Scribd
Upload
20 views

ECG Tutorial

This document provides an introduction to electrocardiograms (ECGs), including the normal ECG waveform, measurements, intervals, abnormalities, and clinical correlations. It covers topics like cardiac axes, hypertrophy, conduction blocks, myocardial infarction locations, and more. The document is intended to teach medical professionals about interpreting and understanding ECGs.

Uploaded by

epic sound ever
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
20 views

ECG Tutorial

This document provides an introduction to electrocardiograms (ECGs), including the normal ECG waveform, measurements, intervals, abnormalities, and clinical correlations. It covers topics like cardiac axes, hypertrophy, conduction blocks, myocardial infarction locations, and more. The document is intended to teach medical professionals about interpreting and understanding ECGs.

Uploaded by

epic sound ever
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 102

Introduction to

ECG
And clinical correlation
For Medical PGs/HOs/Final years
Dr A – Bari
FCPS resident
Cardiology CHK
Introduction – Wiring diagram of Heart
Introduction – ECG paper & basic waves
Introduction – tracing ECG waves on
real ECG paper

05/09/2024
Introduction – square measurements

2
3

5
ECG segments & intervals

05/09/2024
ECG intervals
Calculation of heart rate on ECG

HR = ____ 300_________
Number of large squares b/w 2 R waves

HR = ____ 1500_________
Number of small squares b/w 2 R waves
Calculate heart rate??
Normal ECG appearance
Deflections on ECG

Positive deflection
R>S

Negative deflection
S>R
Shape of QRS complex in chest leads

Septum is depolarized first, from left to right


Shape of QRS complex in chest leads

Depolarization of ventricles. Left  right


Shape of QRS complex in chest leads

Ventricles completely depolarized.


Normal QRS in chest leads

Transition point Movement of TP

• Where R and S waves are equal • If TP has moved to V4/5 or V5/6


• Clock wise rotation
Cardiac axis
-900
-150

1800 00

600
+ 120
+900
Cardiac axis
-900
-150

1800 00

600
+ 120
+900
Cardiac axis
RIGHT AXIS DEVIATION
RIGHT AXIS DEVIATION
LEFT AXIS DEVIATION
P wave abnormalities

BIFID P WAVE

P wave > 3mm or 0.12s


Left atrial hypertrophy
P wave abnormalities
P PULMONALE
P wave > 2.5 mm
Right atrial hypertrophy
P wave abnormalities
DEPRESSED PTa SEGMENT
Segment between P wave & Q wave
•Acute pericarditis
•Atrial infarction
QRS abnormalities
NORMAL QRS COMPLEX
•Duration no greater than 120 m.seconds (3 small squares)

•S wave is greater than R wave in lead V1


•R wave is greater than S wave in lead V5
QRS abnormalities – Right ventricular
hypertrophy

1. R > S wave in lead V1 ( R wave > 7mm in lead v1)


2. Deep S wave in lead V5 or 6 ( S wave > 7mm deep)
3. Right axis deviation
4. Peaked p wave
5. Inverted t wave in lead V1 - 3
Introduction
Introduction

R > 7mm in lead V1

Deep S wave > 7mm in lead V 5

Right axis deviation

Inverted T waves in lead V1 , 2, 3


QRS abnormalities – left ventricular
hypertrophy
Tall R wave > 25 mm in lead V5 or 6

Sum of R wave in lead V 5 + S wave in lead V 1 or 2 = >


35mm

Deep S wave in lead V1 or 2

Inverted T waves in lead I, V5 – 6, or


sometimes lead V 4

Left axis deviation


Introduction
Introduction

Tall R wave > 25 mm in lead V5 or 6

Sum of R wave in lead V 5 + S wave in lead


V 1 or 2 = > 35mm

Deep S wave in lead V1 or 2

Inverted T waves in lead I, V5 – 6, or


sometimes lead V 4

Left axis deviation


QRS abnormalities – pulmonary embolism
Sinus tachycardia

Peaked P wave

Right axis deviation

Tall R wave in V1

Inverted T wave in T 3 & V 1

Shift of transition point to left – V5 – V6

Q wave in lead III resembling inferior wall MI


Introduction
Introduction
Myocardial
ischemia
ST segment

ST segment elevation or depression


 >2mm depression or elevation – ischemia, MI, (chest leads)
> 1 mm depression or elevation – ischemia , MI, pericarditis (limb
leads)
ST segment depression

1. Horizontal depression – with


upright T wave is sign of
ischemia
2. Up slopping depression -
ischemia
3. Down slopping – digoxin side
effects
05/09/2024
STEMI

ECG criteria for diagnosis of STEMI


New ST elevation
 >2mm in chest or > 1mm in limb leads ( 2 contiguous leads)
New onset of LBBB
Shapes of ST elevation

1. ST segment elevation caused by ischemia produces straight,


horizontal, upsloping, or convex ST segment.
2. Concave ST segment are much less likely caused by ischemia
Findings of acute MI on ECG
Reciprocal changes– sign of distant
ischemia
Patients with new Q wave and
ST elevation may have ST
segment depression in other
territories
These additional ST changes
implies ischemia in territory other
than infarction, termed as
ischemia at distance or reciprocal
changes
For example ST segment
depression in anterior leads may
be seen in setting of acute inferior
STEMI
Wallens pattern– sign ofischemia
Deep coronary T wave inversion in
multiple pre-cordial leads V1 – V4
This finding is associated with high grade
stenosis in Proximal LAD coronary arterial
system
T wave inversion may be preceded by ST
segment elevation that might resolve by the
time patient arrives hospital
This pattern of T wave inversion in setting
of unstable angina correlates with segmental
hypokinesia of anterior wall and suggest
myocardial stunning syndrome
De winter’s sign
• When hyperacute T waves
persist for hours
accompanied by ST segment
depression (1 – 3 mm in
leads V1-6)with upsloping
ST segments is termed as De
Winter sign.
• It is a sign of proximal LAD
occlusion
05/09/2024
Poor R wave progression – sign of
ischemia
1. Normal R wave progression implies that R wave amplitude increase gradually
from V1-V5 and then diminish in V6.
2. Abnormal R wave progression implies that gradual increase from V1-V5 is absent.
It may be broken.
05/09/2024
Site of MI
Site of MI Leads ECG findings
Anterior wall MI V2 – V4 ST elevation
(reciprocal
depression)
Inferior wall MI II, III, avF, ST elevation
Reciprocal
depression
Lateral wall MI I, avL, V5. V6 ST elevation
Posterior wall MI V1 – V2 Reciprocal
depression only
05/09/2024
05/09/2024
05/09/2024
Detailed localization of occluded coronary artery

05/09/2024
ECG findings MI pattern Artery blocked
 ST ↑ in lead V1 – V6, I, aVL, Anterior Proximal LAD (proximal
 Fasicular or bundle branch block to first septal)

 ST ↑ in lead V1 – V6, I, aVL, Anterior Mid LAD (proximal to


large diagonal but distal
to septal)
 ST ↑ in lead V1 – V4, or I, aVL, V5,V6 Anterolateral Distal LAD or diagonal
 ST segment ↑in I, aVL High Lateral Diagonal or proximal LCx

 ST segment ↑in I, aVL, V5-V6 Lateral LCx


 Reciprocal changes in V1
05/09/2024
1. ST segment ↑ V1 – V2 Septal Septal branches - LAD
1. ST segment ↑ in lead III exceeds lead II Inferior wall MI Proximal to mid RCA
accompanied by ST ↑ in lead V1 (or right sided
leads)
1. ST segment ↑ in lead II exceeds or equals to that of Inferolateral wall MI Distal dominant RCA
lead III accompanied by ST ↓ in lead V1-V3 or ST ↑ LCX
in lead I, aVL

1. ST↑ in right sided leads (V1) RV infarction Proximal RCA


2. V4R – V6R ST ↑
3. QS/QR pattern in lead V3R/V4R (less accurate)

1. ST segment ↑ in lead aVR and V1 (especially with Left main disease


ST ↓ in other leads) Multiple coronary arteries
1. ST ↓ in V1 – V4 Posterior RCA
2. Tall R wave (R/S ratio > in lead V1-V2
05/09/2024
3. ST ↑ in lead V7-9
Causes of T wave inversion

1. Normal
2. Ischemia
3. Ventricular hypertrophy
4. Bundle branch block
5. Digoxin
6. Pulmonary embolism
Conduction defects – Heart blocks

First degree heart block


PR prolongation
Conduction defects – Heart blocks

First degree heart block


PR prolongation
Conduction defects – Heart blocks

Second degree heart block – MOBITZ TYPE 1


When some excitation fail to pass thru
AV node or bundle of his
Conduction defects – Heart blocks
Conduction defects – Heart blocks

MOBITZ TYPE 2
Constant PR interval
Occasional P wave is not followed by QRS
Conduction defects – Heart blocks

MOBITZ TYPE 2
Constant PR interval
Occasional P wave is not followed by QRS
Conduction defects – Heart blocks

Third degree or complete heart block


•No beat is conducted to ventricles
•Escape mechanism generate pace
maker below atria
Conduction defects – Heart blocks
05/09/2024
ECG criteria for RBBB
• QRS duration > 120 m.seconds
• V1/2 – M pattern or rSR pattern
• V5/6 or I, aVL – deep, broad S wave,
duration of S wave > R wave duration or S
wave duration > 40 msec
• ST/T changes

05/09/2024
Conduction defects – RBBB
1. No conduction occur in Right bundle branch

2. Septum is depolarized as usual from left to right (step1)

3. Then depolarization spread to left ventricles causing S wave

in lead V1 and R wave in lead v 6 (step 2)


Conduction defects – RBBB

• It takes longer time for


excitation to reach right
ventricle because of failure of
normal pathways therefore
right ventricle depolarizes
after left causing another R
wave in lead V1

05/09/2024
Conduction defects – RBBB
ECG criteria for LBBB
• QRS duration > 120
m.seconds
• V1/2 – deep and broad S
wave. Notched S wave.
Appear W pattern
• V5/6 or I, aVL – broad,
clumsy, completely
positive, often notched R
waves
• ST/T changes in V5/6
05/09/2024
LBBB

05/09/2024
Causes of LBBB

05/09/2024
05/09/2024
Conduction defects –LBBB
1. No conduction occur in left bundle branch

2. Septum is depolarized from right to left

3. Rt ventricle depolarize before left


Conduction defects –LBBB
Bradyrythm

Atrial escape & rhythm

Nodal escape & rhythm

Ventricular escape &


rhythm
05/09/2024
Atrial escape

05/09/2024
Atrial escape

05/09/2024
Nodal escape

05/09/2024
Nodal escape

05/09/2024
Nodal Rhythm

05/09/2024
Ventricular escape

05/09/2024
Ventricular escape

05/09/2024
Ventricular rhythm

05/09/2024
Rapid ventricular rhythm
Extr-asystoles – Premature beats

Atrial extrasystole

Nodal extrasystole

Ventricular extrasystole
05/09/2024
Atrial premature
beat

05/09/2024
Atrial premature
beat

05/09/2024
Junctional
premature beats

05/09/2024
Junctional
premature beats

05/09/2024
Ventricular
premature beat

05/09/2024
Tachy arrhythmias

Atrial tachycardia

Nodal tachycardia

Ventricular tachycardia
05/09/2024
Atrial tachycardia
Nodal tachycardia
Ventricular tachycardia
05/09/2024
Torsades de pointes
VF
Atrial fibrillation
Atrial fibrillation
Atrial fibrillation
Introduction
Atrial flutter
QT interval

05/09/2024
Thanks Thanks

You might also like