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A Crash Course On ECG

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120 views100 pages

A Crash Course On ECG

--

Uploaded by

2try7xydhd
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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A Crash Course on ECG

David Yang, M.D.


Dept. of Cardiovascular Medicine
1st Affiliated Hospital of Sun Yat-Sen
University
Nov. 14th, MMXVII
OUTLINE

Review of Normal ECG


The Seven-Step Plan
What does the ECG register?
Electrical activity of
the heart
ECG represents the
sum of the action
potentials of millions
of cardiomyocytes.
Important Concepts
Conduction system (SN node, AV node, the
Purkinje system) vs. Working cells
(cardiomyocytes)

Atria and Ventricles: Anatomical continuity and


electrical insulation (conduction via AV node only)
ECG Leads

Limb/Extremity Leads: I, II, III, aVR, aVL, aVF


Chest/Precordial Leads: V1 – V6
RV Leads: V3R – V5R
Posterior Leads: V7 – V9
ECG Electrodes
Normal Limb Leads
Augmented Limb Leads
Chest / Precordial Leads
Lead Connections (1)
Lead Connections (2)
Lead Vectors
Frontal & Horizontal Planes
The Hexaxial Ref System

@Frontal Plane
Electrical Axis: direction of
activation of the “average”
cardiac fiber
Determined by properties of:
Conduction system
Myocardium
Anatomy  Electrophysiology
PQRST ORIGIN
Sinus Rhythm (flash)
http://nl.ecgpedia.org/images/0/09/Normal_SR.swf
Nomenclature of the QRS Complex
Q: the first negative deflection after the p-wave. If the first
deflection is not negative, the Q is absent.

R: the positive deflection

S: the negative deflection after the R-wave

Small print letters (q, r, s) are used to describe deflections of


small amplitude, e.g. qRS = small q, tall R, deep S.

R’: is used to describe a second R-wave (as in RBBB)


Normal ECG
Normal ECG Intervals
Heart Rate: 50 – 90 bpm
P wave duration: < 0.12 sec
PR Interval: 0.12 – 0.20 sec
QRS Interval: 0.11 – 0.12 sec
QTc: 0.45 sec in M; 0.46 sec in F
QRS axis: - 30 to + 90 degrees
Any questions so
The Seven-Step Plan
Rate
Rhythm
Axis
Conduction
Morphology
Comparison
Conclusion
STEP 1. Rate
Normal Rate: 60-100 bpm

Normal Rate:50-90 bpm


The Large Grid Rule
HR=300 / [RR in “large box” unit]
What is the heart rate?

HR=300/6=50 bpm
What is the heart rate?

HR=300/4=75 bpm
What is the heart rate?

HR=300/1.5=200 bpm
The 6 Second Rule
HR=[Number of QRS in 6 sec]*10
What is the heart rate?

33 QRS complexes in 10 sec


HR=33*6=198 bpm
Factors Affecting HR
Para-/Sympathetic System
Sym.(+): Fight or Flight
Vag. (+): Feed or Breed
Cardiac filling
Arrhythmias
Step 2. Rhythm
Normal Sinus Rhythm?
If not  Arrhythmia Algorithm
Criteria for Sinus Rhythm
A sinus P wave* precedes every QRS complex
Regular, but varies slightly during respirations
HR ranges between 60-100 bpm (OR 50-90 bpm)

* Sinus P wave morphology:


Maximum height at 2.5 mm in II and/or III
Positive in I and II, and biphasic in V1
Arrhythmias
Tachyarrhythmias

Sinus Tachy
Narrow QRS Tachy
Wide QRS Tachy
Bradyarrhythmias

Sinus Brady
AV Block
Escape Rhythms
Step 3. Axis
Vectors: Ups and Downs…

Predominantly Predominantly Equiphasic


Positive Negative
The Quadrant Approach
(1) Lead I, aVF  (2) Lead
II
LAD: Left axis
deviation
RAD: Right axis
deviation
Rationale
Lead I↓; Lead aVF↑ 
Lead I ↑; Lead aVF ↓  Lead II ↑  Normal
The Equiphasic Approach

The direction of the


lead perpendicular
to the equiphasic
lead.
〓 Lead: aVF  ⊥Lead I ↑ ∴ Normal Axis
(QRS≈0⁰)
〓 Lead: II  ⊥Lead aVL ↑ ∴ Extreme RAD
Let’s take a
Step 4. Conduction
PR(PQ) Interval
Atrial Depol.  Ventricular Depol.
Normal range: 0.12~0.20 sec
PR Prolongation:
Atrioventricular (AV) Block
PR Shortening:
+Delta wave  Pre-excitation syn. (WPW Syndrome)
1st Degree AV Block

PR Interval >0.20
sec
2nd Degree AV Block Type 1 (Wenckebach)

PR interval progressively lengthens, until the drop-


out of one QRS complex.
2nd Degree AV Block Type 2 (Morbitz)

QRS drops out irregularly w/o PR prolongation.


Type 1 vs. Type 2 2nd Degree AV Block

Type 1: Type 2:
Block @AV node Block distal to AV node
Relatively benign Pacemaker indicated
3rd Degree (Total) AV Block

P and QRS has no temporal


relationship.
WPW Syndrome

↓PR Interval
Delta Wave
QRS Interval
Ventricular Depol.
Normal Range < 0.12 sec
QRS Prolongation (widening): check V1
LBBB ： neg terminal deflection (rS)
RBBB ： pos terminal deflection (rSR)
Intraventricular Conduction Delay: neither
Left Bundle Branch Block

New LBBB ??
Rule out acute MI st!
Right Bundle Branch Block

“The Rabbit
QT Interval
Ventricular Depol.  Repol.
Vary according to HR: Corrected QT (QTc)
Normal range: <450 msec for M; <460 msec for F
QTc Prolongation (Risk of Tdp; esp. when >500 ms)
Hypokalemia; Post-MI; long QT syn.; meds

QTc Shortening
Short QT syn.
A. Long QT syndrome; B. Torsades de
Pointes
Step 5. Morphology
(Sinus) P Wave Morphology
Upright in II 、 III 、 aVF
Amplitude <2.5 mm
Duration <0.12 sec
Atrial
Enlargement
RA Enlargement:
P > 0.25 mV
P Pulmonale
LA Enlargement:
P > 120 ms; notched in II,
biphasic in V1
P Mitrale
QRS Morphology

Pathological Q Wave
LV Hypertrophy
Microvoltages
Tachyarrhythmias
Narrow / Wide QRS Tachy
Pathological Q Wave

Sign of prior MI
Absence of electrical activity
Hours to days to develop
May disappear if stunned
myocardium is reperfused early
Persists indefinitely
Pathological Q Wave
Old Definition: duration >0.04sec; amplitude > ¼ R

New Definition (per Universal Definition of MI)


Duration >=0.02 sec or QS morphology in V2-V3
Duration >=0.03 sec with amplitude >0.1mV or QS
morphology in two contiguous other leads
R wave >= 0.04sec AND R/S>1 w/ upright T wave
in V1-V2, in the absence of BBB
LV Hypertrophy
Clinical significance: ↑LV afterload
e.g. HTN, AS, etc.
Sokolow-Lyon criteria
RV5 + SV1
> 40mm (M)
> 35mm (F)
Microvoltages
QRS Amplitude (R + S) ：
<5 mm in Limb Leads
<10 mm in Chest Leads

Clinical Significance: COPD, pericardial


effusion/temponade, obesity,
(infiltrative/restrictive) cardiomyopathies.
Let’s take a
Tachyarrhythmias

Narrow QRS Tachy


Wide QRS Tachy

* Physio Limit of Sinus Tachy: 220 - age


Mechanisms of Arrhythmias
Impulse Formation Conduction
Automaticity Delay / Aberrancy
Triggered Activity Re-entry
Re-entry
DDx for Narrow QRS Tachy
DDx for Wide QRS Tachy
Sinus Tachy
Clinical feature: gradual onset
ECG feature: P-QRS ， >100 bpm
Supraventricular Tachy
Clinical feature: on-and-off phenomenon
ECG feature: absence of P wave before narrow QRS; HR
150-250 bpm
Atrial Flutter

Clinical feature: palpitations; rarely causes


hemodynamic compromise
ECG feature: sawtooth-shaped F wave in place
of P wave; regular rate, AR 250-350 bpm, VR
75, 100, 150 bpm (depending upon AV
conduction)
Atrial Fibrillation

Clinical feature: palpitations; systemic


embolism (e.g. stroke/TIA)
ECG feature: f wave in place of P wave (most
prominent in V1); irregularly iregular rate: AR
400-600 bpm; VR
Ventricular Tachy
Clinical feature: palpitation; could lead to
hemodynamic compromise (∴ ”malignant”)
ECG feature: wide QRS complex, VR 110-250 bpm;
AV dissociation, fusion beats, concordance in
precordial leads; Brugada /Vereckei criteria
Monomorphic VT
Clinical feature ： palpitation; could lead to
hemodynamic compromise (∴ ”malignant”)
ECG feature: wide QRS complex of the same
configuration; VR 110-250 bpm
Polymorphic VT
Torsades de Pointes, Tdp
Clinical feature: 2nd to QT prolongation
ECG feature: mostly initiated by a short-long-short
interval; heart axis twisting around baseline
Ventricular Flutter
Clinical feature: hemodynamic compromise
ECG feature: regular flutter wave (“sine”
wave) due to circular depol., VR 150-300 bpm;
quickly deteriorates into Vfib
Ventricular Fibrillation
Clinical feature: hemodynamic compromise
ECG feature: irregular fib waves due to chaotic
depol., VR 400-600 bpm; requires immediate
defib
Narrow QRS Tachy vs. Wide QRS Tachy

Sinus
DDx by Tachy
hxn Ventricular Tachy
Monomorphic
“Supraventricular Tachy
Horizontal Entrance” Tdp
AVNRT
Elderly, with prior MI: VT possible
Walking
AVRT into ER Ventricular FL / Fib
Young, hemodynamically stable: SVT possible
Atrial FL / Fib
When you can’t ddx VT from SVT, treat as VT!
ST Segment Morphology
ST Elevation: Convex vs. Concave
Contiguous Grouping
Step 6. Comparison

Compare w/ previous ECG (Extremely


Important!)
New LBBB/ pathological Q wave
Axis deviation
Increase/decrease in R wave amplitude
Step 7. Conclusion

Summary
ECG Description
Clinical Diagnosis
Let’s have a try.
ECG Description & Clinical Diagnosis

ECG Description: HR 100 bpm, sinus


rhythm; ST elevation for 0.2-0.3mV in II, III,
aVF, with ST depression in I and aVL.

Clinical Diagnosis: STEMI (inferior wall)


The 7-Step Plan
Rate
Rhythm
Axis
Conduction
Morphology
Comparison
Conclusion
谢谢 ！多謝曬 ! Thank You !
Merci ! Gracias !Danke !
Grazie ! Спасибо !Σε
ευχαριστώ !

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