THE NORMAL

ELECTROCARDIOG
RAM
AND ITS (NORMAL)
VARIANTS
Presented by: Moderator:
Dr. Shah Md. Nahid Aktarul Islam Dr. Lima Asrin Sayami
MD (Cardiology) FCPS (Cardiology)
Phase-B (Resident) Assistant Professor
NICVD NICVD
THE GOAL OF THIS ACADEMIC
SESSION
 Interpretation of ECG
 Outline the variations of ECG in normal adults.
 Describe normal aspects of the clinical application of the ECG
 Elaborate the Knowledge of the normal variations of the
Electrocardiogram (ECG)
 INTRODUCTION
 The Electrocardiogram (ECG) is a representation of the electrical
events of the cardiac cycle.
 Each event has a distinctive wave form, the study of wave form can
lead to greater insight into a patient’s cardiac patho physiology.
 Knowledge about the normal electrocardiogram (ECG) and its
(normal) variants is enormously important.
CONTINUE
 When we interpret an ECG we compare it instantaneously with the
normal ECG and normal variants stored in our memory.
 These memories are stored visually in the posterior parts of the
cerebrum and intellectually in the frontal parts
 Therefore, in this presentation, normal components of the ECG and
its variants are discussed so that the reader can make accurate
comparisons.
ECGS CAN IDENTIFY
 Arrhythmias
 Myocardial ischemia and infarction
 Pericarditis
 Chamber hypertrophy
 Electrolyte disturbances (i.e. hyperkalemia, hypokalemia)
 Drug toxicity (i.e. digoxin and drugs which prolong the QT interval)
CLINICAL INTERPRETATION OF
THE ECG
 Accurate analysis of ECGs requires thoroughness and care.
 The patient's age, gender, and clinical status should always be taken
into account.
 Many mistakes in ECG interpretation are errors of omission.
 Therefore, a systematic approach is essential.
NORMAL ECG
THE FOLLOWING 14 POINTS SHOULD
BE ANALYZED CAREFULLY IN EVERY
ECG:
1. Standardization (calibration) and technical features (including lead
placement and artifacts)
2. Rhythm
3. Heart rate,
4. PR interval/AV conduction
5. QRS interval
6. QT/QTc interval
7. Mean QRS electrical axis
CONT.
8. P waves
9. QRS voltages
10. Precordial R-wave progression
11. Abnormal Q waves
12. ST segments
13. T waves
14. U waves
STANDARDIZATION
 The first step while reading ECG is to look for whether standardization is properly done.
 Look for the vertical mark and see that the mark exactly covers two big squares(10 mm or
1mV) on the graph.
 Standard calibration
o 25 mm/s
o 0.1 mV/mm
STANDARDIZATION
THE HEART RATE
 Rule of 300/1500(Regular rhythm)
 10 Second Rule
RHYTHM
 Evaluate the rhythm strip at the bottom of the 12-lead for the
following-
 Is the rhythm regular or irregular?
 Is there a P wave before every QRS complex?
 Are there any abnormal beats?
NORMAL VARIANTS
 Numerous variations occur in subjects without heart disease.
 T waves can be inverted in the right precordial leads in normal persons-occurs
in 1% to 3% of adults and is more common in women (persistent juvenile
pattern).
 The ST segment can be significantly elevated in normal persons, especially in
the right and midprecordial leads.
 The elevation begins from an elevated J point and is commonly associated
with notching of the downstroke of the QRS complex.
 This occurs in 2% to 5% of the population and is most prevalent in young
adults
NORMAL VARIANTS
The following common ECG findings are considered normal variants and are not cause for
deferment unless the patient is symptomatic or there are other concerns.
 Early repolarization
 Ectopic atrial rhythm
 First-degree AV (atrioventricular) block with PR interval less than 0.21 in age < 51
 Incomplete Right Bundle Branch Block (IRBBB)
 Indeterminate axis
 Intraventricular conduction delay (IVCD)
 Left atrial abnormality
 Left axis deviation, less than or equal to -30 degrees
 Left ventricular hypertrophy by voltage criteria only
NORMAL VARIANTS
 Low atrial rhythm
 Low voltage in limb leads (May be a sign of obesity or hypothyroidism.)
 Premature Atrial Contraction (PAC) – multiple, asymptomatic
 Premature Ventricular Contraction (PVC) - single only; 2 or more on ECG require evaluation
 Short QT – if no history of arrhythmia
 Sinus arrhythmia
 Sinus bradycardia.

Up to age 49 if heart rate is >44;

Age 50 and older if heart rate is >48
 Sinus tachycardia – heart rate < 110
 Wandering atrial pacemaker
EARLY REPOLARIZATION

 Early repolarization is most often seen in healthy young adults.

 Look for ST elevation, tall QRS voltage,"fishhook" deformity at the J point,
and prominent T waves.
 ST segment elevation is maximal in leads with tallest R waves.
 Note high take off of the ST segment in leads V4-6
 The ST elevation in V2-3 is generally seen in most normal ECG's; the ST
elevation in V2-6 is concave upwards, another characteristic of this normal
variant.
 CHARACTERISTICS’ OF EARLY
REPOLARIZATION
 Notching or slurring of the terminal portion of the QRS wave
 Symmetric concordant T waves of large amplitude
 Relative temporal stability
 Most commonly presents in the precordial leads but

often associated with it is

 Less pronounced ST segment elevation in the limb

leads
TO DIFFERENTIATE FROM
ANTERIOR MI
 The initial part of the ST segment is usually flat or convex upward
in AMI
 Reciprocal ST depression may be present in AMI but not in early
repolarization
 ST segments in early repolarization are usually <2 mm (but have
been reported up to 4 mm)
TO DIFFERENTIATE FROM
PERICARDITIS
 The ST changes are more widespread in pericarditis
 The T wave is normal in pericarditis
 The ratio of the degree of ST elevation (measured using the PR
segment as the baseline) to the height of the T wave is greater than
0.25 in V6 in pericarditis.
ARRHYTHMIAS
 It is quite difficult to classify certain arrhythmias into those that are
normal variants, and those that are pathologic findings.
 We know, for example, that episodes of ventricular tachycardia
(VT) or a slow ventricular escape rhythm may be found in
apparently healthy individuals, especially in athletes.
 However, a VT or a ventricular rhythm of 30/min would not be
classified as a normal finding
ARRHYTHMIAS
 However, there are a substantial number of arrhythmias that occur so
frequently in individuals without heart disease that they may represent normal
variants. Three conditions must normally be fulfilled:
i. Absence of any heart disease.
ii. Exclusion of many arrhythmias, not representing normal variants.
iii. A ‘normal-variant arrhythmia’ should occur only rarely and should not be
associated with very low or very high rates.
 However, a healthy individual may feel a normal-variant arrhythmia.
ECTOPIC ATRIAL RHYTHM
 Ectopic atrial rhythms occur when the impulses for the atria to beat are
generated in the wrong area.
 The S.A. node rhythm originates in multiple areas of the atria.

 This results in p waves on the electrocardiogram which differ from the normal

appearance of p waves. The rate usually remains at less than 100 beats per
minute.
 Electrocardiogram
 There is a different P wave morphology than in normal sinus rhythm (NSR)
 The sinus rate is < 100 beats per minute
 The rhythm is called an accelerated atrial rhythm when the rate is faster than
the patient's own NSR but < 100 beats per minute.
SINUS ARRHYTHMIA
 Sinus arrhythmia is almost always normal.
 The rate variation depends on respiration, so that during inspiration the rate
increases and during expiration the rate decreases, always with some delay.
 The rate deviation may reach 50% in children and +/− 15% in middle-aged
people; in the elderly the deviation is small or absent.
 In young healthy people the rate variability may exceed 50%.
 Differential diagnosis: Atrial premature beats originating near the sinus node.
 Note: sinus arrhythmia is generally not a component of the sick sinus
syndrome.
SINUS TACHYCARDIA
 Sinus tachycardia is normal during exercise and under conditions of mental
stress.
 Sinus tachycardia is a normal variant if the patients heart rate is less than 110
beats per minute.
 Differential diagnosis: Includes febrile status, heart failure, hyperthyroidism,
tumoral diseases, and cachexia.
SINUS BRADYCARDIA

 Sinus bradycardia is often seen as a normal variant in individuals at rest, and usually in
athletes.
 Episodes of sinus bradycardia at a rate < 40/min were observed in young healthy people, in
24% of men and 8% of women; with sinus pauses of up to 2.06 sec in men and 1.92 sec in
women.
 Especially in sinus bradycardia the J point, and thus the ST segment, may be elevated up to 2–
3 mm, and rarely up to 4 mm
INCOMPLETE RIGHT BUNDLE-
BRANCH BLOCK
 An incomplete right bundle branch block is an RSR pattern that is 0.10 to 0.11 seconds, or
stated differently, is a QRS complex duration less than 0.12 seconds. This is quite common in
healthy people.
 It is a frequent finding in healthy people, especially in young people.
 This pattern may lead to a notching or rSr’ complex in lead III also.
 A notched S upstroke in V1 often corresponds to iRBBB.
 In this case, there is a terminal R wave in lead aVR, as in common patterns of iRBBB.
 In addition, the QRS configuration with r < r’ represents a normal variant in many cases.
 However, we have to exclude diseases of the right ventricle.
INCOMPLETE RIGHT BUNDLE-
BRANCH BLOCK
DIFFERENTIAL DIAGNOSIS
IRBBB
 Right ventricular systolic overload (as in pulmonary embolism and any disease with
pulmonary hypertension, and/or right ventricular hypertrophy),
 RV diastolic overload (as in atrial septal defect) or may represent a precursor of complete
RBBB. iRBBB with r > r’ is a rarer finding in these pathologic conditions.
 A new onset iRBBB may be a sign of acute right ventricular overload, or it can appear after
different placing of lead V1 – in which case it may be harmless
 SINGLE PREMATURE VENTRICULAR
CONTRACTION
 Single PVCs are common in healthy persons. It is a normal variant.
 41% of healthy volunteers below the age of 45 years have been found to have
PVCs on 24-hour Holter ECG recording.
 Rates vary by age with under 1% for those under the age of 11 and 69% in those
older than 75 years. These differences may be due to rates of high blood pressure
and heart disease, which are more common in older persons.
 However, two or more PVCs on a 12-lead ECG would require a workup.
 Isolated PVCs with benign characteristics and no underlying heart disease require
no treatment, especially if there are limited symptoms.
FIRST-DEGREE AV BLOCK
 First-degree AV Block With PR Interval Between 0.21 and 0.29 Seconds Any first-degree
AV block with a PR interval 0.21 to 0.29 seconds is a normal variant.
 Any PR interval greater than 0.30 requires an evaluation.
NOTCHING VERSUS PSEUDO-NOTCHING

 Notching or a ‘notch’ is defined as a small (about 1–2 mm high) additional

deflection with inverse polarity, within the Q, R , or S wave of the QRS
complex
 Notching and slurring correspond either to a localized disturbance (delay) of
conduction and excitation, or merely may be due to projections (known as
pseudo-notching).
 In practice it is important to distinguish between true intraventricular
conduction disturbance (notching) and a harmless functional alteration, based
only on vectorial projection (pseudo-notching).
 Notching in the limb leads may also be seen in old myocardial infarction, with
or without pathologic Q waves.
 NOTCHING VERSUS PSEUDO-NOTCHING
 Differentiation between notching and pseudo-notching may be difficult.
 Slight pseudo-notching is frequently seen in the inferior leads III, aVF and II and
occasionally in lead aVL. A pseudo-notching in lead I is rare.
 A pseudo-notching may also be present in the transition zone of the precordial
leads, mostly in only one lead, and predominantly in V3

Differential diagnosis:
 In cases of notching in three or more precordial leads, an intraventricular conduction disturbance is
probable, often due to an infarction scar
 Left posterior fascicular block: Often ‘slurred R downstroke’ in leads III,aVF and V6.
 Left anterior fascicular block (always with left-axis deviation): Often ‘slurred R downstroke’ in
leads I and aVL.
QRS LOW VOLTAGE
 A QRS voltage of less than 5 mm (0.5 mV) in up to three of the six frontal
leads is not a rare finding.
 True peripheral low voltage is present if the QRS complex is smaller than 5
mm in five out of six or all six limb leads,a rare finding in normal individuals.
Differential diagnosis:
 True peripheral low voltage in pathologic conditions is found in lung
emphysema, obese people, and in patients with extensive pericardial effusion.
 Peripheral low voltage has little clinical importance. The same is valuable for
the very rare horizontal low voltage defined as QRS voltage smaller than 7
mm in all precordial leads.
WANDERING ATRIAL
PACEMAKER
 WAP is an atrial arrhythmia that occurs when the natural cardiac pacemaker
site shifts between the sinoatrial node (SA node), the atria, and/or
the atrioventricular node (AV node).
 This shifting of the pacemaker from the SA node to adjacent tissues is
identifiable on ECG Lead II by morphological changes in the P-wave;
 Sinus beats have smooth upright P waves, while atrial beats have flattened,
notched, or diphasic P-waves.
 It is often seen in the very young, very old, and in athletes, and rarely causes
symptoms or requires treatment.
JUVENILE T-WAVE PATTERN
 The Juvenile T-wave pattern refers to a normal electrocardiographic variant in which T wave
inversions are present in the right precordial leads (V1, V2, and V3) along with an early
repolarization pattern.
 Shallow T-wave inversion is usually found in the right precordial leads during infancy, and T
wave rises upwards during childhood.
 If this inverted T-wave pattern sustained to adulthood, it is called persistent juvenile T-wave
pattern.
 It is more commonly found in females than males
 Patients are typically African American women under age 30.
 It is rare in males over 19 years of age to have T-wave inversion beyond lead V1, unless there
is lead misplacement or also possibly deep inspiration during recording
JUVENILE T-WAVE PATTERN
 It does often extend out to V4 and beyond, has some ST elevation, and biphasic T-waves
 T-waves are slightly asymmetrically inverted in V1-V3.
 T-wave inversion that extends out to V4 and beyond should only be seen in patients under age
12.
 There are no structural cardiac abnormalities.
JUVENILE T-WAVE PATTERN
TECHNICAL ERRORS AND
ARTIFACTS
 Artifacts that may interfere with interpretation can come from movement of
the patient or electrodes, electrical disturbances related to current leakage and
grounding failure, and external sources such as electrical stimulators or
cauteries.
 Misplacement of one or more electrodes is a common cause for errors.
 Significant misplacement of precordial electrodes.
DEXTROCARDIA
SUMMARY
 Reading of ECG is an art, that can be mastered by practice
 It should be read by strict systemic approach, involving describing
the obvious abnormalities.
 Every ‘unusual’ ECG pattern should be interpreted in the context of
the conditions of the person being investigated, including age,
clinical findings and quality of symptoms.
 Try to find any old tracing to compare any abnormalities
REMEMBER…
|
|
TREAT
The patient..
NOT
THE ECG !!