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Ecg

The document discusses the basic principles of ECG analysis. It covers the indications for an ECG, the standard 12-lead setup, steps to read an ECG including calibration, rhythm, intervals and abnormalities. It then describes various arrhythmias and conduction abnormalities that can be identified on an ECG such as atrial fibrillation, ventricular tachycardia, bundle branch blocks and more.

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Mohamed Ibrahim
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41 views6 pages

Ecg

The document discusses the basic principles of ECG analysis. It covers the indications for an ECG, the standard 12-lead setup, steps to read an ECG including calibration, rhythm, intervals and abnormalities. It then describes various arrhythmias and conduction abnormalities that can be identified on an ECG such as atrial fibrillation, ventricular tachycardia, bundle branch blocks and more.

Uploaded by

Mohamed Ibrahim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BASIC PRINCIPLES OF ECG ANALYSIS

Dr. Eiman AlKandari


Consultant family Physician
Head of Ardiya South clinic
Member of diabetes committee

¨ Indications of ECG:
§ Emergencies: angina, MI, arrythmia,…
§ Abnormal physical signs: shifted apex, heart murmur,..
§ Patient symptoms: palpitation, diziness,…
§ Annual screening test in DM & HTN
¨ The ECG Paper

¨ ECG Leads
The standard ECG has 12 leads:
§ 3 Standard Limb Leads: I,II,III
§ 3 Augmented Limb Leads aVR, aVL, aVF
§ 6 Precordial Leads: V1-V6

¨ Steps to read an ECG


1. Calibration
2. Voltage (amplitude)
3. Rhythm
4. Heart rate
5. Axis
6. Comment on
a. waves ( P, QRS, T, U )
b. Intervals ( P-R, Q-T )
c. Segments ( S-T, P-R )
7. Evidence of ECG abnormalities:

1
Ø Chamber hypertrophy
Ø Myocardial ischemia / infarction
Ø Conduction defect & Arrythmia

1- Standard calibration
25 mm/s
0.1 mV/mm

2- Voltage (amplitude)
Normally the sum of total amplitude of QRS complexes (i.e. +ve and –ve deflections) in lead I,
II & III is > 15 mm

3- Rhythm
§ Regular/ Irregular rhythm
§ Regular rhythm = equal distances between 3 consecutive +ve or –ve deflections
§ Sinus rhythm (presence of P wave )
§ not Sinus rhythm (absent of P wave)

4- heart rate
- Normal HR: 60-100 beats/min
- Determining the Heart Rate:
Ø Regular rhythm
§ Rule of 300:
HR= 300 ÷ No. of “large squares” within an R-R interval
§ Rule of 1500:
HR= 1500 ÷ No. of “small squares” within an R-R interval
§ 10 Second Rule:
ECGs record 10 seconds of rhythm per page,
Count the number of beats present on the ECG multiply by 6

Ø Irregular rhythm
§ 10 Second Rule

5- Axis
The QRS axis represents overall direction of the heart’s electrical activity.

I aVF
+ + Normal axis
+ - LAD
- + RAD

2
6. Comment on
a. waves (P, QRS, T, U)
b. Intervals (P-R, Q-T)
c. Segments (S-T, P-R)

P waves should be upright in I, II, and V2 to V6


All waves are negative in lead aVR
PR interval should be 0.12 to 0.2 seconds or 3 to 5 small squares
QRS complex should be dominantly upright in leads I and II
The width of the QRS complex should not exceed 0.1 s or < 3 small squares
There should be no or only a small Q wave (< 1 small square in width & < 2 small square
deep). Pathological Q wave > 2mm deep & > 1mm wide.
R waves must grow in precordial leads from V1 to at least V4. R wave in lead V6 is smaller
than V5.
S wave must grow from V1 to at least V3 & disappear in V6
ST segment should start isoelectric (flat) except in V1 and V2 where it may be elevated.
Elevation or depression of ST segment by ³ 1 mm

J Junction point is the point between QRS and ST segment


T wave must be upright in I, II, V2 to V6. QRS and T waves tend to have the same general
direction in the limb leads. Normal T wave is asymmetrical, first half having a gradual slope
than the second. Abnormal T waves are symmetrical, tall, peaked, or inverted.
Q-T interval is total duration of Depolarization and Repolarization. Q-T interval should be 0.35
- 0.45 s ( 9-11 small squares).
U wave related to after depolarizations which follow repolarization. U waves are small,
round, symmetrical with amplitude < 2 mm, its direction is the same as T wave. It is more
prominent at slow heart rates.

7. Evidence of ECG abnormalities


Right Atrial Enlargement
Tall, pointed P waves (P Pulmonale). P wave amplitude > 2.5 small square
Left Atrial Enlargement
Notched/bifid (‘M’ shaped) P wave (P ‘mitrale)
Left ventricular hypertrophy
Criteria:
§ R in V5 (or V6) + S in V1 (or V2) > 35 mm, or
§ avL: R amplitude > 11 mm
§ Left axis deviation

3
Right ventricular hypertrophy
Criteria:
§ Right axis deviation, and
§ V1: R wave > 7mm tall

Myocardial ischemia/ infarction


S-t segment depression

Variable Shapes of ST Segment Elevations in MI

ECG changes in MI

Arrythmias Classification
• Sinus node:
Sinus Bradycardia
Sinus Tachycardia
Sinoatrial block
• Atrial cells:
Premature Atrial Contractions (PACs)
Atrial Flutter
Atrial Fibrillation

• AV junction:
AV node Blocks
Paroxysmal Supraventricular Tachycardia

4
• Ventricular cells:
Ventricular Tachycardia
Ventricular Fibrillation
ventricular ectopic
SA Block
Sinus impulses is blocked within the SA junction between SA node and surrounding
myocardium
Abscent of complete Cardiac cycle
Present: Young athletes, Digitalis, Hypokalemia, Sick Sinus Syndrome
Premature Atrial Contractions
— These ectopic beats originate in the atria (but not in the SA node).
— The contour of the P wave and the PR interval are different than a normally generated
pulse from the SA node.
Atrial Flutter
P waves: flutter waves (sawtooth pattern)
Atrial Fibrillation
Irregular rhythm
Absent P waves
QRS complex narrow
Paroxysmal Supraventricular Tachycardia (PSVT)
Regular rhythm
tachycardia
Absent P waves
QRS complex narrow

Junctional Rhythm
Bradycardia
Regular rhythm
Absent P waves
Types of AV node Block

5
Short P-R Interval
WPW (Wolff-Parkinson-White) Syndrome
Accessory pathway (Bundle of Kent) allows early activation of the ventricle

Ventricular Tachycardia
Regular rhythm
Absent p waves
Wide QRS complex

Ventricular Fibrillation
Irregular rhythm
Absent p waves
Wide QRS complex

Premature ventricular contraction (ventricular ectopic)


P waves: non for the ectopic
QRS is wide and looks bizarre for the ectopic wave

Bundle Branch Blocks


QRS complex widens (> 0.12 sec).

Right Bundle Branch Blocks


Sinus rhythm
Wide QRS complex
Tall R wave in lead V1

Left Bundle Branch Blocks


Sinus rhythm
Wide QRS complex
Broad, deep S waves in leads V1 & V2

Reference
UpToDate: Basic principles of electrocardiographic interpretation

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