RATE SHARP J POINT

300 150 100 75 60 50 43 • ST seg. & T wave well demarcated, not merged as in STE
• J point elevation is normal in young, healthy athletes
DIFFUSE J POINT
• ST slowly curving with only an area J point can be found
- Count number of complexes x 6 (standard ECG = 10sec)
RHYTHM ST SEGMENT ELEVATION POSTERIOR MI
ANTERIOR ST DEP.
NORMAL ECG
WITH ANGINA
• Locate the P wave (rate, axis, morphology) • (New STE at the J point)
• What is the relationship between the P wave and QRS? • In all leads (except V2-V3), significant STE =
• Analyze QRS morphology • In two contiguous leads
• ≥0.1mV
AXIS DEVIATION Lead I QRS Lead II/aVF QRS • In leads V2-V3, significant STE =
Normal (-30 to 90º) + + • ≥0.15mV in women
Left + - • ≥0.2mV in men ≥40yo
Right - + • ≥0.25mV in men ≤40yo
ST SEGMENT DEPRESSION
HYPERTROPHY • (New horizontal or down-sloping STD)
• LEFT ATRIAL ENLARGEMENT (P mitrale) • Significant STD =
• P wave > 0.12sec and bifid in lead II • In two contiguous leads
• RIGHT ATRIAL ENLARGEMENT (P pulmonale) • ≥0.05mV
LAE RAE • and/or
• P wave > 0.25mV in lead II
• T-wave inversion ≥0.1mV in two contiguous leads with
• LVH
• Prominent R wave or R/S ratio>1
• R wave in V5 or V6 >25mm
• S wave in V1 or V2 >25mm (Known LBBB and pacing make ECG less diagnostic for ACS)
• Sum of R wave in V5 or V6 + S wave in V1 >35mm
• RVH PATTERNS
• R wave > S wave in V1 • Anterior MI (LAD) = V1-V4
• Lateral MI (LCx) = I, aVL, V5-V6
WAVES, INTERVALS, & SEGMENTS
• Anterolateral MI (LAD) = I, aVL, V1-V6
R 5mm=0.2sec(200ms) • Inferior MI (RCA, LCx) = II, III, aVF
• Inferolateral MI (RCA, LCx) = I, aVL, V5-V6, II, III, aVF
ST segment • Acute posterior MI (RCA or LCx):
P 1mm • Dominant R waves in leads V1-V3
=0.1mV LVH RVH • ST depression in V1-V3
T • Upright, tall T waves

STEMI EVOLUTION
1mm= • Hyperacute T waves (tall, peaked,

0.04sec(40ms) symmetric)
Q S • STE in contiguous leads (concave →

0.12s<PR<0.2s
convex, merging with T wave)
• Development of Q wave and T wave

QRS<0.12s inversions as ST returns to baseline
QTc
interval99%ile QTc
QT<(1/2)RR Prepuberty 1-15yo460ms
M W
NORMAL INVERTED T WAVES BBB
www.henrydelrosario.com

HYPERKALEMIA ANTERIOR MI WITH TALL T WAVES

Normal 0.44 <0.43 <0.45
QTc=QT/sqr(RR) Postp Males 470ms
Prolonged >0.46 >0.45 >0.47 • Normal in leads aVR, V1
Postp
(upper Females
1%) 480ms
• Can be normal in lead V2 in young pts, 

lead V3 in black pts, lead III during 

NORMAL Q WAVES V1: “M”
expiration
• Small (septal) q waves normal in leads aVL, I, II, V5, V6 V6: “W”
INVERTED T WAVES IN ISCHEMIA
• Can be normal on expiration in lead III
PATHOLOGICAL Q WAVES (PRIOR MI) • ≥0.1mV in two contiguous leads
TALL T WAVES
• >1-2 small squares deep (or >25% of R wave)
• <1/2 preceding QRS V1: “W”
• >1 small square wide (or ≥30ms)
LVH → LV STRAIN PATTERN → TWI in leads I, aVL, V5-6 V6: “M”
• More likely diagnostic if with inverted T wave Q
RVH → RV STRAIN PATTERN → TWI in leads II, III, aVF
DOMINANT R WAVE
• In lead V1: normal in young children; seen in RVH, RBB, HCM, posterior MI SOURCES: ECG tutorials on UpToDate (Basic principles of ECG analysis, Myocardial ischemia and infarction),
• In lead aVR: TCA poisoning, dextrocardia, VT Making Sense of the ECG by Houghton, Pocket Medicine by Sabatine; Third Universal Definition of Myocardial
POOR R WAVE PROGRESSION Infarction by Thygesen et al; lifeinthefastlane.com; compiled by Henry Del Rosario MD; last update 5/2018
• Prior anteroseptal MI, cardiomyopathy, LVH, RVH/COPD, LBBB