Old inferior myocardial infarction 23/3/22, 9:47 am

A 53 year old man with Ischaemic Heart Disease.

Old inferior myocardial infarction

a Q wave in lead III wider than 1 mm (1 small square) and
a Q wave in lead aVF wider than 0.5 mm and
a Q wave of any size in lead II

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Atrial fibrillation with rapid ventricular response 23/3/22, 9:43 am

A 76 year old man with breathlessness.

Atrial fibrillation with rapid ventricular response

Irregularly irregular ventricular rhythm.
Sometimes on first look the rhythm may appear regular but on closer inspection it is clearly irregular.

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Ventricular tachycardia - AV dissociation (2) 23/3/22, 9:41 am

A 69 year old man 2 weeks after an inferior myocardial infarction

Ventricular tachycardia
A wide QRS tachycardia is VT until proven otherwise (1). Features suggesting VT include:-

evidence of AV dissociation
independent P waves
capture or fusion beats
beat to beat variability of the QRS morphology (shown here)
very wide complexes (> 140 ms)
the same morphology in tachycardia as in ventricular ectopics
history of ischaemic heart disease
absence of any rS, RS or Rs complexes in the chest leads (2)
concordance (chest leads all positive or negative)

1) Griffith MJ, Garrat CJ, Mounsey P, Camm AJ. Ventricular tachycardia as the default diagnosis in broad complex
tachycardia. Lancet. 1994;343:386-

2) Brugada P, Brugada J, Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a wide
QRS complex. Circulation. 1991;83:1649-1659

N.B. The computer-aided diagnosis can often be misleading.

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ECGlibrary.com: Left anterior hemiblock, LVH, LAH, and long PR 23/3/22, 9:45 am

An 84 year old lady with hypertension.

Left anterior hemiblock,

LVH, LAH, and long PR
There are a number of abnormalities here.

left anterior hemiblock

QRS axis (axis.html) more left than -30
degrees
initial R wave in the inferior leads (II, III and
aVF)
absence of any other cause of left axis
deviation (axis.html#l)
left ventricular hypertrophy
In the presence of left anterior hemiblock the
diagnostic criteria of LVH (lvhlah.html) are
changed. Rosenbaum suggested that an S
wave in lead III deeper than 15 mm as
predictive of LVH.
long PR interval (also called first degree heart
block)
PR interval longer than 0.2 seconds
left atrial hypertrophy
M shaped P wave in lead II
P wave duration > 0.11 seconds
terminal negative component to the P wave
in lead V1

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Complete Heart Block 23/3/22, 9:40 am

A 70 year old man with exercise intolerance.

Complete Heart Block

P waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below and
show no relation to the QRS complexes. They 'probe' every part of the ventricular cycle but are never conducted.
The ventricles are depolarised by a ventricular escape rhythm.

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Implantable cardioverter defibrillator. 23/3/22, 9:47 am

A 36 year old lady with recurrent blackouts.

Implantable cardioverter defibrillator

Most of this 12-lead recording is polymorphic ventricular tachycardia but, in the rhythm strip, the large deflection
(arrowed) is the defibrillator discharging.
Following the defibrillation a dual chamber pacemaker can be seen.

OK so I cheated a little with this one as the odds of catching this on a 12-lead ECG recording are very slim indeed. This is a
reconstructed 12-lead recording from an electrophysiology study testing the device after placement.

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Atrial fibrillation and complete heart block 23/3/22, 9:46 am

An 82 year old lady with dizzy spells.

Atrial fibrillation and complete heart block

Fibrillary waves of atrial fibrillation and no P waves.
Regular ventricular rhythm
The wider the QRS of the ventricular escape rhythm the less reliable the escape mechanism.
AF with complete heart block can be easily missed and is an indication for a permanent pacemaker.

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Acute Inferior Myocardial Infarction in the presence of LBBB 23/3/22, 9:47 am

A 79 year old man with 5 hours of chest pain.

Acute myocardial infarction in the presence of left bundle branch block

Features suggesting acute MI
ST changes in the same direction as the QRS (as shown here)
ST elevation more than you'd expect from LBBB alone (e.g. > 5 mm in leads V1 - 3)
Q waves in two consecutive lateral leads (indicating anteroseptal MI)

(ref. Sgarbossa EB et al, N Engl J Med 1996;334:481-7)

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Right Bundle Branch Block 23/3/22, 9:46 am

A 55 year old man with 4 hours of "crushing" chest pain.

Right Bundle Branch Block

wide QRS, more than 120 ms (3 small squares)
secondary R wave in lead V1
other features include slurred S wave in lateral leads and T wave changes in the septal leads

See also Left Bundle Branch Block.

Acute inferior MI and sinus bradycardia are also present.

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Atrial fibrillation with left bundle branch block 23/3/22, 9:43 am

A 60 year old woman with hypertension.

Atrial fibrillation with pre-existing left bundle branch block

Sometimes this can be confused with ventricular tachycardia but closer inspection can identify the irregularity.
Irregularly irregular rhythm - suggesting AF.
Features of typical left bundle branch block
wide QRS >120 ms (3 small squares)
no secondary R wave in lead V1
no lateral Q waves

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ECGlibrary.com: Inferior myocardial infarction 23/3/22, 9:46 am

A 55 year old man with 4 hours of 'crushing' chest pain.

Inferior myocardial
infarction
ST elevation in the inferior leads II, III and aVF
reciprocal ST depression in the anterior leads

See also acute anterior MI (ami.html).

Right Bundle Branch Block (rbbb.html) and sinus

bradycardia (sbrady.html) are also present.

© Copyright ECG Library 1995 - 2017. Dr Dean Jenkins (mailto:[email protected]) and Dr Stephen Gerred.
The ECGs and associated images on ecglibrary.com may only be used with the permission of the authors. We have allowed their use in numerous books, web projects, and educational software packages. ECG
Library is an educational resouce from the authors of ECGs by Example, 3rd Edition, Churchill Livingstone (ecgsbyeg.html)

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Torsade de pointes VT 23/3/22, 9:41 am

A 60 year old man with Ischaemic Heart Disease.

Polymorphous ventricular tachycardia (Torsade de pointes).

This is a form of VT where there is usually no difficulty in recognising its ventricular origin.
wide QRS complexes with multiple morphologies
changing R - R intervals
the axis seems to twist about the isoelectric line
it is important to recognise this pattern as there are a number of reversible causes
heart block
hypokalaemia or hypomagnesaemia
drugs (e.g. tricyclic antidepressant overdose)
congenital long QT syndromes
other causes of long QT (e.g. IHD)

This recording has been kindly donated by Dr G. Butrous of St George's Medical

School London who is a cardiologist involved in EUROTOP.

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Hyperkalaemia 23/3/22, 9:47 am

A 58 year old man on haemodialysis presents with profound weakness

after a weekend fishing trip.

This man's serum potassium was 9.6 mmol/L.

Hyperkalaemia
The following changes may be seen in hyperkalaemia

small or absent P waves

atrial fibrillation
wide QRS
shortened or absent ST segment
wide, tall and tented T waves
ventricular fibrillation

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Ventricular Fibrillation 23/3/22, 9:41 am

A 60 year old man with 2 hours of "crushing" chest pain suddenly collapses.

Ventricular fibrillation
bizarre, irregular, random waveform
no clearly identifiable QRS complexes or P waves
wandering baseline

A 12 lead of Ventricular fibrillation should not usually be taken ... for obvious reasons. Instead of continuing to record the ECG
you should check the patient's pulse and reach for the defibrillator!

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Atrial flutter 23/3/22, 9:44 am

A 68 year old lady on digoxin complaining of lethargy.

Atrial flutter
A characteristic 'sawtooth' or 'picket-fence' waveform of an intra-atrial re-entry circuit usually at about 300 bpm.

This lady was taking rather too much digoxin and has a very slow ventricular response.
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ECG library - Acute Anterior Myocardial Infarction 23/3/22, 9:46 am

A 63 year old woman with 10 hours of chest pain and sweating.

Acute anterior myocardial infarction

ST elevation in the anterior leads V1 - 6, I and aVL
reciprocal ST depression in the inferior leads

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Atrial flutter with 2:1 atrioventricular conduction 23/3/22, 9:44 am

An 57 year old lady with palpitations.

Atrial flutter with 2:1 AV conduction

The sawtooth waveform of atrial flutter can usually be seen in the inferior leads II, III and aVF if one looks
closely. Sometimes the rapid atrial rate can be seen in V1.
Suspect atrial flutter with 2:1 block when you see a rate of about 150 bpm. The atrial rate is shown to be twice
the ventricular rate in the figure below.
See also atrial flutter with slow ventricular response.

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Sinus Bradycardia 23/3/22, 9:42 am

A 55 year old man with 4 hours of "crushing" chest pain.

Sinus bradycardia
P wave rate of less than 60 bpm
the rate in this example is about 45 bpm

See also Sinus Tachycardia.

Acute inferior MI and Right Bundle Branch Block are also present.

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Hypokalaemia 23/3/22, 9:47 am

A 22 year old lady with prolonged vomiting.

This lady's serum potassium was 1.8 mmol/L.

Hypokalaemia
The following changes may be seen in hypokalaemia.

small or absent T waves

prominent U waves (see diagram)
first or second degree AV block
slight depression of the ST segment

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Acute Posterior Myocardial Infarction 23/3/22, 9:46 am

A 60 year old woman with 3 hours of chest pain.

Acute posterior myocardial infarction

(hyperacute) the mirror image of acute injury in leads V1 - 3
(fully evolved) tall R wave, tall upright T wave in leads V1 -3
usually associated with inferior and/or lateral wall MI

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WPW syndrome with atrial fibrillation 23/3/22, 9:44 am

A 47 year old man with a long history of palpitations and, lately, blackouts.

Wolf-Parkinson-White syndrome with atrial fibrillation

irregularly irregular, wide complex tachycardia
impulses from the atria are conducted to the ventricles via either
both the AV node and accessory pathway producing a broad fusion complex
or just the AV node producing a narrow complex (without a delta wave)
or just the accessory pathway producing a very broad 'pure' delta wave
people who develop this rhythm and have very short R - R intervals are at higher risk of VF

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Sinus tachycardia 23/3/22, 9:43 am

A 34 year old lady with asthma.

Sinus tachycardia
P wave rate greater than 100 bpm

See also sinus bradycardia.

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Ventricular tachycardia - AV dissociation (1) 23/3/22, 9:40 am

A 45 year old lady with palpitations and history of chronic renal failure

Ventricular tachycardia
A wide QRS tachycardia is VT until proven otherwise (1). Features suggesting VT include:-
evidence of AV dissociation
independent P waves (shown by arrows here)
capture or fusion beats
beat to beat variability of the QRS morphology
very wide complexes (> 140 ms)
the same morphology in tachycardia as in ventricular ectopics
history of ischaemic heart disease
absence of any rS, RS or Rs complexes in the chest leads (2)
concordance (chest leads all positive or negative)

1) Griffith MJ, Garrat CJ, Mounsey P, Camm AJ. Ventricular tachycardia as the default diagnosis in broad complex
tachycardia. Lancet. 1994;343:386-

2) Brugada P, Brugada J, Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a wide
QRS complex. Circulation. 1991;83:1649-1659

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Long QT interval 23/3/22, 9:40 am

A lady with Romano-Ward syndrome.

Long QT interval
The QT interval normally varies with heart rate - becoming
shorter at faster rates. It is usually corrected using the cycle
length (R-R interval) as shown opposite.
normal QTc = 0.42 seconds

Romano-Ward syndrome is an autosomal dominantly inherited form of

long QT interval and there is a risk of recurrent ventricular
tachycardia, particularly Torsade de Pointes.

Ventricular premature beats (VPBs)

2 ventricular premature beats are also shown in this ECG
They are
broad
occur earlier than normal
and are followed by a full compensatory pause (the distance between the normal beats before and after the
VPB is equal to twice the normal cycle length).

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ECG library, Ventricular bigeminy 23/3/22, 9:40 am

A 50 year old man with chest pain for 24 hours

Ventricular bigeminy
a ventricular premature beat follows each normal beat

There are also features of an acute inferior myocardial infarction.

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