Internal Medicine

Lecture: ECG
Done by Dr. Ahmad Alomari

1
 ECG
ECG stands for electrocardiogram; it’s a record of the heart’s electrical activity.

Whenever you have ECG you should be sure about:

1. The presence of PATIENT’S NAME

2. DATE/TIME
3. The SPEED at the bottom of the ECG: the normal speed is 25mm/s
4. The VOLTAGE at the left side of the ECG: normally 1mv or 10 mm or 2 large squares

*Every large square contains 5 small squares, each 1 small square equals 1 mm and every
large square is 5 mm
*Every small square equals 0.04 second, every large square equals 0.2 second

ECG components and their abnormalities:

P wave: It represents atrial contraction or depolarization (not more than 2.5 mm).

 Abnormalities:
1. P pulmonnale: peaked P waves > 2.5mm in lead II, III & aVF.
*It means right atrial hypertrophy caused by Cor-Pulmonale
2. P mitral: M-shaped or bifid P waves in lead I, aVL, V4 & V5
*It means delayed conduction in left atrial tissue
3. Left atrial enlargement: always seen in V1 : Biphasic P waves with negative deflection
larger than the positive ones this means left atrial hypertrophy or enlargement most
commonly due to LVH because of underlying systemic HTN.

PR interval: the time from the onset of atrial depolarization till the onset of ventricular
depolarization.

2
  Normally: 0.16 seconds
 If more than 0.18 and less than 0.22 it is prolonged PR interval
 If more than 0.22 seconds it is first degree heart block

QRS complex:

 Normally from 0.06 to 0.10 seconds

 If it is between 0.10 and 0.12 it is incomplete bundle branch block
 If more than 0.12 it is complete bundle branch block

QT interval:

 Normally it is between 0.35 and 0.45 seconds

 Prolonged QT interval may be congenital or acquired
 Acquired causes of QT prolongation:
* Some classes of antiarrhythmic drugs; such as class 1c and class 3 antiarrhythmics
*Some antibiotics such as erythromycin
* Antipsychotics such as Phenothiazine, Tricyclic antidepressants
* Hypo-natremia, hypo-calcemia, hypo-kalemia, hypo-phosphatemia
*Organophosphate and carpamate poisoning

ST segment:
 We determine the ST segment whether elevated or depressed based on PR interval
(Isoelectric line).
 If the ST segment is depressed more than 0.5 mm it is pathologic and very important in
treadmill test; any depression of the ST segment of more than 0.5 mm it is positive treadmill
test.

T wave:

 It represents the repolarization of the ventricles

 Its voltage always goes with the voltage of the R wave:
* In chest leads; in V1: very small R and deep S
* In V2: R will be bigger than in V1 and S will be smaller
* In V3 (Transitional zone): The R is equal to the S
* In V4: Higher R wave and small S wave
*In V5 & V6: The largest R wave and no S wave
 Persistent of the S wave in V5 & V6 indicates either emphysema or Right bundle branch
block

3
U wave:

 It represents the repolarization of purkinje system.

Note: Measurement of the voltage or the height of R waves is important in LVH; where we
measure the S in V1 and the R in V5 if it is more than 35 mm then it is LVH according to Sokolow-
Lyon Criteria.

Axis of the ECG *Left Axis deviation: -30 and above

*Right Axis deviation: 110 and above

How to determine:

*We look to lead I, II & III:

 If lead I is positive (R wave) and lead II & III are negative this
is left axis deviation
 If lead III is positive with negative lead I this is right axis
deviation

ECG abnormalities:

*Ventricular ectopic beats (extra systole or premature beats)

o We diagnose it when we see broad bizarre shape QRS complexes

o They are conducted from the ventricles retrogradely toward the atria
o No P waves
o The QRS complexes are always followed by ST and T changes opposite to the main direction
of QRS directions

4
*Supraventricular ectopics or atrial ectopics:

o Not followed by ST or T changes

o It is followed by compensatory pause

*Left ventricular hypertrophy (LVH):

o According to Sokolow-Lyon Criteria: S in V1+ R in V5 > 35

o Another criteria: look at P wave at V1; it is biphasic and the negative deflection larger than
positive one so it is left atrial enlargement which is caused by LVH
(This criteria is better than Soklolow- Lyon)

* LVH with strain:

o LVH criteria with St depression and T inversion in lead 1, AVL, V4,V5 & V6 (Anterolateral
leads)

*Right ventricular hypertrophy:

5
 o Tall P waves in V1 & V2
o In normal neonates and neonates with congenital heart defects both have tall P waves in V1
and V2, so how to differentiate?
1- Right axis deviation: Negative lead 1 and positive lead 3
2- Strain pattern or RVH: St depression & T inversion in V1, V2 & V3

* Right bundle branch block (RBBB):

o Broad bizarre shape QRS complexes in lead 3, AVF, V1 & V2

o Deep slurred S waves in lead 1, AVL, V5 & V6
o St depression and T inversion in V1 & V2

*Left bundle branch block (LBBB):

o Broad bizarre shape QRS complexes in lead 1, AVL, V5 & V6

o Deep slurred S waves in lead 3, AVF, V1 & V2
o St depression and T inversion in lead 1, AVL, V5 & V6
*St elevation and beaked T wave in V1 and V2

6
*Ventricular tachycardia:

o Broad bizarre QRS complexes

o Regular R-R intervals
o Rate: 120-180

*Polymorphic ventricular tachycardia (Torsade de pointes):

o Parts bellow the isoelectric line and parts above isoelectric line
o It is always secondary; the heart muscles are normal but there are prolongation of QT
interval due to:
* Some classes of antiarrhythmic drugs; such as class 1c and class 3 antiarrhythmics
*Some antibiotics such as erythromycin
* Antipsychotics such as Phenothiazine, Tricyclic antidepressants
* Hypo-natremia, hypo-calcemia, hypo-kalemia, hypo-phosphatemia
*Organophosphate and carpamate poisoning

7
 * Treat the underlying cause and magnesium sulphate IV, if no response: pace maker

o Whereas Ventricular tachycardia mostly due to cardiac causes such as acute MI

* the treatment: lidocaine IV bolus, if no response: synchronized cardio version

*Ventricular fibrillation:

o No recognizable P, QRS & T waves

Cardiac arrest: either flat line or VF

*Flat means ventricular asystole which needs CPR
*VF needs defibrillation immediately

*Atrial flutter:

o Saw tooth appearance

o The best places on ECG to see Atrial flutter are lead 2 and V1
o There are two types of atrial flutter:
*Atrial flutter with variable AV block; irregular RR with saw tooth appearance
* Atrial flutter with constant AV block; regular RR with saw tooth appearance

8
*Atrial fibrillation (AF):

o The most common pathological arrhythmia in practice

o Irregular RR intervals with absent P waves

*First degree heart block:

o Prolonged PR >0.22 seconds (>220 mseconds)

* Mobitz type 1 (Wenckebach Phenomenon):

o Progressive prolongation of PR intervals until drop beat occurs

9
*Mobitz type 2 heart block (2:1 AV block):

o Extreme bradychardia HR <40

o Regular RR intervals
o Constant relationship between the P and R waves

*Complete heart block (3rd degree heart block):

o Extreme bradychardia HR <40

o Regular RR intervals
o No relationship between the P and R waves (AV dissociation)

*Hyper acute stage of acute MI:

o Hyper acute T wave with loss of voltage of R wave in V2-V5

o In anterior wall infarction:
*ST elevation in lead 1, AVL & V2-V4
*The reciprocal changes: ST depression in lead 2,3 & AVF “inferior leads”

10
 o In inferior wall infarction:
*ST elevation in lead 2,3 and AVF
*The reciprocal changes: ST depression in lead 1, AVL & V2-V4 “anterior leads”

*Sub-acute stage of MI:

o The reciprocal changes disappear

o Anterior MI:
* Inverted T waves with complete loss of the R waves in V1-V6
* Coved, tented ST segments

o Inferior MI:
* Inverted T waves with complete loss of the R waves in lead 2, 3 & AVF
* Coved, tented ST segments and Q waves in lead 2, 3 & AVF

11
*Acute pericarditis:

o Sinus tachycardia HR >100

o Diffuse ST elevation (Upward concavity opposite to MI) except in V1 & AVR
o Reciprocal changes in V1 & AVR

12
13
14