ELECTROCARDIOGRA

M
Marco Christopher G. Montaos, MD.
Internal Medicine
 ELECTROCARDIOGRAM

 is a graphical record of electric potentials

generated by the heart muscle during each
cardiac cycle. The signals are detected on the
surface of the body using electrodes attached
to the extremities and chest wall. These signals
are then amplified by the electrocardiograph
machine and displayed on special graph paper.
 Indications :
 Rate
 Rhythm
 Axis
 Hypertrophy
 Ischemic or Infarction
 Indications for ordering an
electrocardiogram
1. To determine cardiac rate
2. To accurately define cardiac rhythm
3. To diagnose old or new myocardial infarction
4. To identify intracardiac conduction disturbances
5. To aid in the diagnosis of ischemic heart disease,
pericarditis, myocarditis, electrolyte abnormalities
and pacemaker malfunction
 Position of the chest leads

Leads Position in the chest

V1 4th ICS at the right sternal border
V2 4th ICS at the left sternal border
V3 Halfway between V2 and V4
V4 5th ICS at the left midclavicular line
V5 5th ICS at the left anterior axillary line
V6 5th ICS at the left mid-axillary line
V3R Halfway between V1 and V4R
V4R 5th ICS at the right midclavicular line
I. Rate
A. Rate Interpretation has three possibilities:
1. Bradycardia - (< 60 beats/min.)
2.Normal Rate – ( 60 – 100 beats per
minute )
3. Tachycardia – ( > 100 beats per minute )

B. Rate Analysis:
Mnemonic: Memorize “ 300,150,100…75,60,50”
= if R to R interval > 5 big squares: Bradycardia
= if R to R interval between 3-5 big squares:
Normal Rate
= if R to R interval < 3 big squares: Tachycardia
 FORMULA

Heart Rate = 1500 or 300

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# of small boxes # of big boxes
II. RHYTHM

A. Common Rhythm Interpretations:

1. Sinus Rhythm
2. Common Supraventricular Arrythmias:
a. Atrial Fibrillation
b. Atrial Flutter
c. Supraventricular Tachycardia
3. Heart Blocks
a. First degree AV block
b. Second degree AV block Mobitz type I ( Wenckebach )
c. Second degree AV block Mobitz type II
d. Third degree AV block
e. Left or Right Bundle Branch Block ( complete and
incomplete )

4. Ventricular Arrythmias
a. Premature Ventricular Contractions
b. Ventricular Tachycardia ( sustained and unsustained )
c. Ventricular Fibrillation
B. Rhythm Analysis:
1. Identify the P wave
Determine from the configuration if this is a sinus P
2. Check the relation of P wave to QRS
a. P wave is before QRS ( normal )
b. P wave is buried or after QRS ( e.g. SVT, complete heart
block )
3. Check PR interval ( Normal PR interval: 0.12 – 0.20 sec. )
a. Short PR ( WPW syndrome )
b. Normal PR
c. Prolonged PR ( 1st or 2nd degree AV block )
4. Check QRS duration ( Normal QRS duration < 0.10 sec. )
a. Normal QRS
b. Wide QRS ( Bundle branch blocks )
5. Check the relation of R-R and P-P interval
a. Equal R-R and P-P interval ( Normal )
b. P-P interval shorter than R-R interval ( Complete heart
block )
c. P-P interval longer than R-R interval ( AV dissociation )
III. AXIS
A. Axis Interpretation has Four
Possibilities:
1.Normal Axis
2. Left Axis Deviation ( LAD )
3. Right Axis Deviation ( RAD )
4. Indeterminate Axis
B. Axis Analysis:
 Getting the Axis Deviation
 ( + ) QRS deflection: Average QRS vector
above the baseline in leads I or AVF

 ( - ) QRS deflection: Average QRS vector

below the baseline in leads I or AVF
 LEAD I LEAD AVF
Normal Axis + +

Left Axis Deviation + -

Right Axis - +
Deviation
Indeterminate Axis - -
Differential diagnosis for left and right axis
deviation
QRS Right Axis Deviation
QRS Left Axis Deviation
1. normal variant (thin tall
1. normal variant ( short fat individuals)
individuals)
2. right ventricular hypertrophy
2. left ventricular hypertrophy
3. lateral wall infarction
3. inferior wall infarction
4. pulmonary embolism
4. left bundle branch block
5. left posterior fascicular block
5. left anterior fascicular block

6. WPW syndrome 6. WPW syndrome

IV. Hypertrophy
A. Hypertrophy interpretation has 6
possibilities:
1. no hypertrophy
2. LVH
3. RVH
4. LAE
5. RAE
6. a combination of the above
B. Hypertrophy analysis:
Three LVH ECG Criteria: these are distorted
by the presence of a complete LBBB but not
by complete RBBB
1. S wave in V1 + R wave in v5 or v6 > 35mm
(commonly used)
sensitivity 43%, Specificity 97%
2. R in AVL > 11mm
sensitivity 11%, specificity 100%
3. Romhilt and Estes Criteria (Best Criteria)
sensitivity 50%, specificity 95%
a. amplitude 3 points
largest R or S wave in the limb leads >= 20mm
s wave in v1 or v2 >= 30mm
r wave in v5 or v6 >= 30mm

b. ST-T segment changes typical of LV strain

pattern
without digitalis 3 points
with digitalis 1 point
c. LAE: terminal negativity 3points
of the P wave in v1 is
1mm or more in depth
with a duration of 0.04s or more
d. LAD: 30 degrees or more 2 points
e. QRS duration >= 0.09s but < 0.12s 1 point
f. intrinsicoid deflection 1 point
in v5 and v6 >= 0.05s
interpretation of total score: possible LVH 3 points
probable LVH 4points
definitive LVH >= 5 \
points
 Four RVH ECG Criteria
1. right axis deviation of 110 degrees or more,
with any of the ff
2. lead v1 R wave > S wave
3. deep s wave in v5 and v6
4. ST depression and t wave inversion in v1-v3
 LAE ECG criteria: any of the ff
1. v1: wide terminal component of P wave
which is >= 1mm wide and>= 1mm deep
2. in any lead: P wave wider than 0.12s or
with a >= 1mm notch in the middle
 RAE ECG criteria: any of the ff
1. v1: tall initial component of P wave which
is >= 2mm wide and >= 2mm tall

2. in any lead: P wave >= 2.5mm tall

Biventricular Hypertrophy Diagnostic ECG
criteria: any of the ff
1. the ECG meets one or more of the
diagnostic criteria for isolated left and
right ventricular hypertrophy

2. the precordial leads show signs of left

ventricular hypertrophy, but the QRS axis
in the frontal plane is > 90 degrees
 Biatrial enlargement diagnostic ECG
criteria
1. v1: presence of a large diphasic P wave with the
initial positive component >= 2mm tall and the
terminal negative component >= 1mm deep and
>= 0.04s in duration

2. in any lead: increase in both the amplitude

which is 2.5mm or greater and duration of 0.12s
or more of the P wave
 V. Ischemia and Infarction
A. interpretation has 4 possibilities:
1. within normal limits (WNL). 50% of
patients w/ CAD or chronic stable angina
have normal ECGs
2. non-specific ST-T wave changes

3. myocardial ischemia changes

4. myocardial infarction changes

B. Infarction and Ischemia analysis

Leads involved Corresponding Areas

II, III, AVF Inferior wall
I, AVL High lateral wall
V1,v2 Septal wall
V3, v4 Anterior wall
V5, v6 Lateral wall
V1-v3 Anteroseptal wall
V3-v6, I, AVL Anterolateral wall
V5, v6, II, III, AVF Inferolateral wall
Almost all leads Diffuse, global, massive
Mirror image of v1, v2 Posterior LV wall
V3R, v4R RV wall
 ECG findings in ischemia:
1. at least 1mm ST-segment depression
2. symmetrically inverted t wave
3. abnormallt tall T wave
4. normalization of abnormal T wave
5. prolonged QT interval
6. arrhythmia, bundle branch blocks, AV
blocks
ECG criteria for infarct:
1. ST elevation >= 2mm in 2 or more chest
leads or >= 1mm in 2 or more limb leads
2. Q waves >= 0.04s

Myocardial Infarction In the presence of

BBBs
1. RBBB: usual myocardial criteria

2. LBBB: diminishing R wave forces in the

precordial leads or Q waves at v5 and v6
 Patterns that may mimic MI:
1. complete LBBB
2. early repolarization pattern
3. LV aneurysm
4. hyperkalemia
5. pericarditis
6. intracranial hemorrhage
7. idiopathic subaortic stenosis
8. WPW syndrome
9. electronic pacing of right ventricle
10. pulmonary disorders
 VI. Miscellaneous ECG findings:
1. hypokalemia
 U wave as tall or taller than the T wave at leads v2 v3.
2. hyperkalemia
 in the chest leads, height of T waves >10mm in most
leads.
 In the limb leads, height of T waves > 5mm in most
leads.
3. hypocalcemia
 prolonged QT interval ( normal QT interval is less than
half the RR interval)
4. hypercalcemia
 shortened QT interval
5. digitalis effect
 manifested by prolonged PR interval, scooping of the
ST segment, and short QT interval
6. digitalis toxicity
 all types of arrythmias, usually PVC’s or paroxysmal atrial
tachycardia
7. electrical alternans of QRS complex
 height of QRS varies from beat to beat
 may be due to cardiac tamponade, large pericardial effusion, low
cardiac output, COPD, tension pneumothorax
8. poor R wave progression
 height of the R wave in v3 is < 3mm
 may be due to old anteroseptal wall MI, LVH, normal variant of a
heart rotated clockwise, LBBB
9. persistent S wave in v5 v6
 prominent S waves in v5 and v6
 my be die to RVH, or the heart rotated clockwise
10. early repolarization changes
 normal variant in young males (ST segment elevation of 2-3mm in
leads v2-v4 usually found in males <40yrs old)
 may be due to Acute anteroseptal wall MI, or acute pericarditis
11. juvenile T wave inversion
 normal variant in young females (T wave inversion in v1-v3 in
females <30yrs old)
 may be due to acute anteroseptal wall ischemia
12. low voltage QRS complexes
 the amplitude of the entire QRS complex in all the limb leads is
<5mm
 may be found in normal elderly patients, obese or edematous
patients, cardiac tamponade, large pericardial effusion,
pneumothorax, hypothyroidism, dilated cardiomyopathy.
13. high voltage QRS complexes
 large QRS complexes
 may be found in patients <35yrs old, LVH, RVH, LBBB, RBBB
14. cerebral T waves of intracranial hemorrhage
 wide, prominent, and deeply inverted T waves with a long QT
interval
 may be found in intracranial hemorrhage, subendocardial MI,
and MI
15. wrong lead placement
 an upright P wave in lead AVR accompanied by a
normal R wave progression in the precordial leads
16. wrong speed
 widened PR and QRS intervals and the patient’s
heart rate does not jive with the ECG heart rate.
 Speed used is 50mm/sec instead of the usual
25mm/sec
17. artifacts
 irregular spikes or undulations on the ECG baseline
are not found in the other segments.