MI
2. lateral MI

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Localization of MI
3. inferior MI

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Localization of MI
4. posterior MI

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Anterior ischemia
(T inversion in V1-3)

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 Lateral ischemia
(ST depression and T inversion in leads I, aVL and V5-6)

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 Double wall ischemia
(T inversion in leads II, III, aVF and V2-6)

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SVT with ischemia

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Positive TM test

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 NSTEMI
(ST depression and T inversion in leads I, aVL and V5-6)

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 Hyperacute MI
(hyperacute T wave in the chest leads)

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Acute anteroseptal MI (STEMI)
(ST elevation in V1-3)

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 Acute anterolateral MI
(ST elevation with hyperacute T in V1-6)

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 Acute anterolateral MI
(Q wave, ST elevation and T inversion in V1-6)

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Acute anterolateral MI + LBBB

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 Acute inferior MI
(Q wave and ST elevation in II, III and aVF)

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Acute inferior MI with RBBB

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 Acute inferoposterior MI
(Q wave and ST elevation in II, III and aVF with
reciprocal changes in V2-3)

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 Acute inferior MI with
right ventricular infarction
(Q wave and ST elevation in II, III, aVF
and right chest leads V4R-V6R)

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Modified right chest leads

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 Undetermined inferior MI
(Q wave and T inversion without ST elevation
in inferior leads)

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 Old inferior MI
(Q wave only in inferior leads)

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Old anterior MI
(Q wave in V1-3)

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 Criteria of ventricular enlargement
RVH: LVH:
1. Relatively tall R in V1 1. SV1 + (RV5 or RV6) ≥
2. RV strain 35 mm
(ST depression and (or)
T inversion) RV5 or RV6 ≥ 25 mm
3. RAD 2. LV strain
3. LAE

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 Criteria of atrial enlargement
RAE: LAE:
-Peaked P-wave -Wide notched P-wave
(P-pulmonale) (P- mitrale)
-Amplitude of P wave -Duration of P wave
more than 2.5 mm more than 2.5 mm

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LVH

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LVH

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RVH with RAE

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RAE LAE

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Biatrial enlargement

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 Early repolarization
(normal variant inferior ST elevation)

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 Acute pericarditis
(diffuse concave ST elevation)

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 Pericardial effusion
(low voltage ECG with electrical alternance)

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 Acute pulmonary embolism
(S1 Q3 T3 pattern, deep S in lead I and Q wave with
T inversion in lead III)

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Hyperkalemia
(peaked T wave)

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 Sever hyperkalemia
(peaked T wave with wide QRS complex)

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 Hypokalemia
(ST depression and T inversion)

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 Digoxine effect
(down sloping ST depression)

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Hypocalcemia
(long QT interval)

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 Myocarditis
(non-specific ST T changes)

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Dilated cardiomyopathy
(non-specific ST T changes)

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Hypertrophic cardiomyopathy
(LVH criteria)

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 HOCM
(LVH criteria)

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 SAH
(diffuse T inversion)

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Artificial pacemaker

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