Electrocardiogram Interpretation: A Brief Overview

• Objectives:
13 slides 1. Basic principles for ECG interpretation
2. Normal ECG
3. Abnormal ECG examples

Know that This presentation will not cover “ECG dilemmas”

Should you code Q wave in V1, V2 or only when it involves all V1, V2, V3.”
A: only when V3 is involved
“in LBBB should you code acute MI?”
A: No
Basic principles for ECG interpretation
• Before you look at the ECG:
• Indication
- 20 YO man with syncope
- 50 YO man with acute chest pain
- 65 YO woman with HTN and chronic SOB
- 70 YO man with ESRD medications
include digoxin, coming with altered level
of consciousness - Muscle thickness, QT, arrhythmia
- Chamber size and its complications
- ischemia and its complications
- electrolytes, drug toxicity
Basic principles for ECG interpretation

• Screen the ECG for quality:

• Verify patients name, MRN, and date
• Make sure that voltage is 10 mm/mv and calibrated
• Screen for quality, correct lead placement, noise
 Na, TCA

K Disturbance
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015. Ca Disturbance, Digoxin
Basic principles for ECG interpretation
• Know how to calculate the HR, PR, QRS, and QT
• Know what is a normal sinus morphology and identify abnormal
• Know what is normal axis, normal voltage, normal vs pathologic Q,
juvenile patterns, normal variants

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

 Nomenclature
Waves
-P wave
-T wave
-U wave

Complex
-QRS

Segments
-PR segment
-ST segment

Intervals
-PR interval 1 “little box” = 0.04 seconds (or 40
msec)
-QT interval
1 “big box” = 0.2 seconds (or 200 msec)
Point • 5 “little boxes” = 1 “big box”
-J point • 5 “big boxes” = 1 second
• Step 1:
• Locate RR interval: HR

• Step 2:
• Rhythm & its origin
• Can be difficult and complex
• Most common mistake made by
computer interpretation
For Boards
• Expected not to miss a serious/deadly finding/diagnosis
• ST elevation
• Hyperkalemia
• Drug toxicity
• Major pathology: heart block, arrhythmia, HCM……………………..

Usually, your indication is your guide

• Do not worry about controversial or minor findings

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

ECG Coding Sheet:

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
 Abnormally, normal avR

Unexpectedly "normal"

Inverted lead I
in absence of
Dextrocardia
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Rhythm

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

• So Far:

• You learned to ask about/present the indication before interpretation

• Scan for quality and lead placement

• Know the various electrical waves/intervals and what is normal ECG

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Chamber Abnormality

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

24 year old man with syncope

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

45 year old man with HTN

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

LVH Criteria:
• The Cornell criteria:
• R wave in aVL + S wave in V3 > 28 mm in males and > 20 mm in females of the
voltage criteria.
• Therefore, the best policy is know most or all of the
• Sokolow:
• S in V1 or 2+ R in V5 or V6 > 35 mV
• R avL > 11 mV

• ST and/or T wave abnormalities, “strain” pattern

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:
07 Sinus rhythm
37 Right axis deviation (> +100 msec)
41 Right ventricular hypertrophy
43 RBBB, complete
67 ST and/or T wave abnormalities secondary to hypertrophy
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Chest pain/SOB

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:
10 Sinus tachycardia
43 RBBB, complete
46 Left posterior fascicular block
53 Anterior or anteroseptal Q wave MI (age recent or acute)
57 Inferior Q wave MI (age recent or acute)
65 ST and/or T wave abnormalities suggesting myocardial injury
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q1
• Significant ST segment elevation consistent with myocardial injury or
infarction is defined by:
• ≥ 1 mm STE in leads V1, V2, or V3
• ≥ 2 mm STE in leads V1, V2, or V3
• ≥ 2 in other leads
• ≥ 1 in other leads

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q1
• Significant ST segment elevation consistent with myocardial injury or
infarction is defined by:
• ≥ 1 mm STE in leads V1, V2, or V3
• ≥ 2 mm STE in leads V1, V2, or V3
• ≥ 2 in other leads
• ≥ 1 in other leads

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q2
• Repolarization abnormality that suggest Acute or recent Myocardial
infarction include:
• Peaked T waves followed by T wave inversion
• ST elevation followed by peaked T waves
• Deeply inverted T waves
• Dominant R wave and ST depression in V1-V3

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q2
• Repolarization abnormality that suggest Acute or recent Myocardial
infarction include:
• Peaked T waves followed by T wave inversion
• ST elevation followed by peaked T waves
• Deeply inverted T waves
• Dominant R wave and ST depression in V1-V3

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q3
• Which parameter obtained on initial ECG independently predict 30 day all-
cause mortality in acute myocardial infarction:
• Sinus tachycardia
• Sum of absolute ST segment deviation elevation and or depression
• QRS duration > 100 msec
• Rightward axis deviation

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q3
• Which parameter obtained on initial ECG independently predict 30 day all-
cause mortality in acute myocardial infarction:
• Sinus tachycardia
• Sum of absolute ST segment deviation elevation and or depression
• QRS duration > 100 msec
• Rightward axis deviation

Hathaway WR, et al. JAMA 1996, 273: 387-391.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:
06 Left atrial abnormality/enlargement
10 Sinus tachycardia
36 Left axis deviation (> –30o)
47 LBBB, complete
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q1
• A QRS duration ≥ seconds is necessary for the diagnosis of complete
LBBB:
• 0.10
• 0.11
• 0.12
• 0.13

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q1
• A QRS duration ≥ seconds is necessary for the diagnosis of complete
LBBB:
• 0.10
• 0.11
• 0.12
• 0.13

When LBBB morphology is present and the QRS duration measures > 0.10 seconds but < 0.12
seconds, incomplete LBBB should be coded.

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q2
• LBBB is commonly seen in normal hearts:
• True
• False

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Q2
• LBBB is commonly seen in normal hearts:
• True
• False

Never normal finding

LBBB often occurs in various forms of organic heart disease, including ischemic and non-ischemic
cardiomyopathy, valvular heart disease, LVH, and congenital heart disease. It is rarely seen in normal
hearts
Should not call it STEMI
Should not call LVH: 80% patients with LBBB have abnormally increased LV mass

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Bradycardia:
• A very big book in ECG

• Just on fun example

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:
07 Sinus rhythm
13 Atrial premature complexes

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Tachycardia:
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:
Sinus tachycardia
Paroxysmal SVT

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Killer

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

24 year old man with stressful life

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

Electrolyte/Drug toxicity:

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

65 year old man ESRD on dialysis presented
with acute confusion Peaked T waves

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.

17 year old female found by her room mate
unconscious

Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.