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ECG for Beginners-Part II

Terminology

Aims
To provide an introduction to the
terminology of the electrocardiogram.

Learning Objectives
By the end of the session the students
will be able to:

Describe each wave of the ECG.


List the normal intervals on the ECG.
Describe common abnormalities on the
ECG.
List the causes of Bundle Branch Block.

What is an ECG?
A recording of the changing potentials of the
electrical field imparted by the heart.

P Wave/PR Interval

P Wave

P Wave
SA Node

Lies in right atrium


Initiates atrial
depolarisation
Produces P wave
Electrically the atria
act as one chamber
Little muscle mass
therefore small
deflection

P Wave II
Wave of
depolarisation

Inferiorly to the left


I.e towards leads I
and II
Therefore P wave
upright in leads I
and II

Negative P wave in
lead I

Incorrect lead
placement
Dextrocardia
Ectopic atrial foci

PR Interval
PR interval is the time between the
onset of atrial depolarisation and the
onset of ventricular depolarisation.
From BEGINNING of P wave to first
deflection of QRS.
Normal duration 0.12-0.2 seconds.
PR Interval is constant.

PR Interval

Shortened PR interval
Pre-Excitation

Wolff-Parkinson-White syndrome
Abnormal (accessory) pathway connecting atria

to ventricle. Normal AV nodal delay is


bypassed and ventricular conduction is initially
delayed (delta wave).

Lown-Ganong-Levine syndrome
Normal QRS Complex duration.

Lengthened PR Interval
AV Block

1st degree
2nd degree
Mobitz II
Wenkebach

3rd degree

1st degree AV block


PR interval constant but prolonged.

2nd degree AV Block-Mobitz II


Normal PR interval. Dropped QRS complex

nd
2

degree AV BlockWenkebach
PR prolonged beat by beat until dropped
QRS.

3rd degree AV Block (CHB)


No relation between P wave and QRS complex.

3rd degree AV Block (CHB)

QRS Complex/Bundle Branch


Block

QRS

QRS Complex
Electrical forces generated by
ventricular depolarisation.
QRS complex duration is measured in
lead with widest complex.
QRS<0.11s (3 small squares).
Delay in ventricular depolarisation gives
broad QRS.

Nomenclature-QRS Complex
Q Wave: Any INITIAL negative
deflection after P wave.
R Wave: Any positive deflection.
S Wave: Any negative deflection after
an R wave.

QRS (septal depolarisation)


Left side of SEPTUM depolarises first.
Impulse spreads from left right.
V1/V2 lies to the right of septum and
hence has a small positive deflection R
wave.
Small septal Q waves are present in
lateral leads.

QRS
Non-pathological Q waves

< 2 small squares deep.


< 1 small square wide.
< 25% of the amplitude of corresponding
R wave.

QRS
Depolarisation of right and left
ventricles produces opposing electrical
vectors.
Left ventricle large muscle mass.
Left ventricle predominates.

QRS
Lead V1 small initial R wave followed by
large negative deflection S wave.
Lead V6 small initial Q wave followed by
large positive deflection.
Height of R wave progresses across the
precordial leads.

QRS Progression

RBBB (MaRRoW)
Delayed RV activation

Prolonged QRS (>0.12 s).


2ary R wave in leads facing RV (V1 & V2).
Broad S wave in LV leads (I, aVL, V6).

RBBB
No conduction down right
bundle.
Septal depolarisation
normal.
Excitation of LV S wave in
V1.
RV depolarises after left
therefore secondary R
wave (RSR pattern).

RBBB

Right ventricle depolarises via non specialised


tissue.

Causes RBBB
NORMAL in young people

Right ventricular strain


E.g. PE

IHD
Atrial septal defect (ostium secundum)

Dominant R wave V1
Right ventricular hypertrophy
Posterior MI
Dextrocardia
WPW
RBBB

LBBB (WiLLiaM)
Delay in activation of LV

Prolonged QRS (> 0.12s).


2ary R wave in LV leads (V5/6, I, aVL).

LBBB

Causes LBBB
Always Abnormal

IHD
LVH
Aortic valve disease
Cardiomyopathy
Right ventricular pacemaker

ST Segment/T Wave/QT
Interval

ST Segment
The interval between the termination of
the QRS and the start of the T wave.
End of ventricular depolarisation and
the beginning of repolarisation.
ST segment should be level (isoelectric)
with the subsequent TP segment.

ST Segment

Acute Myocardial Infarction

Changes in AMI
Early

Late

T wave
Ventricular
repolarisation produces
T Wave.
Normal T wave is
asymmetrical.
T wave orientation
usually corresponds to
QRS complex.
T wave inversion in
leads V1-V2 is normal.

T waves
Tall T Waves

Hyper acute
E.g. AMI

Peaked
Metabolic disorders

QT Interval
Measured from beginning QRS to end of
T wave.
Total time for depolarisation and
repolarisation of ventricles.
As heart slows QT interval widens.

QT Interval
QT interval measured relevant to the
heart rate QTc.
QT should not be more than R-R
distance.
Usually <0.44s (11 small squares).
Prolonged QT interval predisposes to
ventricular arrhythmias.

QT Interval

Causes prolonged QT
Congenital
Acquired

Metabolic
Hypo-calcaemia, -thyroidism, -thermia,

kalaemia

IHD
Drugs
Amiodarone, Sotalol, erythromycin, tricyclic

antidepressants

BREAK

Quiz

True/False
The following are correctly paired,

P wave
Q wave
R wave
S wave
T wave

Atrial depolarisation
First positive deflection
Increases in size V1 V6
Negative deflection after R
Ventricular repolarisation

(T, F, T, T, T)

True/False
The following are normal findings on
ECG,

PR interval 0.22s
Mean frontal QRS axis 40
R wave in aVL of 12mm
RBBB
Q wave in lead III

(F, F, T, T, T)

True/False
The ECG ST/T wave,

T wave may be inverted in lead V3 in


afrocaribbeans
If T wave flattened suggests hypokalemia
ST elevation is a sign of acute MI
Digoxin may cause ST abnormalities

(T, T, T, T)

True/False
The following are associated with LBBB,

PE
LVH
Pacemaker
IHD
ASD

(F, T, T, T, F)

True/False
A short PR interval is associated with,

1st degree AV block


WPW
Hypokalaemia
Lown-Ganong-Levine syndrome
Use of beta blockers

(F, T, F, T, F)

Summary

P Wave
SA node initiates atrial depolarisation.
Little muscle mass therefore small
deflection.
P waves upright in leads I, II.
Negative P wave in Lead I abnormal
(check lead positions).

QRS Complex
Ventricular depolarisation.
QRS<0.11s.
Delay in ventricular depolarisation gives
broad QRS complex.
Pacemakers produce LBBB pattern.

Intervals
PR interval measured from beginning of
P wave to first deflection of QRS.
Normal PR interval 0.12-0.2s.
QRS<0.11s.
QT interval varies with rate.
Prolonged QT interval predisposes to
ventricular arrhythmias.

Nomenclature
Q Wave: Any INITIAL negative
deflection.
R Wave: Any positive deflection.
S Wave: Any negative deflection after
an R wave.
T Wave: Ventricular repolarisation.

Bundle Branch Block


Prolonged QRS duration.
RBBB can be normal.
RBBB is associated with PE.
LBBB is always abnormal.
Pacemakers give an LBBB pattern.

HyperK

Miscellaneous diagnoses
Hypothermia

defined as a temperature of less than 34 C, slows


impulse conduction through all cardiac tissue,
resulting in prolongation of all the ECG
intervals, including the RR, PR, QRS, and QT.
There is also elevation of the J point (only if the
ST segment is unaltered), producing a
characteristic J or Osborne wave, The height of
the Osborne wave is roughly proportional to the
degree of hypothermia. These findings are most
prominent in the precordial leads V2 to V5.

Hypocalcaemia

Prolongs QT

Hypercalcaemia

shortening of the QT interval, primarily due to a


decrease in the ST segment duration.
the initial portion of the T wave has an abrupt
upslope.
PR prolongation,
a diffuse increase in the amplitude of the QRS
complex,
biphasic T waves.

Ventricular Hypertrophy
Sokolow and Lyon
Precordial Leads (one or more)

SV1 + RV5 or RV6

> 35mm if > 30yr of age


> 40mm if 20 30 yr
> 60mm if 16 19 yr

RV5 or RV6 > 26 mm


SV1 or SV2 > 26 mm

Limb Leads (one or more)

RI 14 mm
RaVL 12 mm
RaVR 15 mm

(Cornell Criteria- most accurate) R aVL + SV3

> 24 mm in males
> 20 mm in females

Recommended Reading
The ECG made easy

J Hampton

ABC of electrocardiography

BMJ 2002

Any Questions?