ECG Abnormalities Compilation

This summary of ECG abnormalities is part of the almostadoctor ECG series. For a more in depth explanation of ECG
abnormalities, see ECG abnormalities. To learn about the basic principle of an ECG, see Understanding ECGs

Abnormality ECG sign Seen in Pathology

Sinus rhythm regular p waves, and each p All leads None

wave is followed by a QRS. (best to look
60-100bpm at the
rhythm strip)

Sinus Tachycardia Same as above, except All leads Does not represent
>100bpm (best to look cardiac patholoy. May be
at the a sign of anxiety,
rhythm strip) dehydration, recent
exercise, or general illness
(e.g. sepsis, pneumonia,
respiratory pathology,
other illness)

Sinus bradycardia Same as above except All leads This is normal in young fit
<60bpm (best to look people
at the
rhythm strip)

Right ventricular hypertrophy Negative QRS Lead I Because the cardiac axis
has shifted from 11-5
o’clock to 1-7 o’clock, thus
lead I which measures
laterally from right to left
now gets a negative
signal because the signal
is going from left to right.
This axis shift is called
right axis deviation.

Right ventricular hypertrophy Taller QRS Lead III – Because lead III measures
becomes vertically but also slightly
taller than left to right, and this is
lead II pretty much the exact
direction of the new shifted
axis. Lead II, measuring
from right arm to left leg is
no longer lined up as well.
This axis shift is called
right axis deviation.

Transition point moved to Equally

the left – equal sized R and sized R and
S (normally seen in V3/V4) S now
seen in
V5/V6
Left Ventricular Hypertrophy Small lead I QRS, Leads I-III Left axis deviation –
negative leads II and lead this is often the results of
III QRS a conduction defect, and
not an increased bulk of
left ventricular tissue.

1/8
 Atrial fibrillation Absent P waves – just an some? As well as no p waves,
irregular baseline. the rhythm will be
irregularly irregular. There
Irregularly Irregular, irregular Rhythm will be a fibrillating
QRS (but QRS is normal strip baseline due to
shape) uncoordinated activity.
The causes of
Might look messy! E.g. Generally atrial fibrillation
are:
1. Ischaemic
heart disease
2. Thyrotoxicosis
(hyperthyroidism)
3. Sepsis
4. Valvular
heart disease
5. Alcohol excess
6. PE

Note that AF can also

co- exist with complete
heart block, in which
case the QRS will be
regular!
Atrial Flutter Tachycardia Rhythm There will be saw tooth p
strip waves that occur at
300bpm, but the QRS
Can’t tell if T/P waves are Lead where complexes will only be at
present – rhythm is too fast p waves are 150, 100 or 75 bpm due to
(250bpm). Often most easily various blocks. The QRS
associated block; i.e. there visible – can be regular or irregular.
are QRS complexes at a you should It can be very difficult to
lower rate than the p waves use drugs see t waves – what looks
to slow like a T wave will probably
down the just be a p wave. The p
heart rate waves occur at very
to see what regular intervals.
is going on

Atrial tachycardia >150bpm, p waves Any where p Caused by a foci of the

superimposed over t waves are atria (outside of the SA
waves of preceding beat, best seen node) depolarising quickly
normal QRS

Junctional tachycardia P waves very close to Anywhere Due to a ‘re-entry’ loop;

QRS, or no QRS visible. there is an area of
QRS is normal depolarisation near the
AV node; this not only
transmits a signal
throughout the rest of the
ventricles to depolarise
them

1st degree heart block PR interval >0.2s (one Allover – This is an AV node block
big square) best in I or Can be caused by CAD,
V1 acute rheumatic carditis,
digoxin toxicity, or
electrolyte disturbance
It is NOT an
medical
1st Degree Heart Block emergency

2/8
 2nd degree heart block Progressive lengthening Anywhere This can be an AV node
Mobitz type 1 – Wencebach of the PR interval followed block (nearly always), or
by absent QRS, then cycle an SA node block.
repeats. Cycles are usually benign and
variable in length. R-R generally doesn’t require
Mobitz type 2 interval shortens with specific treatment. can be
lengthening of PR interval caused by CHD or acute
MI.
It is usually symptomless,
but can present with:
2:1 and 3:1 conduction –Dizziness / light-
headedness / syncope
Absent QRS every now and Anywhere This can be an SA node
again block, or far more
commonly infra-Hisian
block (distal block). It
can progress to
complete heart block,
from which there is
often no escape
rhythm; and thus this
needs treatment! the
definitive treatment is an
implanted pacemaker.
Can be caused by CHD
or MI
This is the ratio of P:QRS Anywhere May require a pacemaker,
particularly if the rate is
slow

Complete (third degree) heart block 90 P waves/min, only about Best in II This is an AV node
38 QRS/min, and not and V1 block.
relationship between the P Atrial activity will be
waves and the QRS completely normal, but
complexes. QRS will often this conductivity does not
have an abnormal shape, pass into the ventricles.
and be broad (>120ms). This always indicates
However, the P-P intervals underlying disease – the
will be regular, as will the R-R disease is often fibrosis
intervals – they are just not rather than ischaemia, but
in time with each other. The it can occur in MI.
rhythm of the ventricles is the
escape rhythm.

3/8
RBBB – right bundle branch block ECG may appear normal. These are infra-Hisian
In some people there may blocks. In bundle branch
be 2 R waves. This creates blockages, the wave of
a distinctive pattern: depolarisation can still
V1 – there is an M reach the IV septum,
shaped QRS – this is then the PR interval will
sometimes called an RSR be normal – and it is.
pattern However, the time
V6 – there is a W taken for the
shaped QRS depolarisation to
Wide QRS (120ms) spread throughout the
ventricles is longer –
LBBB – left bundle branch block V1 – there is an W
thus QRS complex
shaped QRS
duration is
V6 – there is a M
lengthened.
shaped QRS
In the acute setting it may
Wide QRS (>120ms)
be caused by MI
The axis can be deviated
RBBB – may indicate right
either way in BBB’s, but it is
sided disease. The two R
most commonly normal
waves indicate the
depolarisation of the right
and left sides of the heart
at different times (the
right depolarises after the
left).
You can remember the
pattern with the word
MarroW – there is M in
V1, and W in v6, and the
‘rr’ tells you it is on the
right!
There is NOT specific
treatment, and it is often
caused by an atrial septal
defect.
In the acute setting it may
be caused by MI
LBBB – often indicates
left sided heart
disease. Remember
the pattern with
WillaM.
Causes:
Aortic stenosis, dilated
cardiomyopathy, acute
MI, CAD
Symptoms:
Syncope, and in more
severe cases; heart
failure. Those with
syncope and / or
heart failure will
usually be treated
with a pacemaker.

Sinus bradycardia Normal rhythm <60bpm Anywhere Associated with; athletic

training, fainting,
hypothermia, myxedema
(hypothyroidism), seen
immediately after MI

Sinus Tachycardia Normal rhythm >100bpm Anywhere Associated with; exercise,

fear, pain, haemorrhage,
thyrotoxicosis

Supraventricular rhythms This is any rhythm that Examples include:

originates outside the –Sinus rhythms
ventricle –LBBB
–RBBB

4/8
 Ventricular Wide QRS complexes Anywhere
rhythms (aka escape
rhythms) Atrial Abnormal p wave (e.g. Anywhere This occurs when the SA
escape Junctional inverted) node fails to
escape Ventricular Normal depolarise. Instead,
escape QRS some other part of the
Accelerated idioventricular rhythm Some normal beats after the atrium depolarises and
abnormal one sends the signal to the
ventricles.
No p The escape occurs
waves somewhere at the AV
Normal junction. It occurs when
QRS the rate of depolarisation
Slightly slow rate (max of the SA node falls below
75bpm) the rate of the AV node,
thus the AV node starts
the beat instead. The
resulting bradycardia
reduces cardiac output
and can cause
symptoms similar to
other bradycardias
such as:
–Dizziness
–Light-headedness
–Syncope
–Hypotension
Usually the bradycardia
can be tolerated as long
as it is above 50bpm

Two types: Somewhere along the line

–Many p waves per QRS the p waves isn’t getting
(complete heart block) conducted to the
–Occasional missing p wave, ventricles, and thus the
followed by long gap, and ventricles depolarise at
then a ventricular QRS, then their normal escape rate.
normal rhythm

Wide QRS Don’t confuse this with

Rhythm of about ventricular tachycardia
75bpm – which requires a HR of
No p waves >125pbm. Otherwise it
Abnormal T looks very similar.
waves Usually benign and
does not need to be
treated. Also associated
with MI
Extrasystoles These are easy – they are the same as ventricular escapes, except
(aka ectopics) that where in escapes the escape beat comes after a pause in the
rhythm, in extrasystole, there is an abnormal beat earlier than
expected.
The QRS complexes are the same as those of sinus rhythm, but there
are usually abnormal p waves that tend to come immediately before or
immediately after the QRS.
Inferior MI ST elevation II, III, aVF The ST elevation in these
(probably the right coronary artery) (the leads is often
inferior accompanied by ST
leads) depression in the
antero- lateral leads –
V1-V6, and possibly in
lead I and aVL

Anterior MI ST elevation V2-5 – the This will also cause deep

(probably the left anterior anterior q waves. The presence
descending) leads of Q waves implies a full
thickness infarction.

5/8
 Posterior MI ST depression, tall R V1-V3 Posterior MI is
waves unusual! The changes
that occur are opposite
to the changes of
other type of MI. thus
the tall R waves are the
opposite of Q waves
(remember Q waves are
negative), and ST
depression occurs in
place of ST elevation
ST elevation ST elevation >2mm in 2+ T wave Both factors, if they occur,
MI (STEMI) chest leads OR >1mm in inversion are usually permanent. In
2+ limb leads, occurs a full thickness
T-wave inversion (after within a few infarction then there are
several hours) hours of MI, pathological Q waves,
Pathological Q waves (24 pathological and T wave inversion,
hours +) Q waves but in a non-full
occur thickness MI then there is
several days only T wave inversion.
after initial The differentiation
MI between full /thickness
and non full thickness is
pretty much the same as
NSTEMI Pathological Q waves only ST elevation / non-ST
elevation

Ventricular tachycardia Wide QRS, no p waves, ? Can be difficult to

T waves difficult to differentiate from BBB.
identify, rate >200bpm BBB has p waves, and a
QRS generally 120-160ms.
VT is more likely scenario
after MI, and has QRS
>160ms

Supraventricular tachycardia Narrow QRS

Ventricular fibrillation No discernable pattern, Patient is very likely

no QRS, no P, no T to lose
consciousness –
thus the diagnosis is
easy!
Wolff-Parkinson-White SYndrome Delta waves present, right Accessory pathway,
axis deviation, short PR usually from the left atria
interval, short QRS to the left ventricle allows
direct transition of the
signal, bypassing the AV
node, hence the
shortened PR interval. It
has a risk of mortality
as it can cause re-entry
tachycardia; however,
most patients are
symptomless and live with
no problems.

6/8
 The digoxin effect Depression of ST, inverted T widesprea This causes a sloping ST
waves d segment that has a
‘reversed tick’ look. This
occurs because digoxin
blocks the na/K pump,
which increases
intracellular Ca2+
concentrations. (similarly,
ischaemia causes
reduced production of
ATP, and thus reduced
pump activity)

Pericarditis T wave inversion (rare: also Widesprea If ST elevation does

ST elevation) d occur, then the ST waves
will appear ‘saddle
shaped’ thus helping you
to differentiate it from MI.
also, the elevation in MI
tends to be confined to a
certain area, but in
pericarditis, it is
widespread

P pulmonale Tall ,peaked T waves, p Lead II Seen in cor pulmonale,

wave height >2mm in or pretty much anything
lead II that causes right atrial
enlargement (or
hypertrophy) – such as
tricuspid stenosis or
pulmonary hypertension

Bifid P waves (‘P-Mitrale’) P waves with two peaks, ? Left

broad – looks like an ‘M’; ventricular
hence the name ‘Mitrale’ hypertrophy

Bi-phasic T waves T waves with t peaks Can occur as a result

of MI

Prolonged QT interval Prolonged QT The corrected QT, is the

QT interval as it would be
at 60bpm. if this is long,
then there is a risk of
sudden cardiac death. It
can be congenital, but
also caused by drugs

Hyperkalaemia Wide, tall, ‘tented’ T ? Can lead to VF and AF

waves, shortened/absent ST
segment, small or absent p
waves, wide QRS

Left ventricular hypertrophy S wave in V1 or V2 >35mm AND R wave in V5 or V6

>35mm R in aVF >20mm
R in aVL
>11mm
Any chest lead >45mm
R in lead I >12mm

Pacemaker Occasional P waves, not ? The large spike is

related to QRS, QRS pacemaker stimulus. The
precede by large spike, QRS’s are wide because
QRS complexes broad the stimulus originates in
the ventricles

Axis deviation

7/8
 Lead I Lead II Axis

+ + Normal

+ – LAD

– Either RAD

aVR should always be negative!

If it is positive, it is called north-west axis. it could be due to incorrect limb lead placement, dextrocardia, or artificial
pacing, due to the pacemaker wire – this enters the heart at the apex.
Carotid sinus pressure
By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via vagal stimulation. This will
reduce the frequency of discharge of the SA node, and increase the time of conduction across the AV node.
Thus, by applying pressure to the carotid sinus you can:
Reduce the rate of some arrhythmias
Completely stop some arrhythmias
It will have NO EFFECT ON VENTRICULAR TACHYCARDIAS – thus is can help you differentiate these from
supraventricular tachycardias (SVT)

Applying the pressure reduces the frequency of QRS complexes, and allows the underlying atrial arrhythmia to
become more visible.

8/8