Dr.

saif darif medicine 2013

ECG

ECG (Electro Cardio Gram)

(Electro- from electric, Cardio means heart & Gram Means a drawing)

ECG (Electro Cardio Gram)

1|Page dr saif darif

Dr.saif darif medicine 2013
Its medical method in which the electrical activity of the heart can drawing graphically on paper

 The electrical activity of the heart:-

- The depolarization & repolarization of cardiac tissues (muscle & conducting system).
- Then the electrical activity of the heart reaches the-body surface, it’s-measured by electrode of
the ECG machine positioned on the skin.

Leads: - There is 12 different standard leads used in E.C.G machine (6 frontal & 6 horizontal).
The leads: - it’s the reading of vector (direction of electricity) in two different points results in
6 Frontal (limb) leads Bipolar leads ( I, II, III) & Augmented limb leads unipolar (AVL, AVR, & AVF).

This are 6 frontal limb leads (bipolar & unipolar)

bipolar limb lead unipolar limb lead
Lead I Right arm (negative) Left arm (positive ) AVR heart (negative) Right arm positive
Lead II Right arm(negative) Left leg (positive ) AVL heart (negative) Left arm positive
Lead III Left arm (negative) Left leg (positive ) AVF heart (negative) Left (L.L) positive

Precordial Leads (Unipolar leads):- 6 Horizontal (precordial) leads (V1-V6)

 V1 Right sternal margin at 4th intercostal space.

 V2 Left sternal margin at 4th intercostal space.
 V3 Midway between V2 and V4.

2|Page dr saif darif

Dr.saif darif medicine 2013
TH
 V4 Left midcalvicular line at 5 intercostal space.
 V5 Left anterior axillary line at 5th intercostal space.
 V6 Left midaxillary line at 5th intercostal space.

How ECG is drawn?

 The shape of the ECG depends on:-

1.Speed and calibration of the ECG machine.

The calibrations The Paper speed

Each vertical 10 mm (2 large square) = 1 mv Each horizontal 25 mm per second SO :-
So Each vertical small square (1mm) = 0.1 mv. Each horizontal small square (1mm) = 0.04 sec.
EACH vertical large square (5mm) = 0.5 mv. Each horizontal large square (5mm) = 0.2 sec.

Note: - By the (X-axis in the ECG is the time) & (the Y axis is the amplitude), which depends on the
magnitude of the wave:-
 More powerful contraction (hypertrophy)  higher amplitude.
 Longer time in transmission longer interval.

2.The Relationship between Lead vectors and Cardiac vectors which depends on:-
 The direction of the depolarization: .
A. Depolarization towards recording electrode  positive deflection (+ve wave).
B. Depolarization away from electrode  negative deflection (-ve wave).

3|Page dr saif darif

Dr.saif darif medicine 2013

Important definitions:-
 Waves: - (positive deflection or negative deflection) in ECG represent electrical activity.
 Isoelectric line:- represents no any electrical activity.
 Segments: - distance between to wave & not including any waves.
 Intervals: - distance between to waves but including at least one wave.

The ECG is composed of 3 waves, 2 segments & 3 intervals.

Waves 1. P wave: - represents atrial depolarization.
2. QRS waves: - represents-ventricular depolarization.
3. T wave: - represents ventricular repolarization.
Segments 1. PR segment: - represents the delay at the AV node.
2. ST segment: - represents time at which the ventricles remain depolarized.
Note: - normally segment is isoelectric.
Intervals 1. PR interval: - beginning of the P wave until the Beginning of the QRS complex.
2. RR interval: - distance between two successive R waves. (Inversely proportion
with heart rate).
3. QT interval: - from beginning of Q wave to end of T wave. (Represents
depolarization & repolarization of ventricles.

Extra U wave: - considered abnormal occur after T wave (in hyperkalemia).

Note: - atrial repolarization occurs at the same time of ventricular depolarization which
Is of greater electrical power and masks the atrial repolarization).

Note: -
PR segment extends from the end of P wave until the beginning of the QRS Complex
PR interval extends from the beginning of the P wave until the Beginning of the QRS complex.

QRS drawing
 The first deflection 'is downward it is called Q wave.
 If the first deflection is upward it is called R wave either it was preceded by Q wave or not.
 The any downward deflection after the R wave is called S wave.
 An upward deflection after the. S wave is called ( R ' ) , which indicate abnormality (e.g. RBBB).

4|Page dr saif darif

Dr.saif darif medicine 2013
ECG interpretation
 Steps of ECG interpretation:-

1. Name & Date.

2. Speed & Calibration.
3. Rhythm (Sinus or not), (regular, irregular).
4. Rate.
5. Axis.
6. Waves and Intervals. (P wave, PR interval, QRS Complex, ST segment, T wave).

 Speed and Calibration:-

• Time is on the horizontal axis while Voltage is on vertical axis.
• Usual speed is: - 25mm/s.
- ECG paper has small & large squares
- Small square = 1mm
- Each large square contains 5 small squares = 5 mm.
- 1 large square = 0.2 sec.
- 1 small square = 0.04 sec.
- 1 minute Have 300 large squares or 1500 small squares.
• Calibration is usually 1mv = 10 mm.

 Rhythm :- (sinus or not, regular or not).

The aim is to tell if the rhythm is sinus or not. [Sinus rhythm means that the electrical
Activity of the heart starts from the SAN.
Characteristics of sinus rhythm
1. Each one P-wave is followed by QRS.
2. P waves in leads I & II is upward.
3. P-R interval is regular.
4. R-R interval is regular.

 Rate:-
- When regular count the rate bycount number of large square between R-R intervals / 300.
- When irregular  count the pulses in 15 large squares and multiplies by 20.
 Axis:-
• Normal axis is between ( - 30 TO + 110 ).
• Right axis deviation is axis > + 110.
• Left axis deviation is axis < - 30.

Lead I +ve. -ve. +ve.

5|Page dr saif darif

Dr.saif darif medicine 2013
Lead III +ve +ve -ve
deviation no deviation (normal) Right axis deviation Check Lead (II) IF +ve Normal
If -ve Left axis
D/D of right & left axis deviation
right axis deviation (+ 11O to +150) left axis deviation (-30 to -90)
- in young children and tall adults - Obesity
- Left posterior hemiblock - Left anterior hemiblock
- RVH & RBBB - LBBB
- Anterolateral MI - Inferior MI.
- pulmonary embolism - Emphysema
- Hyperkalemia

NOTE: - NOT all left ventricular hypertrophy cause left axis deviation.

 Waves and interval:-

P wave
Normal P wave characteristics:-
 Look for the P wave in leads II positive & V1 biphasic.
 width < 0.12 sec (3 mm)
 Amplitude < 2.5 mm
 -ve only in AVR.

P wave Abnormalities
1. Width > 0. 12 sec & notched is Called P mitral and indicates Left Atrial enlargement as
In MS. or.  Left Atrial filling pressure as in LVF or MR.
2. Amplitude > 2.5 mm it’s called P Pulmonale which indicates Right Atrial dilatation as in TS ,
TR, pulmonary HTN , PE , RVF.

3. Multiple P wave showing saw toothed appearance  atrial flutter.

6|Page dr saif darif

Dr.saif darif medicine 2013

4. Absent P wave or replaced by F waves Atrial Fibrillation.

5. –ve (inverted) P wave in lead I. II, III & positive in lead AVR. Junctional Rhythm (nodal rhythm).

7|Page dr saif darif

Dr.saif darif medicine 2013

6. P wave not LOOKING like other P waves  Atrial ectopic.

P-R interval
It's the interval from the beginning of P wave to the beginning of the QRS.
Normally P-R interval it (0.12 sec – 0.2 sec) or (3 – 5 small square).

If < 0.12 sec called (short  pre excitation). If > 0.2 sec called prolonged (heart block).
1. Wolf-Parkinson white' syndrome (WPW). 1. 1st degree Heart block.
2. A V nodal reentrant tachycardia (AVNRT). 2. 2nd degree Heart block.
3. Lown Ganong Levine syndrome (LGL). 3. 3rd degree Heart block.

 For pictures Look in examples in last papers of this sheet.

QRS wave
Normal QRS
Width is < 3 small squares (< 0.12sec).
Normal Q wave: <1 small square width & depth ¼ or < 1/3 of R wave height.
Amplitude:-
 (R wave in V1 + R wave in V2 ) < 5rnm.
 (R wave in V5 + R wave in V6 ) < 25mm.
 (S wave in V1 or V2) + (R wave of V5 or V6) < 35 mm.

8|Page dr saif darif

Dr.saif darif medicine 2013

Abnormal QRS
 Wide QRS: - >3 small square = > 0.12 sec
Wide QRS
A. Complete RBBB RSR' in V1. (notched OR M shape QRS)
B. Complete LBBB RSR' in V6 (notched OR M shape QRS) OR wide + deep (S) in V1.
C. Ventricular extrasystole No Preceding P-wave (T inversely to complex).
D. Ventricular tachycardia. No Preceding P-wave (T inversely to complex) > successive beats.
E. Ventricular fibrillations. Deformity of the QRS configuration.
F. Ventricular Pacemaker QRS complex Preceded by spike.

9|Page dr saif darif

Dr.saif darif medicine 2013

 Increase amplitude ( voltage) Ventricular Hypertrophy

Criteria of ventricular hypertrophy in ECG
Right ventricular hypertrophy Left ventricular hypertrophy
 R: S >1 in V1 , OR  R wave at V5 or V6 > 25 mm OR
 R wave in V1 or V2 > 5mm  S wave in V1 or V2 + R wave of V5 or V6 > 35 mm

RVH LVH

D/D OF ventricular enlargement

Causes of RVH (pressure overload) Causes of LVH (pressure overload)
 P.HTN  S.HTN
 PS  AS
 HCM  HCM
Causes of RV dilation (volume overload) Causes of LV dilation (volume overload)
 PR  AR
 TR  MR
 Dilated CM  Dilated CM

10 | P a g e dr saif darif
Dr.saif darif medicine 2013
Difference between Atrial & Ventricular arrhythmias
Atrial Ventricular
QRS look like the one before it. doesn’t look like the one before It.
P wave No P wave
Narrow QRS (which is normal) except in………? Wide QRS
Normal T wave T wave opposite to direction of complex.
Not present (Capture beat and fusion beats May Present Capture beat and fusion beats.
Response to carotid message Not Response to carotid message

ST segment
Normal ST segment:- isoelectric accepted IF :-
 Up to 1mm up-or down in the limb leads.
 Up to 2 mm up or down in Precordial leads.
 If UP > 1 mm in limb leads OR > 2mm in Precordial leads called (ST elevation) d/d:-
1. Acute ST-elevation MI (STEMI).
2. Prinzmetal's angina (coronary spasm) normal cardiac enzyme.
3. Pericarditis diffuses.
4. LV aneurysm  old MI.
5. LBBB.
6. Cocaine abuse.
7. Early stage of subarachnoid hemorrhage.

 If DOWN > 1mm in limb leads OR >2mm in precordial leads + the depression is Horizontal or down
sloping (not up sloping = normal) Called ST depression d/d:-
1. Non-ST elevation Ml (NSTEMI).
2. Ischemia (Stable & Unstable angina).
3. Digitalis effect (down sloping).
4. Ventricular Strain (vent. hypertrophy + signs of ischemia).
5. Hypokalemia.

 Strain-pattern ventricle hypertrophy  Relative ischemia and characterized by:-

 Asymmetric T wave inversion.
 ST depression.

11 | P a g e dr saif darif
Dr.saif darif medicine 2013
T wave
Normal T wave:-
1. Up to 1mm up or down in the limb leads.
2. Up to 2 mm up or down in Precordial leads
3. Normal T wave is upward but may be normally inverted in lead III, V1, & V2.

T wave abnormalities
 Tall = Peaked T wave.  Inverted T or low flat T wave

 Hyperkalemia.  Ischemia [Angina or Ml].

 Acute STEMI  Ventricular Strain pattern.
 Myocarditis.
 Digitalis effect.
 Subarachnoid Hemorrhage.
 Electrolyte abnormality:-
 Hypokalemia.
 Hypocalcaemia.
 Hypomagnesaemia.

Note: - U waves it present in case of hypokalemia not hyperkalemia.

Q-T interval
The QT interval includes both ventricular depolarization and repolarization.
 QT interval  as the heart rate  .
 Q-T is start from beginning of QRS to end of T wave.
 Q-T is corrected according to the rate:- (QTc) = QT/ R-R interval
 Normal (QT.c ) is < 0.44 sec = usually < ½ RR interval.

D/D Prolonged Q-T  Torsade de point.

Drugs Electrolyte Congenital syndrome (rare)
 Antiarrhythmic class (Ia, Ic,III).  Hypokalemia.  Romano- Ward (AD)
 TCA.  Hypocalcaemia  Jervell and Lange-
 Erythromycin  Hypomagnesaemia Nielson(AR + deafness)
 Quinidine.
 Aminoglycoside.

12 | P a g e dr saif darif
Dr.saif darif medicine 2013

Wave Normal by small square Best lead to assessment

p wave  (3 * 2.5 ) S.S Lead ( II & V1)
 Negative in AVR , Biphasic in V1, positive
II
P-R interval ( 3 - 5 ) S.S . Lead II
QRS  < 3 S.S in wide. V1 & V5,V6  for (R&S) waves.
 Q wave < 1 S.S wide or < of 1/3 of R All leads for Pathological Q wave.
height.
 R in ( V1 < 5 S.S ) & ( V6 < 25 S.S )
ST segment  1 S.S in limb leads. In all LEADS.
&  2 S.S in chest leads.
T wave

ECG Abnormalities criteria

Abnormality Criteria
Asinus rhythm P-wave is not followed b QRS
Right axis deviation negative QRS in lead I
Left axis Deviation Negative QRS in lead II AND lead III BUT positive in lead I
right atrial enlargement P wave in II >2.5 mm in amplitude
left atrial enlargement P wave width > 0.12 sec (M shaped)
LVH R wave in V5 or V6 > 25 mm OR
S wave in V 1 or V2 + the R wave in V5 or V6 >35mm
RVH R wave in V1 >5mm
Abnormal rate HR < 60 its bradycardia or HR > .1 00 in tachycardia
ST segment elevation ST. segment,> 1mm in limb lead OR ST segment >2 mm in
precordial leads
pathological Q wave Duration 2: 0.04 sec AND
Amplitude > 1/3 height of corresponding R wave.
Peaked T wave amplitude >6 mm in limb leads OR >10 mm in precordial leads.
LBBB QRS duration > 0.12 sec & RSR’ pattern in leads ( I,V5,V6 ).
RBBB QRS duration > 0.12 sec & RSR pattern in V1, V2

13 | P a g e dr saif darif
Dr.saif darif medicine 2013
Steps to read ECG (V. IMP)

1- Check for  (name, date, speed, calibration).

2- Look in lead II (P wave present, normal morphology, followed by QRS or not).
3- P-R interval leads II & V1 (short or long or normal length).
4- R-R interval IN lead II & V1 (regular or irregular) & (count the rate).
5- Enlargement of atria IN (lead II & V1).
6- Look for BBB IN (V1, V2 RBBB & V5, V6 LBBB).
7- Look for ventricular enlargement in ( V1 & V6), BUT if there BBB don’t comment.
8- Look for axis (I , II , III ) if left axis found & associated with deep S wave in lead III (hemiblock).
Note: - left anterior hemiblock = left axis deviation + deep S wave in (AVF or II or III).
9- Look to sign of ischemia (ST, T & Q) waves in all leads.
Note: - if there LBBB its mask the sign of ischemia so don’t comment about ischemia in LBBB case.

Other findings

Hyperkalemia: - peaked T wave, flat p wave, prolonged PR interval, may disappear of p wave.

Hypokalemia: - flat T wave + appearance of U wave,  QT interval, May ST depression.

Hypercalcemia: - decrease in QT interval.

Hypocalcaemia: - increase in QT interval.

Digoxin
Effect of therapeutic dose Toxicity
- Slight PR prolongation - Sever PR prolongation (heart block).
-  Heart rate  (increase R-R interval). - Flat or inverted T wave.
- Sagging ST depression. - More ST depression.
- Flat T wave. - Ventricular bigeminy (extra systole).
- Ventricular tachycardia.

14 | P a g e dr saif darif