Practice Ekg Part I

Practice ECGs
Part I
Copyright 2006 by Mosby Inc. All rights reserved.
Objectives
Develop a systematic approach for infarct

recognition on the ECG.
Gain familiarity with 12-Lead ECG

interpretation.
Reviewing a 12-Lead ECG
Assess the quality of the tracing.
Identify the rate and underlying rhythm.
Examine for evidence of infarction.
Reviewing a 12-Lead ECG
Ascertain if infarct impostors are present that

may account for ECG changes.
Clinical presentation.
Interpret your findings.
Infarct Impostors
Left bundle branch block
Ventricular rhythms
Left ventricular hypertrophy
Pericarditis
Early repolarization
Figure 9-1
Figure 9-1
Poor R wave progression
Figure 9-1
Baseline wander
or artifact?
Baseline wander V1
Interpretation:
Underlying
rhythm?
Sinus rhythm at 83 bpm
Extensive anterior
infarction, reciprocal
changes
Pathologic Q
waves?
Leads: III?, V2, V3
Low voltage over

entire tracing
Poor R wave
progression?
Leads: V5
ST-segment
elevation?
Leads: I, aVL, V1 V6
ST-segment
depression?
Leads: II, III, aVF
T wave changes?
Leads: Inversion III,

aVF; tall V3 V5
Practice 9-2
32-year-old Caucasian woman
Practice 9-2

Artifact
Practice 9-2
Baseline
wander or
artifact?
Artifact in aVR
Underlying
rhythm?
Sinus rhythm
at 75 bpm
Interpretation:
Normal ECG
PR interval 160 ms
QRS 80 ms
QT/QTc 414/462 ms
P-R-T axes 62 42 31
Figure 9-3
Figure 9-3
Baseline wander
Baseline wander
Baseline wander
Figure 9-3
Baseline
wander or
artifact?
Baseline wander
in II, III, aVL
Underlying
rhythm?
Sinus rhythm at
93 bpm
Pathologic Q
waves?
Leads: III, aVF
ST-segment
elevation?
Leads: V2, V3;

slight in V1
Interpretation:
Anteroseptal infarction,
previous inferior wall
infarction; low voltage in
lead II
Figure 9-4
Figure 9-4
Underlying
rhythm?
Sinus bradycardia at
55 bpm with
occasional PVCs
Interpretation:
Sinus bradycardia with
occasional PVCs,
otherwise normal ECG
PR interval 142 ms
QRS 94 ms
QT/QTc 436/417 ms
P-R-T axes 60 14 54
Figure 9-5
Figure 9-5
Baseline wander
Baseline wander
Baseline wander
Baseline wander
Figure 9-5
Baseline wander or
artifact?
Baseline wander in I, II,

V1, V6
Underlying rhythm?
Atrial fib at 100 bpm
Pathologic Q
waves?
Leads: aVL
Poor R wave
progression?
Leads: V2
ST-segment
elevation?
ST-segment
depression?
Leads: II, III, aVF
T wave changes?
Leads: Peaked T wave

V2, tall/peaked V3, V4
Interpretation:
Anteroseptal
infarction with lateral
extension; reciprocal
changes noted
Figure 9-6
Figure 9-6
Figure 9-6
Underlying
rhythm?
Sinus rhythm at
75 bpm
Interpretation:
PR interval 130 ms
ST-segment
elevation?
Leads: V1 V3
QRS 144 ms
QT/QTc 406/453 ms
P-R-T axes 13 -16 58
ST-segment
depression?
Leads: V4 V6
Figure 9-7
Figure 9-7
Figure 9-7
Underlying
rhythm?
Sinus bradycardia
at 56 bpm
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: I, aVL
Interpretation:
Inferior infarction age
undetermined, ST & T wave
abnormality consider lateral
ischemia
PR interval 168 ms
QRS 88 ms
QT/QTc 424/402 ms
P-R-T axes 7 0 101
T wave
changes?
Leads: I, aVL
Figure 9-8
Figure 9-8
Underlying
rhythm?
Sinus arrhythmia
at 67 bpm
Interpretation:
Normal ECG
PR interval 164 ms
ST-segment
depression?
T wave
changes?
Leads: III
QRS 66 ms
QT/QTc 392/414 ms
Leads: Inversion
in V1
P-R-T axes 81 84
61
Figure 9-9
Figure 9-9
Figure 9-9
Baseline wander
or artifact?
Artifact I, II, III, aVL, V1
Underlying
rhythm?
Pathologic Q
waves?
Leads: V5, V6; Q wave

approaching 40 ms in V4
ST-segment
elevation?
Leads: V1, V2, V3
ST-segment
depression?
Leads: V5, V6
T wave changes?
Leads: Tall in V2-V4;

peaked in II, aVF, V2-V6;
inverted in aVL
Interpretation:
Anteroseptal infarction,
possible previous lateral
infarction. Nearing
voltage criteria for LVH.
Pattern similar to early
repolarization.
Figure 9-10
58-year-old Caucasian man
Figure 9-10
Figure 9-10
Underlying
rhythm?
Sinus
bradycardia at
58 bpm
Interpretation:
ST-segment
elevation?
Leads: I, aVL,
V2 V6
PR interval 184 ms
Extensive anterior
infarction
QRS 92 ms
QT/QTc 416/409 ms
ST-segment
depression?
Leads: II, III,

aVF
P-R-T axes 39 16 16
Figure 9-11
Figure 9-11
Underlying
rhythm?
Sinus
bradycardia at
56 bpm
Interpretation:
Sinus bradycardia,
PR interval 126 ms
QRS 100 ms
QT/QTc 432/416 ms
P-R-T axes 51 24 29
Figure 9-12
Figure 9-12
Figure 9-12
Underlying
rhythm?
Sinus tachycardia at
107 bpm
ST-segment
elevation?
Leads: I, aVL, V1V5
ST-segment
depression?
Leads: II, III, aVF
T wave
changes?
Leads: Tall/peaked
V2 V4; inverted in III
Interpretation:
Anteroseptal
infarction, reciprocal
changes present
Figure 9-13
Figure 9-13
Figure 9-13
Underlying
rhythm?
Sinus rhythm
at 71 bpm
ST-segment
elevation?
Leads: II, III,

aVF
ST-segment
depression?
Leads: V1 V4
Interpretation:
Inferior infarction; low
QRS voltage (<0.5 mV)
in limb leads
PR interval 144 ms
QRS 108 ms
QT/QTc 376/398 ms
P-R-T axes 43 44 38
Figure 9-14
Figure 9-14
Figure 9-14
Underlying
rhythm?
Junctional rhythm at
55 bpm
ST-segment
elevation?
Leads: II, III, aVF
Interpretation:
Inferior infarction;
marked ST depression
consistent with
subendocardial injury
PR interval 0 ms
ST-segment
depression?
T wave
changes?
Leads: Inverted in
aVL, V1
QRS 104 ms
QT/QTc 448/436 ms
P-R-T axes 999 58 84
Figure 9-15
Figure 9-15
Figure 9-15
Baseline
wander or
artifact?
Underlying
rhythm?
Artifact V1,
baseline wander
V2
Sinus rhythm at
74 bpm
Interpretation:
Right bundle branch
block, inferior infarction
age undetermined
PR interval 168 ms
QRS 130 ms
QT/QTc 388/430 ms
Pathologic Q
waves?
Leads: III, aVF
T wave
changes?
Leads: Inverted
V1, V2
P-R-T axes 60 -21 46
Figure 9-16
Figure 9-16
Figure 9-16
Underlying
rhythm?
Sinus rhythm at
67 bpm
Interpretation:
Right bundle branch block
PR interval
208 ms
QRS
122 ms
QT/QTc
430/454 ms
P-R-T axes 33 80 6
Figure 9-17
Figure 9-17
Figure 9-17
Underlying
rhythm?
Sinus tachycardia
with short PR
interval, short QT
interval
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: I, aVL
T wave
changes?
Leads: Inverted
in aVL, V1
Interpretation:
Inferior infarction
PR interval 116 ms
QRS 76 ms
QT/QTc 228/306 ms
P-R-T axes 59 2 77
Figure 9-18
Figure 9-18
Underlying
rhythm?
Sinus
bradycardia at
58 bpm
Interpretation:
Sinus bradycardia,
PR interval 122 ms
QRS 86 ms
QT/QTc 416/408 ms
P-R-T axes 41 54 22
Figure 9-19
Figure 9-19
Figure 9-19
Underlying
rhythm?
Sinus rhythm
at 81 bpm
Pathologic Q
waves?
Leads: III
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: I, aVL, V5, V6
T wave
changes?
Leads: Inverted in I,
aVL
Interpretation:
Inferior infarction
PR interval 184 ms
QRS 92 ms
QT/QTc 352/389 ms
P-R-T axes 60 23 106
Figure 9-20
Figure 9-20
Figure 9-20
Baseline wander
or artifact?
Baseline wander and

artifact in lead I, artifact
in II, III, aVL
Underlying
rhythm?
Pathologic Q
waves?
Leads: II?, III, aVF
Poor R wave
progression?
Leads: V3; no initial R

wave in V1
ST-segment
elevation?
Leads: V1 V4
ST-segment
depression?
Leads: II
T wave
changes?
Leads: Flattened T
wave aVL
Interpretation:
Anteroseptal
infarction,
possible previous
inferior infarction
Figure 9-21
Figure 9-21
Figure 9-21
Baseline
wander or
artifact?
Baseline wander
V5, V6
Underlying
rhythm?
Sinus rhythm
at 95 bpm
ST-segment
elevation?
Leads: V1 V3
Interpretation:
Septal infarction,
possible anterior
epicardial injury
PR interval 164 ms
QRS 96 ms
QT/QTc 380/433 ms
ST-segment
depression?
Leads: II, III, V5, V6
T wave
changes?
Leads: Inverted in
aVL
P-R-T axes 62 -62

83
Figure 9-22
Figure 9-22
Figure 9-22
Underlying
rhythm?
ST-segment
depression?
Sinus rhythm at
65 bpm
Interpretation:
Inferolateral ischemia
Leads: II, III,

aVF, V4 V6
Note: This is the same

patient as in figure 9-26
29 minutes after the ECG in
figure 9-26 was obtained
PR interval 182 ms
T wave
changes?
Leads: II, III,

aVF, V5 V6
QRS 82 ms
QT/QTc 410/426 ms
P-R-T axes 76 52 -79
Figure 9-23
Figure 9-23
Figure 9-23
Baseline wander
or artifact?
Baseline wander lead I
Underlying
rhythm?
Pathologic Q
waves?
Leads: V2-V4
ST-segment
elevation?
Leads: II, III, aVF, V4 V6
ST-segment
depression?
Leads: V1
T wave
changes?
Leads: Peaked in II, III,

aVF, V3, V4
Interpretation:
Low voltage
throughout
tracing. Inferior
infarction, lateral
extension
Practice 9-24

Artifact
Practice 9-24
Baseline
wander or
artifact?
Artifact in V1
Interpretation:
Normal ECG
Underlying
rhythm?
Sinus rhythm at
78 bpm
PR interval 154 ms
QRS 80 ms
QT/QTc 394/449 ms
P-R-T axes 77 78 55
Figure 9-25
Figure 9-25
Artifact
Artifact
Figure 9-25
Underlying
rhythm?
Sinus rhythm at
69 bpm with
occasional PVCs
Interpretation:
RSR (QR) in V1/V2
consistent with right
ventricular conduction
delay
PR interval 172 ms
QRS
104 ms
QT/QTc 400/420 ms
P-R-T axes 74 69 44
Figure 9-26
Figure 9-26
Baseline wander
Figure 9-26
Baseline
wander or
artifact?
Baseline wander
V2
Interpretation:
Lateral ischemia
Underlying
rhythm?
Sinus rhythm at
67 bpm with
occasional
PVCs
PR interval 190 ms
ST-segment
depression?
Leads: II,
aVF, V3-V6
P-R-T axes 76 53
111
T wave
changes?
Leads: V5, V6
QRS 82 ms
QT/QTc 408/431
ms
Figure 9-27
Figure 9-27
Figure 9-27
Underlying
rhythm?
Sinus rhythm at
100 bpm
Pathologic Q
waves?
Leads: III
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: aVL
T wave
changes?
Leads: aVL
Interpretation:
Inferior infarction
PR interval 180 ms
QRS 96 ms
QT/QTc 380/436 ms
P-R-T axes 73 35 84
Figure 9-28
Figure 9-28
Figure 9-28
Baseline
wander or
artifact?
Baseline wander
V5, V6
Interpretation:
Septal infarction,
possible anterior
epicardial injury
Underlying
rhythm?
Sinus rhythm at
95 bpm
ST-segment
elevation?
Leads: V1- V3
ST-segment
depression?
Leads: II, III, V5,

V6
QT/QTc 380/433
ms
T wave
changes?
Leads: Inverted
in aVL
P-R-T axes 62 -62

83
PR interval 164 ms
QRS 96 ms
Figure 9-29
Figure 9-29
Underlying
rhythm?
Electronic atrial
pacemaker at 80
bpm
Interpretation:
Electronic atrial pacemaker
PR interval 626 ms
QRS
92 ms
QT/QTc 358/412 ms
P-R-T axes 0 52 16
Figure 9-30
Figure 9-30
Underlying
rhythm?
Sinus tachycardia
with nonconducted
(blocked) premature
atrial complexes at 92
bpm
Interpretation:
Sinus tachycardia with
nonconducted
(blocked) premature
atrial complexes,
PR interval 156 ms
QRS 88 ms
QT/QTc 326/403 ms
P-R-T axes 54 26 54
Figure 9-31
Figure 9-31
Figure 9-31
Underlying
rhythm?
Sinus rhythm at
62 bpm
ST-segment
elevation?
Leads: V2 V5
Interpretation:
Anterolateral infarction;
meets minimal voltage
criteria for LVH, may be
normal variant
PR interval 168 ms
ST-segment
depression
?
Leads: II, III, aVF
T wave
changes?
Leads: Tall in
V2 V5
QRS 100 ms
QT/QTc 388/393 ms
P-R-T axes 55 -29 35
Figure 9-32
Figure 9-32
Figure 9-32
Underlying
rhythm?
ST-segment
elevation?
Sinus rhythm at
82 bpm
Leads: V1
Interpretation:
Incomplete right
bundle branch block
PR interval 136 ms
ST-segment
depression?
Leads: II, III,

aVF, V5, V6
QRS 96 ms
QT/QTc 388/453 ms
P-R-T axes 62 12 27
Figure 9-33
Figure 9-33
Figure 9-33
Baseline
wander or
artifact?
Underlying
rhythm?
Baseline wander II, III,

aVL, aVF
Sinus rhythm with firstdegree AV block at 66
bpm with occasional
supraventricular
premature complexes
Pathologic Q
waves?
Leads: II, III, aVF
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
T wave
changes?
Leads: Tall in II, III, aVF;

depressed in I, aVL,
V1 V3
Interpretation:
Inferior infarction,
reciprocal changes
present
PR interval 260 ms
QRS 104 ms
QT/QTc 444/458 ms
P-R-T axes 90 -75
105
Figure 9-34
Figure 9-34

Baseline wander
Baseline wander
Baseline wander
Figure 9-34
Baseline
wander or
artifact?
Underlying
rhythm?
Baseline wander
V4 V6
Atrial fibrillation
at 107 bpm
Interpretation:
Atrial fibrillation with
rapid ventricular response
PR interval None
QRS 90 ms
QT/QTc 304/405 ms
ST-segment
depression?
Leads: V6
T wave
changes?
Leads: Tall in V2
P-R-T axes None 69 17
Figure 9-35
Figure 9-35
Figure 9-35
Underlying
rhythm?
Sinus rhythm at
73 bpm
ST-segment
elevation?
Leads: V1 V2
Interpretation:
PR interval 136 ms
ST-segment
depression?
Leads: I, II, aVL,

aVF, V5 V6
QRS 144 ms
QT/QTc 438/482 ms
P-R-T axes 28 -5 238

Practice Ekg Part I

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Practice Ekg Part I

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Practice ECGs

Copyright 2006 by Mosby Inc. All rights reserved.

Develop a systematic approach for infarct

Gain familiarity with 12-Lead ECG

Copyright 2006 by Mosby Inc. All rights reserved.

Reviewing a 12-Lead ECG

Assess the quality of the tracing.

Identify the rate and underlying rhythm.

Examine for evidence of infarction.

Copyright 2006 by Mosby Inc. All rights reserved.

Reviewing a 12-Lead ECG

Ascertain if infarct impostors are present that

Interpret your findings.

Copyright 2006 by Mosby Inc. All rights reserved.

Left bundle branch block

Left ventricular hypertrophy

Copyright 2006 by Mosby Inc. All rights reserved.

Copyright 2006 by Mosby Inc. All rights reserved.

Poor R wave progression

Copyright 2006 by Mosby Inc. All rights reserved.

Sinus rhythm at 83 bpm

Leads: III?, V2, V3

Low voltage over

Leads: II, III, aVF

Leads: Inversion III,

32-year-old Caucasian woman

Copyright 2006 by Mosby Inc. All rights reserved.

32-year-old Caucasian woman

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Copyright 2006 by Mosby Inc. All rights reserved.

Copyright 2006 by Mosby Inc. All rights reserved.

Copyright 2006 by Mosby Inc. All rights reserved.

Leads: III, aVF

Leads: V2, V3;

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Copyright 2006 by Mosby Inc. All rights reserved.

Copyright 2006 by Mosby Inc. All rights reserved.

Poor R wave progression

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Baseline wander in I, II,

Atrial fib at 100 bpm

Leads: II, III, aVF

Leads: Peaked T wave

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67-year-old Caucasian woman

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67-year-old Caucasian woman

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Copyright 2006 by Mosby Inc. All rights reserved.

71-year-old Caucasian woman

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71-year-old Caucasian woman

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Leads: II, III, aVF

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42-year-old Caucasian woman

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Copyright 2006 by Mosby Inc. All rights reserved.

Copyright 2006 by Mosby Inc. All rights reserved.

Artifact I, II, III, aVL, V1

Sinus rhythm at 77 bpm