ECG

A 55 Year Old Man With 4 Hours of "Crushing" Chest Pain.

 A 55 Year Old Man With 4 Hours of "Crushing" Chest Pain.

• Name 3 abnormalities on
this ECG
• What is the diagnosis?
• Name 3 treatments
modalities?
 Acute Inferior Myocardial
Infarction

• ST elevation in the inferior leads II, III

and aVF
• reciprocal ST depression in the anterior
leads
A 63 Year Old Woman With 10 Hours of Chest Pain and Sweating. 
 A 63 Year Old Woman With 10 Hours of Chest Pain and Sweating.

• Name 2 abnormalities on
this ECG
• What is the diagnosis?
• Name 3 treatments
modalities?
 Acute Anterior Myocardial
Infarction

• ST elevation in the anterior leads V1 - 6,

I and aVL
• reciprocal ST depression in the inferior
leads
A 60 Year Old Woman With 3 Hours of Chest Pain. 
A 60 Year Old Woman With 3 Hours of Chest Pain. 

• Name 2 abnormalities in
this ECG
• What is the diagnosis?
 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
A 53 Year Old Man With Ischaemic Heart Disease. 
A 53 Year Old Man With Ischaemic Heart Disease. 

• Name two abnormalities

within this ECG
• What is the diagnosis?
• What other investigations
would you recommend?
 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
A 79 Year Old Man With 5 Hours of Chest Pain. 
A 79 Year Old Man With 5 Hours of Chest Pain. 

• Name 3
abnormalities in
this ECG
• What is the
diagnosis?
 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)
An 83 Year Old Man With Aortic stenosis.
An 83 Year Old Man With Aortic stenosis.

• What abnormality is seen in

this ECG?

• What clinical signs might

you find on cardiovascular
examination?
There Are Many Different Criteria for LVH.

• Sokolow + Lyon (Am Heart J, 1949;37:161)

– S V1+ R V5 or V6 > 35 mm
• Cornell criteria (Circulation, 1987;3: 565-72)
– SV3 + R avl > 28 mm in men
– SV3 + R avl > 20 mm in women
• Framingham criteria (Circulation,1990; 81:815-820)
– R avl > 11mm, R V4-6 > 25mm
– S V1-3 > 25 mm, S V1 or V2 +
– R V5 or V6 > 35 mm, R I + S III > 25 mm
A 75 Year Old Lady With Loud First Heart Sound and Mid-diastolic
Murmur.
A 75 Year Old Lady With Loud First Heart
Sound and Mid-diastolic Murmur.

• What is the diagnosis?

• What further investigations

would you recommend?

• What are the goals of

treatment?
 Mitral Stenosis

• There is atrial fibrillation. No P waves

are visible. The rhythm is irregularly
irregular (random).
 Mitral Stenosis
• There is the suggestion of right ventricular
hypertrophy. Right axis deviation and deep S
waves in the lateral leads. Another important
feature of right ventricular hypertrophy not
shown here is a dominant R wave in lead V1.
• The combination of Atrial Fibrillation and Right
Axis Deviation on the ECG suggests the
possibility of mitral stenosis.
 Mitral Stenosis
• Goals of treatment
– provide prophylaxis for infective endocarditis,
– reduce symptoms of pulmonary congestion
(eg, orthopnea, paroxysmal nocturnal dyspnea),
– control the ventricular rate if atrial fibrillation is
present,
– prevent thromboembolic complications
A 59 Year Old Lady With Chronic Bronchitis.
A 59 Year Old Lady With Chronic Bronchitis.

• What diagnosis is
suggested by the
abnormality in the
ECG?

• What are the other

clinical signs in this
condition?
 Right atrial hypertrophy

• A P wave in lead II taller then 2.5 mm

(2.5 small squares).
• The P wave is usually pointed.
A 64 year old man is being evaluated in your emergency department after
an episode of chest pain and dizziness which has now resolved.
A 64 year old man is being evaluated in your emergency department after
an episode of chest pain which has now resolved.

• What is the abnormality?

• How would you treat him?

A 73 Year Old Woman With Dizziness.
 2 to 1 AV Block
• every other P wave is conducted to the
ventricles
– 2 to 1 AV block starts after the 5th QRS in this 3
channel recording. The first non-conducted P wave
is indicated with an arrow.
• the PR interval of conducted P waves is
constant
A 70 Year Old Man With Exercise Intolerance.
A 70 Year Old Man With Exercise Intolerance.

• What is the ECG

diagnosis?

• What clinical signs would

you look for?

• How would you treat him?

 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.
A 55 Year Old Man with sudden onset of pleuritic chest pain
A 55 Year Old Man with sudden onset of pleuritic chest pain

• What is the ECG

diagnosis?
• What may cause
this?
Causes of RBBB
• Right ventricular hypertrophy / cor
pulmonale
• Pulmonary embolus
• Ischaemic heart disease
• Rheumatic heart disease
• Myocarditis or cardiomyopathy
• Degenerative disease of the
conduction system
• Congenital heart disease (e.g. atrial
septal defect)
 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
A 34 Year Old Lady With Asthma.
A 34 Year Old Lady With Asthma.

• What is the
diagnosis?
 Sinus tachycardia

• P wave rate greater than 100 bpm

A 76 Year Old Man With Breathlessness.
A 76 Year Old Man With Breathlessness.

• What is the abnormality?

• What may cause this?
• What other investigations
would you recommend?
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.
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.
A 25 Year Old Man With Bouts of tachycardia. 
A 25 Year Old Man With Bouts of tachycardia. 

• What are the

abnormalities?
• What is the diagnosis?
• How would you treat him?
 Wolf-Parkinson-white
Syndrome

• short PR interval, less than 3 small

squares (120 ms)
• slurred upstroke to the QRS indicating pre-
excitation (delta wave)
• broad QRS
• secondary ST and T wave changes
Another young man with bouts of tachycardia. 
A 72 Year Old Man With a Permanent Pacemaker. 
• Name two
abnormalities on
this ECG?
 Ventricular Pacemaker

• pacing spikes (best seen here in V4 - V6)

will be seen - they may be subtle
• the paced QRS complexes are
abnormally wide
Ventricular Pacemaker
A 45 Year Old Lady With Palpitations and History of Chronic Renal
Failure
 
A 45 Year Old Lady With Palpitations and
History of Chronic Renal Failure
 
• What is the ECG
diagnosis?
• What is the main
differential?
• How would you
treat this patient?
 Ventricular Tachycardia
• A wide QRS tachycardia is VT until proven otherwise . 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
– concordance (chest leads all positive or negative)
A 60 Year Old Man With 2 Hours of "Crushing" Chest Pain
Suddenly Collapses.
A 60 Year Old Man With 2 Hours of "Crushing" Chest Pain
Suddenly Collapses.

• What clinical signs

would you find?
• How would you
treat this man?
 Ventricular fibrillation

• bizarre, irregular, random waveform

• no clearly identifiable QRS complexes or
P waves
• wandering baseline
A 40 Year Old Woman With pleuritic Chest Pain and Breathlessness.
A 40 Year Old Woman With pleuritic Chest Pain and Breathlessness.

• What are the abnormalities on

this ECG?
• What clinical signs might you
find?
• What investigations would you
arrange to confirm the finding?
 Acute Pulmonary Embolus
• The following, often transient, changes may be
seen in a large pulmonary embolus.
– an S1Q3T3 pattern
• a prominent S wave in lead I
• a Q wave and inverted T wave in lead III
– sinus tachycardia
– T wave inversion in leads V1 - V3
– Right Bundle Branch Block
– low amplitude deflections
A 58 Year Old Man on Haemodialysis Presents With Profound
Weakness After a Weekend Fishing Trip.
 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
A 22 Year Old Lady With Prolonged Vomiting.
 Hypokalaemia

• The following changes may be seen in

hypokalaemia.
– small or absent T waves
– prominent U waves
– first or second degree AV block
– slight depression of the ST segment
A 64 Year Old Lady on digoxin
 Digitalis Effect
• shortened QT interval
• characteristic down-sloping ST depression,
reverse tick appearence, (shown here in leads
V5 and V6)
• dysrhythmias
– ventricular / atrial premature beats
– paroxysmal atrial tachycardia with variable AV
block
– ventricular tachycardia and fibrillation
– many others