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Medicine 2016: medicine 2: ECG (Dr.

Jing Calibuso) [Category]

Basic Electrocardiography
A diagnostic exam to help in the diagnosis and management
primarily of cardiac conditions (others: renal, brain abn)

Recording of the electrical activity of the heart


Cellular electrophysiology

Cardiac cells:
o electrically polarized at resting state
o mainly negatively charged inside, positively charged outside
o charge: -90 millivolts

Depolarization:
o Fundamental electrical event of the heart
o Lose their internal negativity
o What happens is positive ions go inside the cell, and then it will
depolarize the rest of the cardiac cells, cardiac cells lose their
internal negativity, it will proceed to transfer to another cell until
everything is depolarized
Repolarization
o Restoration of polarity (opposite the direction of depolarization)
o Return of negative charge inside the cell
o Last one to be depolarized is the first one to repolarized

Negative deflection: when the electric


wave is going AWAY from the electrode

Biphasic wave: if Perpendicular to the


electrode; equal positive and negative
deflections.
Conduction System of the Heart

Sinus node
o Main pacemaker of the heart
o 60-100bpm (fastest pacemaker)
o Influenced by the ANS (Sympa=HR;
Vagal=HR)
o Main blood supply: left coronary system
and right coronary system

Atrioventricular node
o 40-60 bpm
o Influenced by ANS
o Main blood supply: right coronary artery and left circumflex
artery

Electrical conducting cells


o Hard wiring of the heart
o Conduct current to the distant regions of the heart
o Atrial conducting system: Bachmans bundle
o Ventricular conducting system:

His bundle Left and Right bundles (Left bundles further


subdivided into the ant and post fascicles)Purkinje
system supply the myocardial cells

Myocardial cells
o Contains abundant contractile proteins actin and myosin
o Contractile unit of the heart
o Current is spread slowly across the entire myocardium causing
the heart to beat at 30-45bpm
o Ventricular pacemaker

If you put an electrode on one side of a cardiac cell, if the wave


would proceed from here to that
(+) electrode, on ECG you will

see a positive deflection towards the electrode, if however the wave


of depolarization is opposite of that the electrode, on ECG you would
appreciate a negative deflection.
If the wave of depolarization start here going to this electrode,
initially it will register a (+) deflection, at the point where it becomes
perpendicular to the electrode, it will go back to isoelectric level, if
wave of depolarization go further, it becomes a negative deflection,
so the end result you will have a biphasic wave (up and down)
Positive deflection: recording when the electric wave is TOWARDS the
electrode

ECG leads

Limb leads
o Bipolar leads

Consist of 2 electrodes (positive and negative) placed at 2


different sites

Register the difference in potentials between these 2 sites


o Unipolar leads

Measure the absolute electrical potential at one site relative


to an electrode with zero potential

Limb lead placements

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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

Red (R): R UE
Yellow (L): L UE
Green (F): L foot
Black (N): just a ground

On top of the chest


6 leads : V1-V6
V3/V4 are designated as transition zones; here you see more or
less equal?? R wave and
Leads
Ventricular region
S wave
V1-V2
Septal
o Unipolar leads
Bipolar limb lead
V3-V4
Anterior
representing the coronal
o Lead I: registers the potential
V5-V6
Lateral
plane of the heart
between the R arm (-) and L arm (+)
o Can represent whole anterior portion
o Lead II: registers the potential between L foot (+) and R arm (-)
of the heart
o Lead III: registers the potential between L foot (+) and L arm (-)
o Einthovens triangle
o Axial reference system

Placement:

Represents the frontal 3 of

V1: 4th ICS R parasternal border

V2: opposite V1, 4th ICS L


the heart

Lead I: reference lead: zero


parasternal border

V4: 5th ICS mid clavicular line


degree

V3: between V2 and V4

Lead II: +60 from lead I

V5: 5th ICS anterior axillary line

Lead III: +120positive from lead I

V6: 5th ICS mid axillary line


Everything clockwise to lead I- positive
o
o
o
o

o
o
o

Counter clockwise to lead I- negative


Represents Frontal plane of the heart

Augmented Unipolar limb leads


o Augmented as much as 50%
o Lead aVR: records the
potential of R arm in reference
to the average potential
between L arm + L foot

-150 from lead I


o Lead aVL: records the
potential of L arm in
* shows the direction of
reference to the
average
depolarization so lead 1 is
potential of R arm + L
foot
designated at zero degrees,

-30 from lead I


anything below it designated
as (+), above designated as
o Lead aVF: records the
potential of
(-)
L foot in reference to
the average
potential of R arm + L arm

+90 from lead I


o Axial graphic system
Leads
Ventricular region
I, aVL
Lateral
II, III, aVF
Inferior
aVR
Right

Precordial leads

ECG READING

Standardization

Regularity

Rhythm

Rate

Axis

Intervals
STANDARDIZATION:

ECG paper:
o 1 big square = 5 small square
o Big square: 0.2 sec and
0.5mV
o Small square: 0.04 sec and
0.1mV
o Should cover 10mm
o Duration express in seconds

Standard speed: 25mm/sec


o Height/amplitude express in millivolts

Standard amplitude: 10mm/mV

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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

ECG tracing
o P wave: atrial depolarization
o QRS wave: ventricular depolarization, atrial repolarization

Q wave: 1st negative deflection after P

R wave: 1st positive deflection after Q

S wave: 1st negative deflection after R


o T wave: ventricular repolarization

REGULARITY

P waves: distances more likely equal, may vary in 10% still


considered normal

QRS waves: fairly regular; measure distance by caliper


RHYTHM

Sinus: appreciate P wave


o Pacing is from sinus node

E.g. Regular sinus rhythm


RATE

Normal: 60-100bpm

Heart = 1500/(# of small squares b/n 2 consecutive R waves)


o
o
o
o
o

1
2
3
4
5

large
large
large
large
large

square = 300 bpm


squares = 150 bpm
squares = 100 bpm
squares = 75 bpm
squares = 60 bpm

AXIS

Mean direction of vector for


atrial depolarization
o R to L and slightly
inferiorly
o Going to lead II: (+)
deflection in P wave
o V1: biphasic P wave

Direction of vector for


ventricular depolarization
o Depolarization of the rest
of the ventricle
o Dominated by the left ventricle because of bigger muscle mass
o Leftward and inferiorly

Lead 1 and aVF


o Both up: normal axis (-30 - +100)
o Lead 1 (+/up) and aVF (-/down): left axis deviation (-30- -90)
o Lead 1(-/down) and aVF(+/up): right axis deviation(+90- 180)
o Both (-/down): Extreme axis deviation (-100 - 180)

INTERVALS

P wave: recording of atrial


depolarization
o Duration: not more than 0.12
seconds
o Amplitude: not more than 2.5
millivolts

PR intervals: Measures the time from


the start of atrial depolarization to the
start of ventricular depolarization
o Normal: 0.12-0.20 sec

QRS interval: measures the duration of


the ventricular depolarization, start is Q and ends in S
o Normal: 0.8-0.10 sec
o Direction of vector for ventricular depolarization
o Septal depolarization

Left to right direction

V1: (+) deflection

V6 (-) deflection
o Depolarization of the rest of ventricle, dominated by left ventricle

Leftward and inferiorly

V1: (-) deflection S wave

V6: (+) deflection R wave


o R wave progression

Movement from V1 to V6

LV depolarization
o S wave

smaller
o V3 and V4: transition zone (equal + and equal deflections)

ST segment
o End of S and beginning of T wave
o Measures the time of the end of the ventricular depolarization to
the start of ventricular repolarization

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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

J point
o Junction of S wave and beginning of ST segment
o Should be at the level of the PR segment
o Basis of ST elevation or depression

T wave
o ventricular repolarization

U wave: comes after T wave


o Ht: 5-25% of the T wave (usually <1.5mm)
QT interval: measures the time from the beginning of the
ventricular depolarization to the end of ventricular repolarization
o Normal: up to 0.44 sec
o Varies with the heart rate
o Not occupy more than 40% of RR interval

Sinus arrhythmia
o Normal in all respects except
that it is slightly irregular

Variation > 10%


o Associated with respiration

Inspiration: accelerates HR

Expiration: slows HR

Sinus bradycardia
o Heart rate: <60
o May be normal in athlete, seen in inferior wall MI, drug induced
(B-blockers, Ca channels)

Sinus tachycardia
o Heart rate >100
o Causes: infection, anemia, HF, hyperthyroidism

Sinus arrest/pause
o Failure of the sinus node to fire
o PP interval during the pause
>2secs
o Sinus rhythm resumes at a PP
interval that is not a multiple of the basic sinus PP interval

Sinoatrial exit block


o Second degree

Some sinus impulses fail


to capture the atria

Intermittent absence of P
wave

Type II (Mobitz)

QTc interval
o Tachycardial: falsely short QT interval
o Bradycardia: falsely long QT interval
o Bazetts formula:

QTc interval = QTa/square root of RR

Cardiac cycle

Depolarization first before mechanical contraction

ATRIAL RHYTHMS
Narrow QRS; usually supraventricular
Sinus rhythm
o Normal P

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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

Sinus node fires but the wave of depolarization is


immediately blocked and not transmitted to the
surrounding atrial tissue

Ectopic atrial rhythm


o P wave morphology different
from sinus node

Atrial rate: <100bpm

PR interval >/= 0.12secs


o Inverted P waves seen in
inferior leads (II, III, aVF)

Wandering atrial pacemaker


o P wave with >/= 3
morphologies
o Rate <100bpm
o May have varying PR, RR,
RP interval
o Distinct isoelectric baseline
is present

Premature atrial
depolarization
o Atrial premature beat originated at an atrial site distant from the
sinus node
o Occurs before the
next anticipated sinus
wave
o Normal looking QRS
wave
o May be followed by a pause

Atrial tachycardia
o P wave is different from sinus node
o 3 or more beats in succession at an
atrial rate of 100-180bpm
o QRS complex resembles normal QRS
during sinus rhythm
o PR interval may be normal or
prolonged
o May see in V1
o Form of atrial flutter
Multifocal atrial tachycardia
o Atrial rate > 100bpm
o P wave with >/= 3 morphologies with distinct isoelectric baseline
o Varying PR, RR, RP interval

Supraventricular tachyardia
o No identifiable P waves, often buried in
the QRS
o Narrow QRS
o Regular rhythm
o 150-250bpm
o May be paroxysmal (PSVT)
o Seen:

Normal hearts

Stimulants ( coffee, alcohol)

Coronary artery disease


o Treatment: carotid massage, adenosine

Atrial fibrillation
o Different circuits are occurring in the atria, some can produce
ventricular response
o No Identifiable P waves (fibrillation waves)
o Irregularly irregular ventricular rhythm
o Heart rate: HR = # of R waves in 6 secs x 10

Slow ventricular response: HR < 60bpm

Controlled ventricular response: HR 60-100bpm

Rapid ventricular response: >100bpm


o Seen:

Coronary artery disease

Mitral valve disease

Hyperthyroidism
o Treatment: rate control or rhythm control digoxin, B blockers,
amiodarone

Atrial flutter
o Circuit in : Sinus node, tricuspid area, IVC (clockwise or
counterclockwise)
o P waves rate: 250-350 bpm
o Rapid regular atrial undulations (flutter waves)

Saw-toothed appearance

Best seen in inferior leads


o No isoelectric area

AV JUNCTIONAL RHYTHMS
Area of AV node
QRS in between supraventricular and ventricular
0.10-0.12 sec
AV junctional premature
complex
o Premature QRS complex
may be narrow
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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

o
o

Inverted P waves leads II, III, aVF and upright P waves in leads I
and aVL commonly seen
P wave may precede the QRS by less than 0.12 seconds or may
be buried in QRS

AV junctional Rhythm
o Depolarization
originates from the
AV node
o No P wave or
presence of inverted
P wave
o HR: <60bpm
o QRS usually narrow

Accelerated AV junctional rhythm


o Same with AV junctional
o HR> 60
o No distinct P wave
o Narrow QRS

Wide QRS

Premature ventricular depolarization


o QRS is wide, notched or slurred not preceded by a P wave
(0>.12secs)
o Occurs before the next anticipated sinus beat
o Usually followed by a compensatory pause
o May alternate
with normal
sinus beat in a
regular pattern

1 PVD : 1
sinus beat Bigeminy

1 PVD : 3 sinus beat Trigeminy

1 PVD : 4 sinus beats Quadrigeminy


o Lowns grading for PVD

0: none

1a: <30/hr or <1/min

1b:= >1/min

2: > 30/hr

3: multiform, bigeminy, trigeminy

4a: couplets (2 successive PVDs)

4b: salvos (3 successive PVDs)

5: R on T phenomenon can induce ventricular tachycardia

VENTRICULAR RHYTHMS

Ventricular tachycardia
o Run of three or more consecutive PVDs
o HR: 120-200bpm
o Regular
o Monomorphic or polymorphic
o Seen in MI, electrolyte abnormalities, myocarditis
o Management:

Unstable: cardioversion or defibrillation

Stable: anti-arrhythmics (amiodarone)


o Distinct characteristics:

AV dissociation

Atrial and ventricular rhythms are independent of each


other

Fusion beats

Results from simultaneous activation of the ventricle from


2 sources

QRS complex intermediate in morphology b/n the QRS


complexes of each source

Capture beats

Occurs when an atrial impulse is conducted and


stimulates the ventricle during a ventricular tachycardia

QRS complex may appear similar to that during the sinus


rhythm or may appear as a fusion beat

QRS concordance

From V1-V6, all QRS are upright or negative

Monomorphic ventricular VT

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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

Polymorphic VT

Torsades de pointes (twisting of


points)

VT preceded by prolonged
QT interval
o Prolonged QT caused by:
congenital, electrolyte
abnormalites
(hypoK,Ca,Mg)

different forms of QRS

Idioventricular Rhythm
o Regular ventricular
rhythm
o QRS morphology
similar to PVD
o Rate: < 60bpm
o slow VT
o Accelerated idioventricular rhythm

Rate 60 -100

Ventricular fibrillation
o No true QRS complexes,
ECG tracing appears
coarse or fine
o Chaotic and irregular
deflections of varying
amplitude and contour
o Preterminal event
o Tx: defibrillation

o
o

Asystole
Flat line
Check first if leads are properly placed

AV CONDUCTION ABNORMALITIES

First degree AV block


o Prolonged delay in the conduction in
the AV node or His bundle
o Prolongation of the PR interval
o Can be normal, myocarditis, druginduced (eg. B blockers)

Second degree AV block


o Some atrial impulses are not able to
pass through the AV node and into
the ventricles
o Types:

Mobitz type I 2nd deg AV block (Wenchebach block)

Progressive lengthening of each successive PR interval


until one P wave fails to conduct (dropped beat)

Block is usually in AV node

Mobitz type 2 2nd deg AV block

2 or more normal beats with normal PR interval and then


a P wave that is not followed by QRS complex (dropped
beat)

Block below the AV node, in the His bundle

More dangerous than type I

May lead to 3rd degree AV block

Third degree AV block


o The atria are contracting independent of the ventricles

Atrial rate 60-100bpm

Ventricular rate: 30-45bpm

ARREST RHYTHMS
Pulseless electrical activity (PEA) or electromechanical dissociation
(EMD)
See QRS but no pulse

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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

o
o

Example of AV dissociation
Causes: Degenerative, complication of MI

ACCESSORY PATHWAY

Wolff-Parkinson-White pattern
(WPW)
o Normal P wave
o PR interval <0.12 sec
o Initial slurring of the QRS (delta
wave) resulting in wide QRS
(>0.10 sec)
o Secondary ST- T wave changes
o Accessory pathway: Bundle of
Kent
o When stimulus comes from sinus
AV node accessory pathway

o
o

Lown-Ganong-Levine
o Normal P wave
o PR interval <0.12 sec
o No delta wave
o Accessory pathway: James bundle

o
o

INTRAVENTRICULAR CONDUCTION ABNORMALITIES

Conduction blocks
o Bundle Branch Block (BBB)

Blocks in one or both ventricular bundle branches

Associated repolarization changes (eg. ST segment


depression)
RBBB
o Obstruction in the conduction of the R bundle
o RSR in V1 and V2
o Incomplete

QRS duration between 0.10-0.12 secs

No associated repolarization abnormalities

Does not interfere with the diagnosis of ventricular


hypertrophy or Q wave MI

Present in

2% healthy adults

R ventricular hypertrophy

Post wall MI
Complete

QRS interval is between >0.12

Repolarization changes in V1 and


V2

Down slopping SR segment

T wave inversion

Wide slurred S wave in lead I, V5 &


V6

LBBB
Obstruction in the conduction through the L bundle
QRS changes in Lead I, aVL, V5 and V6: marked prolongation in
the rise of the R waves which will be either broad or notched
(RSR pattern)

The presence of LBBB precludes the diagnosis of ventricular


hypertrophy
Diagnosis of MI In CLBBB

ST elevation >/= 1mm concordant to the major deflection of


the QRS

ST depression >/= 1mm VI,V2,or V3


Intraventricular conduction delay: QRS duration 0.12 secs without
any other criteria for BBB
HEMIBLOCKS

Normal QRS duration and no ST segment or T wave changes


Left anterior hemiblock (LAHB)
o LAD (-45 to -90)
o qR complex in leads I and aVL and S wave in lead III
o No other cause for the LAD (Left axis deviation)

Left posterior hemiblock


o RAD (+100 to +180)
o Deep S in lead I
o No other cause for the RAD
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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

Bifascicular block
o RSR in V1 (RBBB)
o LAD (LAHB)
o RBBB cannot explain LAD

Trifascicular block
o RSR in V1 (RBBB)
o LAD (LAHB)
o 1st degree AV block

Cornell criteria: R wave in aVL + S wave in V3

>24 mm in male

>20 mm in female
Non-voltage criteria for LVH

Left atrial enlargement

LAD
Causes:

HPN

CAD

Valvular disease (aortic stenosis)


ECG criteria for LVH has low sensitivity (~50%) but high
specificity (~90%)

ENLARGEMENTS AND HYPERTROPHIES

ECG wave changes:


o Increase in duration
o Increase in amplitude
o Shifting of the electrical axis
RA enlargement
o Amplitude: >2.5 mm in inferior leads
o >1.5 mm in V1 & V2
o May produce P pulmonale (often caused by lung disease)

LA enlargement
o Amplitude of the terminal component of the P wave may be
increase in V1
o Increase duration of P wave in inferior leads (>/= 0.12 secs)
o May produce P mitrale (often caused by mitral valve disease)
o parang M shape sya

RV hypertrophy
o RAD
o R/S ration in V1 > 1
o R/S ration in V5 or V6 </=1
o R wave in V1 is >/= 7mm
o Normal: R biggest in V5 & V6, S biggest in V1
o Seen in

Pulmonary disease

Cyanotic heart disease

Dextroposition

LV hypertrophy
o LAD
o Sokolows criteria: S wave in V1 + R wave In V6 >/=35mm

REPOLARIZATION ABNORMALITY

Seen in Ventricular hypertrophy


Occur in leads with tall R waves
o RVH: V1 and V2
o LVH: V5 and V6
T wave inversion or ST segment depression
ABNORMALITY OF QRS

Low voltage QRS


o Amplitude of the entire QRS complex (R + S) < 5mm in all limb
leads
o Amplitude of QRS in precordial leads < 10mm
o Seen

Chronic lung disease

Pericardial effusion

Obesity

Pleural effusion
LAD
o
LAHB
o LBBB
o LVH

RAD
o RVH
o COPD
o Pulmonary embolism
o Dextrocardia

Electrical alternans
o Alternation in amplitude and/or direction of the P, QRS & PQ
o Seen in:
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Medicine 2016: medicine 2: ECG (Dr. Jing Calibuso) [Category]

Pericardial effusion

Suspect for cardiac tamponade


Severe heart failure

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