PAFP Refresher Course

September 27, 2014

Marilyn Benedith Anastacio-Laceda, MD, DPAFP

Indications for Ordering an ECG

1. To determine cardiac rate

2. To accurately define cardiac rhythm
3. To diagnose old or new myocardial
infarction
4. To identify intracardiac conduction
disturbances
5. To aid in the diagnosis of ischemic heart
disease, pericarditis, myocarditis,
electrolyte abnormalities, and pacemaker
malfunction
Boxes

1 big box = 0.2 sec

• BOXES:
1 big box = 0.2 seconds or 5 mm
1 small box = 0.04 seconds or 1 mm
Boxes

1 small box = 0.04 sec

• BOXES:
1 big box = 0.2 seconds or 5 mm
1 small box = 0.04 seconds or 1 mm
Waves

T
P
U

S
The basic waveform
Segments

PR ST TP

• SEGMENT:
horizontally-directed line representing the numeric distance (in mm) between two
waves or complexes
Intervals
PR
interval

• INTERVAL:
the time frame (in seconds) that elapses as the distance between two reference
points on the ECG tracing is traversed
Intervals
QRS

• INTERVAL:
the time frame (in seconds) that elapses as the distance between two reference
points on the ECG tracing is traversed
Intervals
QT interval

• INTERVAL:
the time frame (in seconds) that elapses as the distance between two reference
points on the ECG tracing is traversed
Intervals
RR interval

• INTERVAL:
the time frame (in seconds) that elapses as the distance between two reference
points on the ECG tracing is traversed
Intervals
PP interval

• INTERVAL:
the time frame (in seconds) that elapses as the distance between two reference
points on the ECG tracing is traversed
Correlating the ECG with electrical activity
P Atrial activation
R
PR AV conduction

QRS Ventricular depolarization

T
P ST-T Ventricular repolarization
U

S
Before you start reading the ECG...
standardization
R

T
P
U

S
Normal Values

P wave <0.12 sec

<0.25 mV in limb leads
<0.1 mV terminal negative
deflection in V1

PR interval <0.12-0.20 sec

QRS duration <0.11-0.12 sec
T wave <5-10 mm (0.5-1.0 mV)
QTc <0.48 (female)
<0.47 (male)
Rhythm rhythm
rate

• Sinus rhythm or not? axis

P
PR
Q P
QRS
QT

ST

T
U

V
Rhythm rhythm

rate

• Sinus rhythm or not? axis

P
PR
Q P
QRS
QT

ST

T
U

V
Rate computation for regular rhythms rhythm

rate
• Formula 1: 1500 / RR small squares axis
• Formula 2: 300 / RR big squares P
• Eye-balling PR

300 150 100 75 60 Q P

QRS
QT

ST

T
U

V
Rate computation for irregular rhythms rhythm

rate
• Get a 6-second strip (long lead II) axis
• Count number of QRS complexes P
• Multiply by 10 to get the rate in 1 min PR
Q P
QRS
QT
ST

17 x 10 = 170 beats per minute U

V
Axis Classification
rhythm

rate
axis
Right Axis Deviation (RAD) >100˚ P
Left Axis Deviation (LAD) >-30˚ PR
Normal Axis -30˚to 100˚ Q P
Extreme Axis Deviation -90˚to 180˚ QRS
QT
ST

T
U

V
Axis* rhythm

rate
axis
Extreme axis Left axis
-90o to -180o -100o to -30o P
PR
Q P
QRS
QT

ST
Right axis Normal axis
T
+100o to +180o -30o to +100o
U

*based on PGH Harmonization Criteria

V
Axis rhythm

• “Thumb” method rate

axis
P
Normal axis
PR P
Q
Left axis
QRS
QT
Right axis
ST

T
Indeterminate U

V
Axis rhythm

rate
• “Toxic” formula method axis
P
Axis = [ 90 (aVF) ] PR
Q P
[│I │ ‌+‌│aVF│] QRS
QT

• aVF and I are integers derived by subtracting the positive ST

deflection from the negative deflection
• aVF in the numerator is an integer while I and aVF in the T
denominator are the absolute values of the integers U
• If I is a negative integer, then adjust the axis by adding │90│
V
ECG Harmonization at PGH
rhythm
Atrial enlargement
rate
axis
P
RIGHT ATRIAL ENLARGEMENT PR
Q P
P wave with 2.5 mm amplitude (0.25mV) in any of QRS
Lead II, III or aVF QT
ST

T
U

V
Right atrial enlargement
rhythm

rate
axis
P
PR
Q P
QRS
QT
ST

T
U

V
Atrial enlargement
rhythm

rate
axis
LEFT ATRIAL ENLARGEMENT P
PR
• P wave widened ≥3mm (≥0.12 sec) especially Q P
lead II OR QRS

• Terminal segment of P wave in VI > 1 small box QT

(> 0.04 sec OR 0.1 mV depth ST

T
U

V
Left atrial enlargement
rhythm

rate
axis
V1 P
PR
Q P
QRS
QT
ST

T
U

V
II V1
Atrial enlargement
rhythm

rate
BIATRIAL ENLARGEMENT
axis
P
• RAE (tall P waves > 2.5 mm in leads II,III, aVF) +
PR
• LAE (terminal segment of P wave > 1 small box (>0.04 sec) in V1 OR Q P
widened P wave especially lead II ≥ 3mm (≥0.12 sec)
QRS
QT
ST

T
U

V
PR segment/interval
rhythm

rate
SHORTENED PR INTERVAL
axis
P
• Myocardial infarction
PR
• Myocarditis Q P
QRS
• Pre-excitation syndromes
QT
• Obstructive lung diseases
ST

T
U

V
PR segment/interval
rhythm

rate
PROLONGED PR INTERVAL
axis
P
• hypothermia
PR
• Infectious diseases Q P
QRS
• Electrolyte abnormalities (K, K, Mg)
QT
• Congenital diseases
ST
• Conduction disturbances T
U

V
Conduction System of the Heart
 Sino-atrial blocks

 Atrial blocks

 Atrio-ventricular blocks

 Bundle branch blocks

Criteria:
 There must be P waves

 There
must be one P wave to each QRS
complex

 P-R interval is constant

 P-R interval is prolonged (i.e. >0.20 sec.)

First degree AV block
Criteria:
 there must be P waves

 there must be QRS complexes

 progressiveprolongation of P-R interval

with each succeeding beat until there is a
dropped beat
 longest
P-R interval is the one
immediately before the dropped beat

 shortestP-R interval is the one

associated with the first conducted
beat after the dropped beat
2º Type I AV Block (Wenkebach)
Criteria:
 there must be P waves & QRS complexes

 P-R
interval of conducted beats may be
normal or long then there is a dropped beat
Mobitz Type II

 failureof conduction is not seen in relation to

two or more consecutive P waves

 P-Rinterval must be constant for all

conducted beats

 QRS complexes after the transient AV

conduction failure have the same morphology
as those preceding it
Mobitz Type II 2º AV Block
Criteria:
 no consistent or meaningful relationship
between atrial and ventricular activity

 QRS may be normal in shape, duration

and axis but more often are abnormal

 form
of QRS complexes is usually
constant
Third degree...

 QRS rate is usually constant and lies

within the range of 15-70 beats/min.

 Any form of atrial activity may be seen or

there may be no atrial activity
Third degree AV Block
Bundle branch blocks
rhythm

rate
axis
P
PR
Q P
QRS
QT
ST

T
U

V
Criteria for Right-Bundle-Branch Block

• Lead V1 Late intrinsicoid, M-shaped QRS (RSR²);

sometimes wide R or qR
• Lead V6 Early intrinsicoid, wide S wave
• Lead I Wide S wave
Right bundle branch block
rhythm

rate
Conditions associated with right bundle branch
block axis
P
PR
• Rheumatic heart disease
Q P
• Cor pulmonale/right ventricular hypertrophy
QRS
• Myocarditis or cardiomyopathy
QT
• Ischemic heart disease
ST
• Degenerative disease of the conduction system
T
• Pulmonary embolus
U
• Congenital heart disease – i.e. atrial septal defects
V
Criteria for Left-Bundle-Branch Block rhythm

rate
axis
P
 Lead V1 QS or rS PR
 Lead V6 Late intrinsicoid, no Q waves, Q P
monophasic R QRS
 Lead I Monophasic R wave, no Q QT
ST

T
U

V
CLBBB
Significance of Left bundle branch block
rhythm

rate
axis
• Left bundle branch block is most commonly P
caused by PR
• coronary artery disease Q P

• hypertensive heart disease, or QRS

QT
• dilated cardiomyopathy
ST

T
• It is unusual for left bundle branch block to
U
exist in the absence of organic disease
V
 rhythm
QT interval
rate
axis
• corresponds to “electrical systole” P
• is a function of heart rate PR
• corrected using Bazett’s equation: Q P
QRS
• QT corrected = QT actual /  RR QT
ST

T
U

V
 rhythm
QT interval
rate
axis
P
PR
Q P
QRS
QT
ST

T
U

V
Causes of prolonged QT interval rhythm

rate
axis
• Hypocalcemia
P
• Ischemia
PR
• Inflammation
Q P
• Arrhythmias
QRS
QT
ST

T
U

V
T wave changes
rhythm

rate
HYPERKALEMIA
axis
P
• At least ≥ 2 contiguous leads with peaked T waves ≥
PR
10mm (1.0 mV)
• Read as peaked T waves, T/C hyperkalemia Q P
QRS
QT
ST

T
U

V
U wave changes
rhythm

rate
axis
• “u” wave prominent + normal T wave → read as prominent ‘u’
wave P

• prominent ‘u’ wave + flattened T wave →read as T/C PR

hypokalemia Q P
• ST segment depression + ‘u’ wave + normal T wave →read as QRS
cannot rule out ischemia Prominent ‘u’ wave QT
• Flattened T waves + normal QRS complex →read as non-specific ST
ST T wave changes
T
U

V
U wave changes
rhythm

rate
axis
P
PR
Q P
QRS
QT
ST

T
U

V
Ventricular hypertrophy
rhythm

rate
LEFT VENTRICULAR HYPERTROPHY
axis
P
• S in V1 + R in V5 or V6 > 35mm (Do not use S in V2)
PR
OR aVL > 11mm
Q P
or QRS
QT
• S in V3 + R in aVL ST
Female : ≥ 20mm
T
Male : ≥278mm
U

V
`
13 X 2

S in V1 + R in V5 or V6 > 35mm
20 X 2 LEFT VENTRICULAR HYPERTROPHY

Sinus rhythm, normal axis, left ventricular hypertrophy

Ventricular hypertrophy
rhythm

rate
RIGHT VENTRICULAR HYPERTROPHY
axis
P
• RAD + R/S ratio>1 in V1 +R/S ratio < 1 in V6
PR
Q P
QRS
QT
ST

T
U

V
Answer: B. LAE, RAE, RVH

RVH
Supraventricular Arrhythmias
SINUS ARRHYTHMIA
 Variation in the P-P interval (and R-R
interval) > 120 msec
 P waves normal and unchanging

2 Types:
A. Phasic- respiratory variation
(heart rate faster on inspiration,
slower during expiration).
B. Non phasic- not influenced by
respiration.
Premature Atrial Complexes (PAC)
with normal conduction
1. A premature P wave with an abnormal P
axis and/or morphology.
2. Normal QRS morphology
3. A compensatory pause may follow PACs:
a. If full, the SA node is not reset.
b. If not full, the SA node is reset.
Premature Atrial Complex
Junctional Rhythm
 Analysis of SVT

1. P wave axis and morphology

2. P wave regularity (QRS regularity)
3. Atrial rate
4. P-QRS relationship (P-R and R-P
intervals)
 Criteria for Diagnosis of Atrial Flutter

1. Uniform, rapid, continuous undulating

deflections of baseline with a characteristic
saw-toothed appearance and absence of
the isoelectric interval between
consecutive P waves.

2. The P waves are best seen in leads II, III,

AVF and V1.
Atrial Flutter…

3. Atrial rate is approximately 300/min (220-

350/min).

4. Ventricular rate is usually 150/min with a

2:1 or 4:1 AV nodal conduction.

5. Usually normal QRS complex.

Atrial Flutter
Criteria for Diagnosis of Atrial Fibrillation

1. Absent normal P wave.

2. Irregular or random oscillations of the

baseline.

3. Irregularly irregular R-R cycles with normal

QRS morphology .
Atrial Fibrillation
ISCHEMIA, INJURY &
INFARCTION
 Sensitivity& Specificity of ECG
for Ischemia & MI

INITIAL ECG

 diagnostic of acute MI in approximately 50%

 abnormal but not diagnostic in approx. 40%

 normal in about 10%.

***Serial tracings increase the sensitivity to near

95%
ECG changes associated with ischemia,
Injury & infarction
Evolution of changes in MI
Myocardial ischemia
Criteria:
1. Symmetrical T wave inversion on
leads overlying involved areas

2. ST depression either on resting or

exercise ECG
a. At least 1.0 mm (0.10 V) depression at the J point
lasting at least 80 msecs
b. Horizontal or downward slope toward the end of ST
segment at its junction with the T wave
ST changes associated with ischemia
Myocardial Infarction

Criteria:
1. Development of new Q waves on
areas overlying the infarct which is:

a. >0.04. secs duration

b. >25% of the height of associated
R wave
Significant Q wave
Contiguity of leads rhythm

rate
High axis
lateral
P
PR
Q P
QRS
QT

ST

T
U

V
Contiguity of leads rhythm

rate
axis
P
PR
Q P
QRS
QT

ST
Inferior
wall T
U

V
Contiguity of leads rhythm

rate
axis
P
septal PR
wall
Q P
QRS
QT

ST

T
U

V
Contiguity of leads rhythm

rate
axis
P
PR
Q P
QRS
QT

ST
anterior
wall T
U

V
Contiguity of leads rhythm

rate
axis
P
PR
Q P
QRS
QT
lateral
wall ST

T
U

V
Anterior wall MI
Anterolateral wall MI
Inferior wall MI
Ventricular Arrythmias
Premature Ventricular Contractions

 comes from an automatic focus within

the ventricle
 associated with an existing cardiac
disease or drug intoxication
 signal development of a more ominous
and fatal arryhthmias
General Features of PVCs

 QRS duration is usually > 0.1. sec.

(wide QRS)
 QRS complex appears bizarre and
notched
 ST segment and T wave are usually
displaced in the direction opposite the
main deflection of the QRS complex
General Features of PVCs

p waves may precede, be hidden or

follow the QRS complex
 a long, compensatory pause follows the
PVC
 PVCs have a greater amplitude than
normal QRS complexes
Premature Ventricular Contractions
Variations of PVC Patterns
Interpolated PVCs - no compensatory
pause when the sinus rhythm is slow
Variations of PVC Patterns

Bigeminy
Variations of PVC Patterns
Trigeminy
Variations of PVC Patterns
Quadrigeminy
Variations of PVC Patterns
Multifocal PVCs
caused by several ventricular ectopic foci
variable morphology in a single lead
Variations of PVC Patterns

couplets : 2 consecutive PVCs

Variations of PVC Patterns
Triplets : 3 consecutive PVC’s
Ventricular Tachycardia

 run of more than 3 PVCs in rapid

succession
 rate : 140 - 220 beats / min
 slightly irregular rhythm
 indicative of serious organic heart
disease or drug (digitalis or quinidine)
intoxication
Ventricular Tachycardia
Ventricular Arrythmias
Ventricular Fibrillation
 originates from numerous ventricular
foci firing at the same time
 results in irregular twitching of the
ventricles
 totally irregular appearance on the
tracings
 cardiac contractions are ineffective
 virtually no cardiac output
Ventricular Fibrillation
Ventricular Flutter

 produced by a single ventricular focus

 rate : 200 - 300 / minute
 cardiac contractions are useless
 invariably deteriorates to ventricular
fibrillation
Ventricular Flutter
Paced Rhythm Recognition

DDD / 60 / 120
Paced Rhythm Recognition

DDD / 60 / 120