F. Propagation of cardiac impulse The Normal Conduction System.

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Propagation of cardiac Propagation of cardiac impulseimpulse

The Normal Conduction The Normal Conduction SystemSystem

ECG machineECG machine

Generation of normal ECG Generation of normal ECG complexcomplex

What is the heart rateWhat is the heart rate??

(300 / 6 = )50 bpm

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What is the axisWhat is the axis??

Normal- QRS up in I and aVFNormal- QRS up in I and aVF

What is the diagnosisWhat is the diagnosis??

Acute inferior MI with ST elevation Acute inferior MI with ST elevation in leads II, III, aVFin leads II, III, aVF

What is this rhythmWhat is this rhythm??

First degree AV blockFirst degree AV block

What is this rhythmWhat is this rhythm??

Type 1 second degree block Type 1 second degree block (Wenckebach)(Wenckebach)

What is this rhythmWhat is this rhythm??

Type 2 second degree AV block Type 2 second degree AV block Dropped QRSDropped QRS

What is this rhythmWhat is this rhythm??

33rdrd degree heart block (complete) degree heart block (complete)

1414

ECTOPIC BEATSECTOPIC BEATS

1515

ECTOPIC BEATSECTOPIC BEATS

1616

ECG LeadsECG LeadsLimb leads:Limb leads: I, II, III, aVR, aVL, aVF, I, II, III, aVR, aVL, aVF, Chest leads: Chest leads: V1-V6V1-V6

Anterior surface: Anterior surface: V1-4.V1-4. Inferior surface: Inferior surface: II, III and aVF.II, III and aVF. Lateral surface: Lateral surface: I, aVL and V5-6.I, aVL and V5-6.

ECG PaperECG Paper

Normal ECGNormal ECG

P-waveP-wave

Normal valuesNormal values

1.1. Polarity.Polarity. up in I&II and up in I&II and down in aVR.down in aVR.

2.2. Duration.Duration. < 2.5 mm. < 2.5 mm.

3.3. Amplitude.Amplitude.

< 2.5 mm. < 2.5 mm.

AbnormalitiesAbnormalities1. Inverted P-wave1. Inverted P-wave Junctional rhythm.Junctional rhythm.2.2. Wide P-waveWide P-wave (P- mitrale)(P- mitrale) LAELAE3.3. Peaked P-wave (P-Peaked P-wave (P-

pulmonale)pulmonale) RAERAE4. Saw-tooth appearance4. Saw-tooth appearance Atrial flutterAtrial flutter5. Absent P wave5. Absent P wave Atrial fibrillationAtrial fibrillation

P- mitrale P- pulmonale P- mitrale P- pulmonale

( (LAELAE) () (RAERAE) )

PR intervalPR interval

Definition:Definition: the time the time interval between interval between beginning of P-beginning of P-wave to beginning wave to beginning of QRS complex.of QRS complex.

Normal PR intervalNormal PR interval 3-5mm (0.12-0.2 3-5mm (0.12-0.2 sec)sec)

AbnormalitiesAbnormalities

1. Short PR interval 1. Short PR interval WPW syndromeWPW syndrome

2. Long PR interval2. Long PR interval First degree heart First degree heart

blockblock

QRS complexQRS complex

Normal valuesNormal values DurationDuration: < 3 mm.: < 3 mm. MorphologyMorphology::

progression from progression from Short R and deep S Short R and deep S (rS) in V1 to tall R and (rS) in V1 to tall R and short S in V6 with short S in V6 with small Q in V5-6 (qRs).small Q in V5-6 (qRs).

AbnormalitiesAbnormalities::1. Wide QRS complex1. Wide QRS complex Bundle branch block.Bundle branch block. Ventricular rhythmVentricular rhythm..

2. Tall R in V12. Tall R in V1 RVH.RVH. RBBB.RBBB. Posterior MI.Posterior MI. WPW syndrome. WPW syndrome. 3. abnormal Q wave3. abnormal Q wave [ > 25% of R wave][ > 25% of R wave] MI.MI. Hypertrophic Hypertrophic

cardiomyopathy.cardiomyopathy. Normal variant.Normal variant.

Normal Q waveNormal Q wave

Q wave in MIQ wave in MI

Q wave in septal hypertrophyQ wave in septal hypertrophy

ST- segmentST- segment

NormallyNormally it's it's isoelectric.isoelectric.

[i.e. at same level of [i.e. at same level of TP segment]TP segment]

AbnormalitiesAbnormalities::

1.1. ST elevation:ST elevation: Acute MI.Acute MI. Prinzmetal angina.Prinzmetal angina. Acute pericarditis.Acute pericarditis. Early repolarizationEarly repolarization..

2. ST depression:2. ST depression: Ischemia.Ischemia. Ventricular strain.Ventricular strain. BBB.BBB. Hypokalemia.Hypokalemia. Digoxin effect.Digoxin effect.

Abnormalities of ST- segmentAbnormalities of ST- segment

T-waveT-waveNormal values.Normal values.1. Polarity: 1. Polarity: Always up in I,II,V4-6Always up in I,II,V4-6 Always down in aVR.Always down in aVR. Variable in III, aVL, Variable in III, aVL,

aVF, V1-3.aVF, V1-3.

2. amplitude:2. amplitude: < 10mm in < 10mm in the chest leads.the chest leads.

Abnormalities:Abnormalities:1. 1. Peaked T-wave:Peaked T-wave: Hyper-acute MI.Hyper-acute MI. Hyperkalemia.Hyperkalemia. Normal variant.Normal variant.2. 2. T- inversion:T- inversion: Ischemia.Ischemia. Myocardial Myocardial

infarction.infarction. MyocarditisMyocarditis Ventricular strainVentricular strain BBB.BBB. Hypokalemia.Hypokalemia. Digoxin effect.Digoxin effect.

QT- intervalQT- interval

DefinitionDefinition: : Time interval between beginning of Time interval between beginning of

QRS complex to the end of T wave.QRS complex to the end of T wave.

Normally:Normally: At normal HR: QT ≤ 11mm (0.44 sec)At normal HR: QT ≤ 11mm (0.44 sec) (or(or) ) QTc = QT/ √RR QTc = QT/ √RR

AbnormalitiesAbnormalities::1.1. Prolonged QT interval:Prolonged QT interval: hypocalcemia and hypocalcemia and

congenital long QT syndrome.congenital long QT syndrome.

2.2. Short QT interval:Short QT interval: hypercalcemia. hypercalcemia.

INTERPRETATION OF ECGINTERPRETATION OF ECGSTANDARD? NAME? DATE?STANDARD? NAME? DATE?P(SR-nonSR ? rate? regular or P(SR-nonSR ? rate? regular or

irregular?) irregular?) ORSORS(wide or narrow? (wide or narrow? LBBBLBBB OR OR RBBB?RBBB?

rate? regular or irregular?)rate? regular or irregular?)T(tall? invert? biphasic?)T(tall? invert? biphasic?)P-RP-R(long? short? fixed or no? (long? short? fixed or no?

relation?)relation?)ST(elevate? Depressed? )ST(elevate? Depressed? )QTQT(long? short?)(long? short?)AXIS? AXIS?

RateRate

Rule of 300- Divide 300 by the Rule of 300- Divide 300 by the number of boxes between each QRS number of boxes between each QRS

= rate= rate

Number of big boxes

Rate

1300

2150

3100

475

560

650

RateRate

HR of 60-100 per minute is normalHR of 60-100 per minute is normal

HR > 100 = tachycardiaHR > 100 = tachycardia

HR < 60 = bradycardiaHR < 60 = bradycardia

Interpretation of ECG Interpretation of ECG contcont..

4. Axis (mean QRS axis):4. Axis (mean QRS axis): normally -30 to +100 normally -30 to +100

LAD:LAD: LVH LAFB Inf. MIRAD: Normal RVH Lat. MI LPFB

5. Analysis of complete 5. Analysis of complete ECG complexECG complex in each in each lead.lead.

Calculation of electrical axis Calculation of electrical axis depending on QRS polarity in leads I depending on QRS polarity in leads I

and aVFand aVF

WPWWPW

Long QT syndromeLong QT syndrome

Bundle branch blockBundle branch block

Left Bundle branch block Left Bundle branch block (LBBB)(LBBB)

Right Bundle branch block Right Bundle branch block (RBBB)(RBBB)

VT VT (with RBBB pattern)(with RBBB pattern)

VT VT (with LBBB pattern)(with LBBB pattern)

ECG changes in IHDECG changes in IHD

Signs of ischemia:Signs of ischemia: ReversibleReversible ST depression, ST ST depression, ST

elevation or T inversion.elevation or T inversion. Signs of MI:Signs of MI:1.1. Hyperacute T wave.Hyperacute T wave.2.2. ST elevation (STEMI)ST elevation (STEMI) ST depression(NSTEMI)ST depression(NSTEMI)1.1. Q wave (Q or transmuralQ wave (Q or transmural infarction) infarction)2.2. T inversion.T inversion.

Evolution of ECG changes in Evolution of ECG changes in MIMI

Q wave infarctionQ wave infarction

Localization of MILocalization of MI1. anterior MI1. anterior MI

Localization of MILocalization of MI2. lateral MI2. lateral MI

Localization of MILocalization of MI3. inferior MI3. inferior MI

Hyperacute MIHyperacute MI

Acute anteroseptal MI Acute anteroseptal MI (STEMI)(STEMI)

Acute anterolateral MI Acute anterolateral MI (with (with hyperacute T)hyperacute T)

Acute anterolateral MIAcute anterolateral MI Old inferior MI Old inferior MI

Acute inferior MIAcute inferior MI

Right ventricular infarctionRight ventricular infarction

Old ant. MIOld ant. MI

Old inf. MIOld inf. MI

Old inf. MIOld inf. MI

Criteria of ventricular Criteria of ventricular enlargementenlargement

LVHLVH::

1. SV1 + (RV5 or RV6) ≥ 35 mm (or)

RV5 or RV6 ≥ 25 mm

2. LV strain 3. LAE

RVHRVH::

1. Relatively tall R in V1

2. RV strain3. RAD

LVHLVH

LVHLVH

RVH with RAERVH with RAE

RAE LAE RAE LAE

Acute pericarditisAcute pericarditis

SAHSAH

HyperkalemiaHyperkalemia

Sever hyperkalemiaSever hyperkalemia

PACPAC

PAC bigeminyPAC bigeminy

PVCPVC

PVCPVC

PVC. bigeminyPVC. bigeminy

PVC. trigeminyPVC. trigeminy

VTVT

Multifocal PVCMultifocal PVC

PVC. CoupletPVC. Couplet

Sinus tachycardiaSinus tachycardia

Paroxysmal supraventricular Paroxysmal supraventricular tachycardia tachycardia

[PSVT][PSVT]

PSVTPSVT

Atrial fibrillation [fine]Atrial fibrillation [fine]

Non-sustained VTNon-sustained VT

VTVT

Ventricular fibrillationVentricular fibrillation

Sinus bradycardiaSinus bradycardia

Junctional rhythm Junctional rhythm

Sinus arrestSinus arrest

Sinus arrestSinus arrest

First degree heart blockFirst degree heart block

Second degree heart blockSecond degree heart blockMobitz type I (Wenckebach block)Mobitz type I (Wenckebach block)

Complete heart blockComplete heart block

Complete heart blockComplete heart block

Sinus rhythm (SR), rate Sinus rhythm (SR), rate 60, normal ECG60, normal ECG..

SR rate 66, benign early repolarization SR rate 66, benign early repolarization (BER)(BER)..

SR, rate 91, with first SR, rate 91, with first degree AV blockdegree AV block..

Ectopic atrial rhythm, rate Ectopic atrial rhythm, rate 82, otherwise normal ECG82, otherwise normal ECG..

AV junctional rhythm,AV junctional rhythm, rate 50 rate 50

Accelerated idioventricular Accelerated idioventricular rhythm (AIVR), rate 65rhythm (AIVR), rate 65

SR, rate 100, right bundle SR, rate 100, right bundle branch block (RBBB)branch block (RBBB)

SR, rate 80, first degree AV block, SR, rate 80, first degree AV block, left bundle branch block left bundle branch block

(LBBB),old inf MI(LBBB),old inf MI

SR, rate 85, RBBB, left SR, rate 85, RBBB, left posterior fascicular block posterior fascicular block

(LPFB)(LPFB)

rate 50, acute anterolateral myocardial rate 50, acute anterolateral myocardial infarctioninfarction

SR with second degree AV block type 1 SR with second degree AV block type 1 (Mobitz I, Wenckebach), rate 50, left (Mobitz I, Wenckebach), rate 50, left

ventricular hypertrophyventricular hypertrophy(LVH), RBBB(LVH), RBBB..

Ventricular tachycardia Ventricular tachycardia (VT), rate 140(VT), rate 140

SR, rate 87, Wolff-SR, rate 87, Wolff-Parkinson-White Parkinson-White syndrome (WPW)syndrome (WPW)

ST, rate 155ST, rate 155

This ECG was recorded from a 25-year-old pregnant woman who complained of an irregular heart beat.Auscultation revealed a soft systolic murmur but her heart was otherwise

normal^ .

ANSWER 1The ECG shows:

•Sinus rhythm •Ventricular extrasystoles

•Normal axis •Normal QRS complexes and T waves

Clinical interpretationThe extrasystoles are fairly frequent but the ECGis otherwise normal. Ventricular extrasystoles arevery common in pregnancy, and systolic murmursare almost universal. Her heart is almost certainlynormal.What to doRemember anaemia

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