SYSTEMATIC EVALUATION OF THE ECG

1. GENRAL: Check PX ID; dates; place in sequence 2. CALIBRATION: Std; std; chair; NB generalised small complexes DDX: Obesity; COPD; pericardial effusion; hypothyroidism 3. RYTHM & RATE: RR-interval if constant - regular (Rate = 300/no. of blocks), else irregular (Rate = no. of complexes x 6) 4. P-WAVE: Precede every QRS-complex?; size and morphology 5. PR-INTERVAL: Length 6. QRS-COMPLEX: Axis; width; height; Q-wave morphology 7. ST-SEGMENT: Position about iso-electric axis (depression and elevation) 8. T-WAVE MORPHOLOGY: Size, shape 9. QT-INTERVAL: Length 10. PATTERNS: Pulmonary embolism; mitral valve lesions (MS, MInc.); hyper/hypokalaemia; hyper/hypocalcaemia;ischemia; dysrhytmias 11. LOCALISATION: Localisation of infarcts

ST-SEGMENT
ST-elevation

ST-depression
Myocardial Ischemia NSTEMI Post. infarct Digoxin VH with systolic pverload Reciprocal changes of infarct

INFARCTION
Leads
II; III; aVF II; III; aVF; V5; V6 V1-V3 I; aVL; V1-V6 V4-V6 I; aVL V1-V3 (mirror image) V4r; V5r; V6r

Location
Inferior Inferolateral Anteroseptal Wide anterior Lateral High Lateral True posterior (R) ventrivle

Artery
RCA or circumex Circumex or RCA LAD (L)Main stem/ LAD Circumex 1st Diagn. of LAD Circumex RCA

T P Q
QT

MI Pericarditis Prinzmental angina Ventricular anuerysm

T-WAVE MORPHOLOGY

Inverted T-waves
T-waves are usually (+)ve, Inversion may be normal in SII; aVR; V1

Peaked T-waves
Hyper acute MI Hyper kalaemia

Flattened T-waves
Ischemia Pericarditis Myocarditis Hypercalcaemia

QRS-COMPLEX Axis

BBB MI Myocardial myopathy VH WPW Syndrome Ventricular rhythms May be normal in septal region of black patients

Pathalogical Q-waves No electrical activity Shows electrical activity in opposing wall

SI

aVF

(N): -30<axis<90

(L) Axis DDX

[-90<axis<-30]

(R) Axis DDX

QT-INTERVAL
[90<axis<180]

(N): QT<11 blocks

ST-elevation: ST straighten Elimination of ST-junction Slope elevaion J-point elevates T-inversion T amplitude increase Giant peaked T ST-elevation T (N) 2/52 post MI

deep Q; inf. infarct (L) ant. hemi block Primum ASD WPW Syndrome

RVH antero-lat. infarct WPW Syndrome (L) post. hemi block

QT-interval Congenital defects of K+ channel (Long QT-syndr.) K+; Mg++; Ca++

Drugs Ischemia/ Infarction QT-interval Ca++

TACHYARRHYTHMIAS DDX P-WAVE MORPHOLOGY

Left atrial enlarement

BRADYARRHYTHMIAS BRADYCARDIAS Sinus bradycardia Intermittend cond. Slow escape rhythms HEARTBLOCKS

SII

V1

Width

V1

V6

(N): QRS<2 blocks

RBBB

LBBB

Right atrial enlarement

Bi-fascicular block
P-mitrale [SII] Biphasic-P [V1] P-Pulmonale [SII]

Combination of RBBB & LBBB + (L) axis deviation

V6

RVH

Amplitude V1 PR-INTERVAL
(N): 3<PR<5 (blocks)

PR: Pre-excitation (WPW)

ectopic atrial focus

Tall R in V1: DDx RVH; RBBB; WPW; true post. infarct; Duchennes MD
Pathological (infarct) if present in two or more adjacent leads.

BROAD

LVH

Tall R [V6] + deep S [V1] 35mm + T-inversion [V5-V6] = Systolic overload

(N): width < 1 block height < 3 blocks

Large R in V1 + (R) axis; T-inversion [V1-V3]

NARROW

Tall slurred R [V1] Deep slurred S [V6; SII] Inverted T [V1-V3]

Negative QRS [V1-V3] Broad, M-shaped QRS [V6]

REGULAR
Sinus tachy Ectopic atrial tachy Atrial utter AVNRT AVRT VT SVT + BBB SVT + Ab-cond SVT + Ec-cond Ventricular pacemaker

IRREGULAR
AF Atrial utter with var. block MAT

MVT Torsade de Point AF with BBB VF

SA Block/arrest AV Blocks: 1 2 - Mobitz 1

(Wenckebach)

Qwave

PR: 1 AV Block

- Mobitz 2 3

Pulmonary Embolism Sinus tachy Atrial arrythmias incl. AF (R) VH (R) BBB S1Q3T3 pattern

PATTERNS

COPD Gen. small complexes P-pulmonale (R) axis deviation (R) VH (R) BBB

Mitral Stenosis (L) AH, if sinus rhythm AF commonly present (R) VH (R) axis deviation

Mitral Incompetence (L) AH, if sinus rhythm AF commonly present (L) VH (R) VH due to PHTN

K+ Flat/ absent P-waves Broad QRS-complex Larger, peaked T Arrhythmias

K+ Flat T-waves Prominent U-waves 1 or 2 block ST-depression

Ca++ QT

Ca++ QT

Ischemia NNB: Horizontal STdepression ST-segment becomes horizontal

ST-elevation (Prinz ST-T junction mental angina) becomes angular T becomes symmetric T attened/ inverted T apex becomes sharp May cause a BBB ST displaced down