ECG interpretation for

beginners – 2

Axel en Luc De Wolf

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40 MANAGEMENT
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20 CLINICAL
QUESTIONS

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REFERENCES

TREATMENT DELAY IN HOURS SYSTEM

Boersma et al. Lancet 1996; 348: 771–775. REQUIREMENTS

IMPRESSUM
A heart
• Blood circulates, passing near
every cell in the body, driven by this
pump
• …actually, two pumps…
• Atria = turbochargers
• Myocardium = muscle
• Mechanical systole
• Electrical systole
Excitation of the Heart
Excitation of the Heart
Cardiac Electrical Activity
 A system
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
 A system
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
 P wave
• Are there P waves….?

– Pointy = P pulmonale (RA hypertrophy)>2,5mm

– Bifid = P mitrale (LA hypertrophy)>2,5mm

• Not very accurate or useful….

 PR interval

 Start of P wave to start of QRS

 Normal = 0.12-0.2s

 Too short – can mean WPW syndrome (ie. an

accessory pathway), or normal!

 Too long –means AV block (heart block) -

1st/2nd/3rd degree
 A system
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
 QRS complex
• Should be <0.12s duration
• >0.12s = BBB (either LBBB or RBBB)

• ‘Pathological’ Q waves can mean a previous

MI (? territory)

• >25% size of subsequent complex

• Q waves are allowed in V1, aVR and III
BBB
Look at V1 and V6

W I LL ia M = LBBB

M a RR o W = RBBB
 QRS complex
 Is there LVH?
 Sum of the Q or S wave in V1 and the biggest R
wave in V5 or V6 >35mm
 (R wave in aVL >11mm)

 Not actually very useful….

 A system
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
 ST segment
 ST depression
◦ Downsloping or horizontal = abnormal
◦ Ischaemia (coronary stenosis)
◦ If lateral (V4-V6), consider LVH with ‘strain’ or digoxin (reverse
tick sign)
 ST elevation
◦ Infarction (coronary occlusion)
◦ Pericarditis (widespread)

 These are usually in ‘territories’ eg. anterior/lateral/inferior

etc. and will be present in contiguous leads
 T wave
• Peaked (hyperkalaemia or normal young man)
• Inverted/biphasic (ischaemia, previous infarct)
• Small (hypokalaemia)

• No pot, no tea!
 QT interval
 Don’t worry about too much…

 Start of QRS to end of T wave

 Needs to be corrected for HR
 Various formulae
◦ eg. Bazett’s:

 Computer calculated often wrong

 Long QT can be genetic (long QT sy.) or secondary eg. drugs

(amiodarone, sotalol)
 Associated with risk of sudden death due to Torsades de Pointes
 Morfologische afwijkingen

Hypertrofie
Voorkamer en Kamer
 K51 – Rechter voorkamerhypertrofie
• Dilatatie van de rechter voorkamer
• Hoge spitse P toppen in afl. II & aVF ( 0,25 mV)
• Toename initiële P voltage in afl. II, III, aVF & V1
• Normale duur P golf
• Vaak in combinatie met tekenen van rechter kamerhypertrofie

P pulmonale
 K52 - Linker voorkamerhypertrofie
• Dilatatie van de linker voorkamer
• P golf > 120 ms
• Gehaakte P top door toename amplitude terminaal deel van P golf in afl. I,
II, aVL & V6
• Bifasische P golf in afl. V1 met terminaal negatief deel ( 0,1 mV,  40 ms)

Risico op atriale fibrillatie

 K53 - Linker kamerhypertrofie
• (R in V5 of V6) + (S in V1 of V2) > 3,5 mV (35 mm)
• ST elevatie concaaf naar boven met hoge positieve
T top in rechtszijdige afleidingen
• ST depressie convex naar boven met asymmetrisch negatieve T top in
linkszijdige afleidingen
• Normale as
 Left Ventricular Hypertrophy
Why is left ventricular hypertrophy characterized by tall QRS
complexes?
As the heart muscle wall thickens there is an increase in
electrical forces moving through the myocardium resulting in
increased QRS voltage.

LVH ECHOcardiogram
Increased QRS voltage
For more presentations
www.medicalppt.blogspot.com
 Left Ventricular Hypertrophy
• Criteria exists to diagnose LVH using a 12-lead ECG.
– For example:
• The R wave in V5 or V6 plus the S wave in V1 or V2 exceeds 35
mm.

• However, for now, all

you need to know is
that the QRS voltage
increases with LVH.

For more presentations

www.medicalppt.blogspot.com
 K55 – Rechter kamerhypertrofie
• Hoge R in V1 (> 0,7 mV) met R/S ratio > 1
• Vlakke R progressie
• Diepe S in V5-V6 ( > 0,7 mV) met R/S ratio < 1
• qR of rSR’ in V1 met hoge spitse R’ (diff. diagnose RBTB)
• Hoge, terminale R in aVR
• Rechter asdeviatie
(komt overeen met diepe S in I en aVL)

Kliniek van longlijden

Ischemie en Infarkt
 K56 - Ischemie
• Wanneer een elektrode geplaatst wordt tegenover een zone van ischemie
betekent
- ST segment depressie:
subendocardiale ischemie
- ST segment elevatie:
transmurale (subepicardiale) ischemie
 Characteristic changes in AMI
• ST segment elevation over area of damage
• ST depression in leads opposite infarction
• Pathological Q waves
• Reduced R waves
• Inverted T waves
 ST elevation

R • Occurs in the early stages

ST
• Occurs in the leads facing the
P infarction
• Slight ST elevation may be
Q
normal in V1 or V2
 Deep Q wave

• Only diagnostic change of

R
myocardial infarction
ST
• At least 0.04 seconds in
P duration
T • Depth of more than 25% of
Q ensuing R wave
 T wave changes

• Late change
R

ST
• Occurs as ST elevation is
P returning to normal
• Apparent in many leads
T
Q
 Bundle branch block
Anterior wall MI Left bundle branch block
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Sequence of changes in evolving AMI
R
R R
ST ST
T

P P P

T
Q S Q
Q

1 minute after onset 1 hour or so after onset A few hours after onset

ST T
P P ST
P

T T
Q Q Q

A day or so after onset Later changes A few months after AMI

 Anterior infarction
Anterior infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left
coronary
artery
 Inferior infarction
Inferior infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Right
coronary
artery
 Lateral infarction
Lateral infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left
circumflex
coronary
artery
Location of infarct combinations

I aVR V1 V4

ANT
LATERAL
POST ANT
II aVL V2
SEPTAL
V5

ANT
V3 V6 LAT
III aVF
INFERIOR
Diagnostic criteria for AMI

• Q wave duration of more than 0.04

seconds
• Q wave depth of more than 25% of
ensuing r wave
• ST elevation in leads facing infarct
(or depression in opposite leads)
• Deep T wave inversion overlying
and adjacent to infarct
• Cardiac arrhythmias