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Describing a ECG

Rate number of large squares between R-R divided by 300 Rhythm regular or irregular (between R-R) Conduction PR interval if sinus rhythm Cardiac Axis lead I and avF (+ lead II if I +ve and aVF ve) QRS complex width/duration (V1 and V6 (WLM and MRW), height (V1 and V6) and Q waves ST segments depression or elevation T waves inversion

Paper speed o 25mm/sec, large squares = 0.2sec (5mm), small squares = 0.04sec (1mm) 12 leads 6 standard leads and 6 chest leads o aVL, I and II look at left lateral heart surface o aVF and III at inferior heart surface o aVR looks at RA o V1-V6 looks at anterior heart surface o V1 and V2 look at RV o V3 and V4 at interventricular septum and anterior LV o V5 and V6 at LV Standard intervals o PR interval <0.2sec o QRS complex <0.12sec o ST segment <1mm from isoelectric line Nomenclature for QRS complex o Q: 1st +ve deflection o R: 1st -ve deflection o S: -ve deflection following R wave Deflections o When depolarisation wave spreads towards a lead stylus moves upwards and when it spreads away it moves downwards (for repolarisation wave it is the opposite) o Depolarisation wave spreads through ventricles in many directions at once but the QRS complex shape shows the average direction in which the wave spreads through If QRS predominately upwards (+ve) (i.e. R wave > S wave) depolarisation moving towards lead

Specific ECG Abnormalities

Cardiac axis Average direction of spread of depolarisation wave through the ventricles as seen from the front is called the cardiac axis Direction of axis most easily derived from leads I and aVF Normal cardiac axis (direction = 11 oclock to 5 oclock, range = -30 to +90) o If both I and aVF have +ve deflections of QRS complexes the normal CA Right axis deviation deflection in lead I predominately ve (downwards) & aVF +ve (upwards), due to RV hypertrophy (e.g. due to pulmonary hypertension, pulmonary stenosis or PE) Left axis deviation QRS complex predominately +ve in lead I & -ve in aVF but this still may be normal so need to look at lead II if its +ve the axis is normal and if Ve then have left axis deviation o LAD more likely due to conduction defect then a increase in LV muscle bulk) Long thin individuals may have a right axis deviation Short fat individuals may have a left axis deviation

Heart block 1st degree HB one P wave per QRS complex but PR interval prolonged (>0.2sec) 2nd degree HB 3 types o Mobitz type 1/Wenckebach progressive PR lengthening then non-conducted P wave and then repetition of cycle o Mobitz type 2 constant PR interval but occasional non-conducted beats o 2:1/3:1 block 2 or 3 P waves per QRS complex, with normal P wave rate rd 3 degree/complete HB no relationship between P waves and QRS complexes o Atrial contraction normal but no beats conducted to ventricles o When this occurs ventricles excited by a slow escape rhythm o Acutely may be due to MI (usually transient), chronically may be due to fibrosis of bundle of his P wave morphology P.pulmonale peaked P wave due to RA hypertrophy P.mitrale broad and bifid P wave due to LA hypertrophy QRS Width/Duration (normal <0.12sec) Relates to time taken for spread of excitation through the ventricles QRS complex width <0.12sec normal & implies origin of rhythm is supraventricular QRS complex width >0.12sec implies ventricular rhythm or BBB o Conduction within ventricles must have occurred by an abnormal and therefore slow pathway o In sinus rhythm with BBB normal P waves are present with a constant PR interval, but this is not the case with rhythms beginning in ventricles If depolarisation wave reaches interventricular septum normally then PR interval will be normal, but if there is abnormal conduction through either the R or L bundle branches there will be a delay in depolarisation in part of the ventricle o This extra time taken for depolarisation of whole ventricular muscle causes widening of QRS complex Block of both bundle branches has same effect as block of bundle of His and causes 3rd degree/complete HB RBBB often indicates problems with right side of heart, but RBBB patterns with a QRS complex of normal duration quite common in healthy people sometimes called a partial RBBB, can be considered a normal variant LBBB always indicates heart disease usually on the left side Important to recognise BBB present as LBBB prevents further interpretation of the cardiogram & RBBB makes interpretation difficult When determining whether left or right BBB evaluate V1 and V6 o In LBBB V1 QRS complex will have a W pattern and V6 a M o In RBBB V1 QRS complex will have a M pattern and V6 a W So WLM and MRW QRS Height Increase muscle mass in either ventricle will lead to increase electrical activity and to a increase in height of QRS complex RV hypertrophy best seen in V1 (tall R waves) and V6 (deep S waves) LV hypertrophy V5 or V6 (tall R waves (>25mm)) and V1 (deep S waves)

Q waves May be physiological or pathological and can be due to 3 reasons: o Axis Q wave may be seen in a lead with a overall ve QRS complex (e.g. aVR, III, V1) o Small (septal) Q waves - appear in LV leads (I, aVL and V6) as result from depolarisation of septum from left to right o Previous MI - Q waves > 1 small square in width and >2mm in depth are pathological and indicates a MI, with the leads in which these Q waves appear giving some indication as to the part of the heart that has been damaged Presence of a Q wave does not give a indication of the age of an infarction because once a Q wave has developed it is usually permanent ST segment ST segment should be isoelectric Elevation of the segment (in a lead with a upright QRS) is a indication of acute myocardial injury due to recent infarction or pericardiits o Leads in which elevation occurs indicate part of heart which is damaged, and as pericarditis is not usually a localised affair it causes ST elevation in most leads Depression of ST segment associated with a upright T wave, generally non-specific but is usually a sign of ischaemia as opposed to infarction (other causes hypokalaemia, hypokalaemia, digoxin (down-sloping, as opposite to horizontally depressed ST segments usually due to treatment with digoxin)) o When a ECG at rest is normal ST segment depression may appear during exercise particularly when exercise induces angina T waves Polarity the T wave should follow the QRS (be upright is QRS upright and negative if QRS is negative) o T wave inversion may be seen in following circumstances: Normality normally inverted in VR and V1, and in V2 in young people and V3 in some black people Ischaemia Infarction Ventricular hypertrophy in leads looked at hypertrophied ventricle BBB the abnormal path of depolarisation in BBB is usually associated with a abnormally path of repolarisation and therefore inverted T waves associated with widened QRS complexes have no significance in themselves Digoxin treatment get T wave inversion with characteristic sloping depression of ST segments. May be helpful to record to ECG before giving digoxin to save later confusion about significance of T wave changes Size o Small hypokalaemia o Large hyperkalaemia, ischaemia

Myocardial Infarction Sequence of ECG chances o Normal ECG o ST segment elevation (hours) o Appearance of Q waves (hours permanent) o Normalisation of ST segment o Inversion of T waves (hours weeks) Rhythms Supraventricular Rhythms o Constitutes sinus rhythm (one P wave per QRS complex), atrial rhythm and junctional rhythm o Depolarisation wave spreads to ventricles normally via bundle of His and its branches and hence QRS complex is normal (narrow) Ventricular Rhythms o Depolarisation wave spreads through ventricles by an abnormal and therefore slower pathway and hence QRS complex is wide and abnormal o Repolarisation also abnormal so T wave is of abnormal shape Supraventricular tachyarrhythmias o Supraventricular extrasystole Premature P wave followed by normal QRS with normal or lengthened PR interval Treatment nil o Supraventricular tachycardia Rapid atrial rate >100/min, regular Normal rapid QRS, P waves may be present in QRS o Atrial flutter Rapid P wave rate (250-350/min), sawtooth pattern on ECG Normal P waves, normal QRS but slower and often regular Treatment acute attack: digoxin, cardioversion If QRS complex Prophylaxis sotalol, amiodarone rapid & there are o Atrial fibrillation no P waves: Rapid P wave rate (>350/min) but none identifiable completely irregular a wide QRS baseline indicates VT & a narrow QRS Irregular P waves, normal but irregular QRS 50-160/min indicates Treatment acute attack: digoxin, cardioversion supraventricular Prophylaxis sotalol, amiodarone tachycardia Chronic digoxin, warfarin to prevent thrombo-embolism Ventricular tachyarrhythmias (wide QRS complexes) o Ventricular extrasystole Premature abnormally shaped QRS but no P (as did not arise in atrial region) Treatment usually nil, B-blocker o Ventricular tachycardia Rapid QRS rate (100-250/min) Regular but abnormal QRS, P waves typically dissociated Treatment acute attack: cardioversion Prophylaxis amiodarone

Ventricular fibrillation Rapid QRS rate (>350/min) Irregular and abnormal QRS, no P waves Treatment cardioversion (immediately) Prophylaxis amiodarone