Ecg Interpretation 5g584h
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ECG INTERPRETATION
dr. Infan Ketaren SpJP-FIHA SMF Kardiologi & Pembuluh Darah RSUD Soedarso/FK Untan Pontianak
The ECG “The ECG (electrocardiogram) is a transthoracic interpretation of the electrical activity of the heart.”
The ECG
Why perform an ECG? • It’s part of the ission bundle • Indicated by the patient’s symptoms - symptoms of IHD/MI - symptoms associated with dysrhythmias • Indicated by the patient’s examination findings - cardiac murmur
Lead Placement
aVF
All Limb Leads
Precordial Leads
EKG Distributions • • • • • •
Anteroseptal: V1, V2, V3, V4 Anterior: V1–V4 Anterolateral: V4–V6, I, aVL Lateral: I and aVL Inferior: II, III, and aVF Inferolateral: II, III, aVF, and V5 and V6
ECG interpretation •
Quality of ECG?
• • •
Rate Rhythm Axis
• • • • • • • •
P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval
Quality of the ECG • • • •
Patient name Date of the ECG Is there any interference? Is there electrical activity from all 12 leads?
• Calibration: - speed = 25mm/second - height = 1cm/mV
Calibration
Calibration
ECG interpretation •
Quality of ECG?
• • •
Rate Rhythm Axis
• • • • • • • •
P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval
Rate • 300/number of big squares between R waves • Rate is either: - normal - bradycardic - tachycardic
Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes
Rate
1
300
2
150
3
100
4
75
5
60
6
50
Rate • HR of 60-100 per minute is normal • HR > 100 = tachycardia • HR < 60 = bradycardia
Differential Diagnosis of Tachycardia Tachycardia Narrow Complex ST Regular
Irregular
SVT Atrial flutter A-fib A-flutter w/ variable conduction MAT
Wide Complex ST w/ aberrancy SVT w/ aberrancy
VT A-fib w/ aberrancy
A-fib w/ WPW VT
What is the heart rate?
www.uptodate.com
(300 / 6) = 50 bpm
Rate
Rhythm • Are there P waves? • Are they regular? • Does one precede every QRS complex? • Regular vs. irregular
Rhythm • Sinus – Originating from SA node – P wave before every QRS – P wave in same direction as QRS
What is this rhythm? Normal sinus rhythm
Axis
Axis
The QRS Axis Represents the overall direction of the heart’s activity Axis of –30 to +90 degrees is normal
The Quadrant Approach • QRS up in I and up in aVF = Normal
Axis Positive in I and II = NORMAL
Positive in I and negative in II = LAD Negative in I and positive in II = RAD
Axis
ECG interpretation •
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 present? • Bifid = P mitrale (LA hypertrophy) • Pointy = P pulmonale (RA hypertrophy)
P mitrale
P pulmonale
PR interval • Start of P wave to start of QRS complex • Normal = 0.12 - 0.2 seconds (3-5 small squares) • Decreased = can indicate an accessory pathway • Increased = indicates AV block (1st/2nd/3rd)
Normal Intervals • PR – 0.20 sec (less than one large box)
• QRS – 0.08 – 0.10 sec (1-2 small boxes)
• QT – 450 ms in men, 460 ms in women – Based on sex / heart rate – Half the R-R interval with normal HR
ECG interpretation •
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 • Normal = <0.12 seconds • >0.12 seconds = Bundle Branch Block
QRS complex 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 tallest R wave in V5 or V6 >35mm is suggestive of LVH
Hypertrophy Add the larger S wave of V1 or V2 in mm, to the larger R wave of V5 or V6. Sum is > 35mm = LVH
Q waves • Q waves are allowed in V1, aVR & III • Pathological Q waves can indicate previous MI
ECG interpretation •
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 • ST elevation - infarction - pericarditis (widespread)
Ischemia • Usually indicated by ST changes – Elevation = Acute infarction – Depression = Ischemia
• Can manifest as T wave changes • Remote ischemia shown by q waves
ST segment
ST segment
ST segment
What is the diagnosis? Acute inferior MI with ST elevation II, III, aVF
in leads
What do you see in this EKG? ST depression II, III, aVF, V3-V6 = ischemia
T wave • Small = hypokalaemia • Tall = hyperkalaemia • Inverted/biphasic = ischaemia/previous infarct
T wave
T wave
T wave
QT interval • Start of QRS to end of T wave • Needs to be corrected for HR • Normal QTc = < 400ms • Long QT can be genetic or iatrogenic
QT interval
Prolonged QT • Normal – Men 450ms – Women 460ms
• Corrected QT (QTc) – QTm/√(R-R)
• Causes – – – – – –
Drugs (Na channel blockers) Hypocalcemia, hypomagnesemia, hypokalemia Hypothermia AMI Congenital Increased I
Blocks • AV blocks – First degree block • PR interval fixed and > 0.2 sec
– Second degree block, Mobitz type 1 • PR gradually lengthened, then drop QRS
– Second degree block, Mobitz type 2 • PR fixed, but drop QRS randomly
– Type 3 block • PR and QRS dissociated
What is this rhythm? First degree AV block and longer than 0.2 sec
PR is fixed
What is this rhythm? Type 1 second degree block (Wenckebach)
What is this rhythm? Type 2 second degree AV block
Dropped QRS
What is this rhythm? 3rd degree heart block (complete)
ECG quiz
ECG 1
ECG 2
ECG 3
ECG 4
Normal Sinus Rhythm
Mattu, 2003
First Degree Heart Block
PR interval >200ms
Accelerated Idioventricular
Ventricular escape rhythm, 40-110 bpm Seen in AMI, a marker of reperfusion
Junctional Rhythm
Rate 40-60, no p waves, narrow complex QRS
Hyperkalemia
Tall, narrow and symmetric T waves
Premature Atrial Contractions
Trigeminy pattern
Atrial Flutter with Variable Block
Sawtooth waves Typically at HR of 150
Torsades de Pointes
Notice twisting pattern Treatment: Magnesium 2 grams IV
Digitalis
Dubin, 4th ed. 1989
Lateral MI
Reciprocal changes
Inferolateral MI
ST elevation II, III, aVF ST depression in aVL, V1-V3 are reciprocal changes
Anterolateral / Inferior Ischemia
LVH, AV junctional rhythm, bradycardia
Left Bundle Branch Block
Monophasic R wave in I and V6, QRS > 0.12 sec Loss of R wave in precordial leads QRS T wave discordance I, V1, V6
Right Bundle Branch Block
V1: RSR prime pattern with inverted T wave V6: Wide deep slurred S wave
Supraventricular Tachycardia
Retrograde P waves
Narrow complex, regular; retrograde P waves, rate <220
Wolff-Parkinson-White Syndrome
Short PR interval <0.12 sec Prolonged QRS >0.10 sec Delta wave Can simulate ventricular hypertrophy, BBB and previous MI
Hypokalemia
U waves Can also see PVCs, ST depression, small T waves
Summary • Discussed the indications for performing an ECG • Introduced an approach to interpreting ECGs • Discussed common ECG abnormalities
dr. Infan Ketaren SpJP-FIHA SMF Kardiologi & Pembuluh Darah RSUD Soedarso/FK Untan Pontianak
The ECG “The ECG (electrocardiogram) is a transthoracic interpretation of the electrical activity of the heart.”
The ECG
Why perform an ECG? • It’s part of the ission bundle • Indicated by the patient’s symptoms - symptoms of IHD/MI - symptoms associated with dysrhythmias • Indicated by the patient’s examination findings - cardiac murmur
Lead Placement
aVF
All Limb Leads
Precordial Leads
EKG Distributions • • • • • •
Anteroseptal: V1, V2, V3, V4 Anterior: V1–V4 Anterolateral: V4–V6, I, aVL Lateral: I and aVL Inferior: II, III, and aVF Inferolateral: II, III, aVF, and V5 and V6
ECG interpretation •
Quality of ECG?
• • •
Rate Rhythm Axis
• • • • • • • •
P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval
Quality of the ECG • • • •
Patient name Date of the ECG Is there any interference? Is there electrical activity from all 12 leads?
• Calibration: - speed = 25mm/second - height = 1cm/mV
Calibration
Calibration
ECG interpretation •
Quality of ECG?
• • •
Rate Rhythm Axis
• • • • • • • •
P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval
Rate • 300/number of big squares between R waves • Rate is either: - normal - bradycardic - tachycardic
Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes
Rate
1
300
2
150
3
100
4
75
5
60
6
50
Rate • HR of 60-100 per minute is normal • HR > 100 = tachycardia • HR < 60 = bradycardia
Differential Diagnosis of Tachycardia Tachycardia Narrow Complex ST Regular
Irregular
SVT Atrial flutter A-fib A-flutter w/ variable conduction MAT
Wide Complex ST w/ aberrancy SVT w/ aberrancy
VT A-fib w/ aberrancy
A-fib w/ WPW VT
What is the heart rate?
www.uptodate.com
(300 / 6) = 50 bpm
Rate
Rhythm • Are there P waves? • Are they regular? • Does one precede every QRS complex? • Regular vs. irregular
Rhythm • Sinus – Originating from SA node – P wave before every QRS – P wave in same direction as QRS
What is this rhythm? Normal sinus rhythm
Axis
Axis
The QRS Axis Represents the overall direction of the heart’s activity Axis of –30 to +90 degrees is normal
The Quadrant Approach • QRS up in I and up in aVF = Normal
Axis Positive in I and II = NORMAL
Positive in I and negative in II = LAD Negative in I and positive in II = RAD
Axis
ECG interpretation •
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 present? • Bifid = P mitrale (LA hypertrophy) • Pointy = P pulmonale (RA hypertrophy)
P mitrale
P pulmonale
PR interval • Start of P wave to start of QRS complex • Normal = 0.12 - 0.2 seconds (3-5 small squares) • Decreased = can indicate an accessory pathway • Increased = indicates AV block (1st/2nd/3rd)
Normal Intervals • PR – 0.20 sec (less than one large box)
• QRS – 0.08 – 0.10 sec (1-2 small boxes)
• QT – 450 ms in men, 460 ms in women – Based on sex / heart rate – Half the R-R interval with normal HR
ECG interpretation •
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 • Normal = <0.12 seconds • >0.12 seconds = Bundle Branch Block
QRS complex 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 tallest R wave in V5 or V6 >35mm is suggestive of LVH
Hypertrophy Add the larger S wave of V1 or V2 in mm, to the larger R wave of V5 or V6. Sum is > 35mm = LVH
Q waves • Q waves are allowed in V1, aVR & III • Pathological Q waves can indicate previous MI
ECG interpretation •
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 • ST elevation - infarction - pericarditis (widespread)
Ischemia • Usually indicated by ST changes – Elevation = Acute infarction – Depression = Ischemia
• Can manifest as T wave changes • Remote ischemia shown by q waves
ST segment
ST segment
ST segment
What is the diagnosis? Acute inferior MI with ST elevation II, III, aVF
in leads
What do you see in this EKG? ST depression II, III, aVF, V3-V6 = ischemia
T wave • Small = hypokalaemia • Tall = hyperkalaemia • Inverted/biphasic = ischaemia/previous infarct
T wave
T wave
T wave
QT interval • Start of QRS to end of T wave • Needs to be corrected for HR • Normal QTc = < 400ms • Long QT can be genetic or iatrogenic
QT interval
Prolonged QT • Normal – Men 450ms – Women 460ms
• Corrected QT (QTc) – QTm/√(R-R)
• Causes – – – – – –
Drugs (Na channel blockers) Hypocalcemia, hypomagnesemia, hypokalemia Hypothermia AMI Congenital Increased I
Blocks • AV blocks – First degree block • PR interval fixed and > 0.2 sec
– Second degree block, Mobitz type 1 • PR gradually lengthened, then drop QRS
– Second degree block, Mobitz type 2 • PR fixed, but drop QRS randomly
– Type 3 block • PR and QRS dissociated
What is this rhythm? First degree AV block and longer than 0.2 sec
PR is fixed
What is this rhythm? Type 1 second degree block (Wenckebach)
What is this rhythm? Type 2 second degree AV block
Dropped QRS
What is this rhythm? 3rd degree heart block (complete)
ECG quiz
ECG 1
ECG 2
ECG 3
ECG 4
Normal Sinus Rhythm
Mattu, 2003
First Degree Heart Block
PR interval >200ms
Accelerated Idioventricular
Ventricular escape rhythm, 40-110 bpm Seen in AMI, a marker of reperfusion
Junctional Rhythm
Rate 40-60, no p waves, narrow complex QRS
Hyperkalemia
Tall, narrow and symmetric T waves
Premature Atrial Contractions
Trigeminy pattern
Atrial Flutter with Variable Block
Sawtooth waves Typically at HR of 150
Torsades de Pointes
Notice twisting pattern Treatment: Magnesium 2 grams IV
Digitalis
Dubin, 4th ed. 1989
Lateral MI
Reciprocal changes
Inferolateral MI
ST elevation II, III, aVF ST depression in aVL, V1-V3 are reciprocal changes
Anterolateral / Inferior Ischemia
LVH, AV junctional rhythm, bradycardia
Left Bundle Branch Block
Monophasic R wave in I and V6, QRS > 0.12 sec Loss of R wave in precordial leads QRS T wave discordance I, V1, V6
Right Bundle Branch Block
V1: RSR prime pattern with inverted T wave V6: Wide deep slurred S wave
Supraventricular Tachycardia
Retrograde P waves
Narrow complex, regular; retrograde P waves, rate <220
Wolff-Parkinson-White Syndrome
Short PR interval <0.12 sec Prolonged QRS >0.10 sec Delta wave Can simulate ventricular hypertrophy, BBB and previous MI
Hypokalemia
U waves Can also see PVCs, ST depression, small T waves
Summary • Discussed the indications for performing an ECG • Introduced an approach to interpreting ECGs • Discussed common ECG abnormalities
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