ECG Mastery Yellow Belt Workbook

8/9/2019 ECG Mastery Yellow Belt Workbook

http://slidepdf.com/reader/full/ecg-mastery-yellow-belt-workbook 1/118

"""#$%&$'()%*+#,-$ .

YELLOW

WORKBOOKBELT



"""#$%&$'()%*+#,-$ /

012 3'()%*+4 5%66-" 7%6) 8-*9:--9

:+ ;%)%* <=>?@ 3A@ 16%$%?( B'?C@ '?& D*'?E 8F%(:'G%*@ 3A 3;H

1-I+*FC>) " /J.K :+ 3%&$'()%*+ 2$:H

L66 *FC>)( *%(%*M%&#

>))I4NN"""#$%&$'()%*+#,-$



"""#$%&$'()%*+#,-$ O

#$ %$$&'()%'* (++,&(-. )& /(0)*,%$1 ).* 234

"#$%&'# (& ()# *#$$&+ ,#$( "&-./&&.0 1 )1234 %&'5126&2 (& ()# 1+1-37+622628 9:; <1=(#-4

5-&8-1'>/-&?8)( (& 4&? /4 <#3'1=(#-4@ A)# 9:; <1=(#-4 5-&8-1' 6= 12 62(#-1%(6B#0 %1=#7/1=#3

&2$62# %&?-=# ()1( '1.#= $#1-2628 ()# 9:; =6'5$#0 )123=7&20 123 C?2@ 9:; <1=(#-4 6= &5#2 C&-

-#86=(-1(6&2 1 %&?5$# &C (6'#= 5#- 4#1-@ DC 4&?E-# 2&( 1$-#134 #2-&$$#30 8& (& !!!"#$%#&'($)*"+,#

(& -#86=(#- C&- 1 C-## (-162628 =#F?#2%# 123 C623 &?( 1$$ 1/&?( ()# C?$$ 5-&8-1'@

G?=( $6.# ()# 9:; <1=(#-4 H-&8-1'0 ()# *#$$&+ ,#$( "&-./&&. 6= /1=#3 &2 -#1$7$6C# %1=#= ()1( +6$$

(#1%) 4&? )&+ (& 62(#-5-#( ()# 9:; $6.# 1 5-&@ D( 5-#=#2(= ()# 62C&-'1(6&2 B6=?1$$4 =& ()1( 6( 6= %$#1-

123 6''#361(#$4 ?23#-=(1231/$#@ D( $#1B#= &?( ()# I1-8&2 123 =(6%.= (& ()# 5-1%(6%1$ 62C&-'1(6&2

()1(J= -#1$$4 6'5&-(12(@ K23 6( 62%$?3#= )68)$4 #CC#%(6B# F?6LL#= /1=#3 &2 1%(?1$ %1=#=@ MN&$?(6&2= (&

()# F?6LL#=0 62%$?3628 #O5#-( 121$4=6=0 1-# 1B16$1/$# (& 124&2# #2-&$$#3 62 ()# 9:; <1=(#-4 &2$62#

%&?-=#@P

A)# *#$$&+ ,#$( =#%(6&2 &C ()# 9:; <1=(#-4 H-&8-1' (#1%)#= ()# /1=6%= &C ()# 9:; $128?18# 123 )&+

(& -#%&826L# '124 %&''&2 123 3128#-&?= 36=#1=#=@ "6() I?=( ()6= (-162628 4&?J$$ /# 1/$# (& C&$$&+ 1

%1=# 36=%?==6&2 1'&28 4&?- %&$$#18?#= 123 /#862 ?=628 ()# 9:; 62 4&?- 316$4 %$626%1$ 5-1%(6%#@

92-&$$##= 62 ()# &2$62# %&?-=# 1$=& 8#( 1%%#== (& ()# 9:; <1=(#-4 ,$?# ,#$( =#%(6&20 +)6%) (#1%)#=

)&+ (& 36182&=# '&-# ()12 QR 5#-%#2( &C 51()&$&86#= +6()&?( ()# )#$5 &C 1 '&-# =#26&- %&$$#18?#@

"6() <#3'1=(#-4 1= 4&?- 8?63#0 4&? )1B# 9:; '1=(#-4 1( 4&?- C628#-(65=@

92I&4 ()# $#1-2628S



"""#$%&$'()%*+#,-$ .

!"#$%#$&

(%)%* +, -%."#&$/0.$1#2 $3% 4!5 .0/)%6$3% ."78"#%#$& "9 $3% $/:.1#2 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; <

/&%0)12+103 )4% ,-$5-0%0)( -2 )4% 678 ,-$59%: ####################################################################################### ;

<:'$59%= 1&%0)12+103 > "'?%(@ 678 ,-$59%:%(@ '0& A "'?%( ##################################################################### B

6C1D 8%,)1-0 ##############################################################################################################################################EF

(%)%* =, >#$%/):* ?$17%@ :#A :78*1$0A% ?)"*$:2%@ 7%:&0/%7%#$& ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; ++

A4% GH':1(I'$591)C&% $%'(C*%$%0) #######################################################################################################EE

A4% JH':1(I)1$% $%'(C*%$%0) ################################################################################################################ EK

L%'(C*103 10)%*?'9( ##################################################################################################################################EK

6C1D 8%,)1-0 ##############################################################################################################################################E.

(%)%* B, C3%# $3% $171#2 1& "996$3% 9"0#A:$1"#& "9 1#$%/):* 1#$%/8/%$:$1"# ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; +<

MC*')1-0 -2 )4% > "'?% #############################################################################################################################EN

MC*')1-0 -2 )4% >7 10)%*?'9 #######################################################################################################################E; 678 &C*')1-0 #############################################################################################################################################EB

6C1D 8%,)1-0 ##############################################################################################################################################KF

(%)%* D, E3% 8/%."/A1:* *%:A&6F3:$ #"G"AH %)%/ $%**& H"0 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; ==

O-" )- 59',% )4% 5*%,-*&1'9 9%'&( ############################################################################################################KK

O-" )- 210& '0& ,-C0) )4% 10)%*,-()'9 (5',%( ,-**%,)9+ ###########################################################################KP

Q4') '0')-$1,'9 *%31-0( '*% &%51,)%& R+ "4') 9%'&(S ############################################################################ KP

A4% 0-*$'9 5'))%*0 ###################################################################################################################################KN

A4% 7T8 *')1- UV7 )- 8 *')1-WX #####################################################################################################################KN

6C1D 8%,)1-0 ##############################################################################################################################################PE

(%)%* I, E3% .3%&$ *%:A&6+JJK ."#91A%#.% ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; B=

6C1D 8%,)1-0 ##############################################################################################################################################PN

(%)%* <, C3:$ H"0 /%:**H #%%A $" L#"F :G"0$ )%#$/1.0*:/ 3H8%/$/"83H ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; BM

A4% 8-Y-9-" 10&%: ####################################################################################################################################PB

Z-"@ 9%)[( )C*0 )- *134) ?%0)*1,C9'* 4+5%*)*-54+\ #################################################################################### .F

6C1D 8%,)1-0 ##############################################################################################################################################.E

(%)%* N, OE A%8/%&&1"# :#A E #%2:$1)1$H6: &178*% :88/":.3 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; DD

A'9Y103 'R-C) 9-,')1-0\ ############################################################################################################################.]

A'9Y103 'R-C) (4'5%\ ###############################################################################################################################.]6C1D 8%,)1-0 ##############################################################################################################################################.;

(%)%* M, C3:$ %)%/HG"AH "023$ $" L#"F :G"0$ 7H".:/A1:* 1#9:/.$1"# :#A $3% PQO ."78*%R ;;;;;;;;;;;;;;;; I+

M*-"0103 10 0%3')1?1)+ ##############################################################################################################################]E

>')4-9-31, -* 0-) 5')4-9-31,I)4') 1( )4% ^C%()1-0 ################################################################################## ]P

A"- 1$5-*)'0) )*1,Y( 2-* +-C* )--9R-: ######################################################################################################]]

6C1D 8%,)1-0 ##############################################################################################################################################];

(%)%* S, >#9%/1"/ F:** 7H".:/A1:* 1#9:/.$1"#68%:/*& :#A 81$9:**& ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; IS

A4% 91$R 9%'&( ###########################################################################################################################################]B

_--Y103 ') $1**-* 1$'3%( ########################################################################################################################## NE `5&')103 -C* Y0-"9%&3% 'R-C) )4% 6 "'?% ,*1)%*1' ################################################################################# NK

6 "'?% '0& 0-0a6 "'?% 102'*,)1-0( ######################################################################################################## NK



"""#$%&$'()%*+#,-$ ]

>9%'(% "%9,-$% ### )4% <bc ,--YR--Yd #####################################################################################################NP

6C1D 8%,)1-0 ##############################################################################################################################################N.

(%)%* +J, T.0$% ."/"#:/H &H#A/"7%&67:&$%/1#2 $3% OE &%27%#$ ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; <N

81)C')1-0( / '0& //Ieb8 "1)4 8A %9%?')1-0 ################################################################################################Nf

81)C')1-0 ///Ieb8 "1)4-C) 8A %9%?')1-0 #################################################################################################### NB

81)C')1-0 /gI>*10D$%)'9 '0310'= ' (5%,1'9 ,'(% ######################################################################################## ;F

>%*1$+-,'*&1)1( ######################################################################################################################################### ;F

g'3-)-01' ################################################################################################################################################## ;E

6C1D 8%,)1-0 ##############################################################################################################################################;.

(%)%* ++, E3% 4!5 $/1"6.:/A1:. :R1&U :$/1:* 3H8%/$/"83HU :#A *"FV)"*$:2% ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; NM

A4% (4-,Y103 )*C)4 'R-C) )4% ,'*&1', ':1( ################################################################################################;f

e)*1'9 4+5%*)*-54+ #####################################################################################################################################ff

_-" ?-9)'3% ###############################################################################################################################################fB

6C1D 8%,)1-0 ##############################################################################################################################################BK

(%)%* +=, T &3"/$ &$"/H :G"0$ %*%.$/"*H$%& :#A 3%:/$ /:$% ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; SI

O+5%*Y'9%$1' ############################################################################################################################################B]

O+5-Y'9%$1' #############################################################################################################################################B]

O+5-,'9,%$1' h O+5%*,'9,%$1'################################################################################################################BN

O%'*) *')% ^C1,Y )15 ###################################################################################################################################B;

6C1D 8%,)1-0 ############################################################################################################################################EFF

(%)%* +B, Q3H$37 +J+6$3% #"/7:* &1#0& /3H$37 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; +JI

6C1D 8%,)1-0 ############################################################################################################################################ EFB



_%?%9 E """#$%&$'()%*+#,-$ N

QRS

T

QRS

T

P

P

!"#"$ &' (")*+,-./)-0+1 -2" 345 )/.#"6-2" )*78*+"+-, *9 -2"

-.:)0+1/0 )41( 21*() ,4'5)%*@ +-C "199 9%'*0 'R-C) )4% &122%*%0) "'?%( -0 )4% <bc '0& 4-" )- *%,-301D% )4%$#

<9%,)*1,'9 A%8"*:/1W:$1"# "9 $3% )%#$/1.*%& 9%'&( )- (4'*5 &%29%,)1-0( 10 )4% <bc ,'99%& PQO ."78*%R%&#

<?%*+ &%5-9'*1D')1-0 1( 2-99-"%& R+ ' 54'(% -2 *%5-9'*1D')1-0# Q%8"*:/1W:$1"# "9 $3% )%#$/1.*%& 1(

*%5*%(%0)%& R+ )4% (-H,'99%& E F:)%&# A4% A "'?% ,'0 R% 5-(1)1?% -* 0%3')1?%#

T$/1:* A%8"*:/1W:$1"# 1( &%51,)%& R+ )4% X F:)%@ "41,4 1( ()%%5%* )4'0 )4% A "'?% RC) 29'))%* )4'0 )4% 678

,-$59%:# Q% ('1& )4') %?%*+ &%5-9'*1D')1-0 1( 2-99-"%& R+ ' 54'(% -2 *%5-9'*1D')1-0# iC) (10,% ')*1'9

*%5-9'*1D')1-0 4'55%0( ') )4% ('$% )1$% '( )4% 678 ,-$59%:@ 1) ,'00-) R% *%,-301D%& -0 )4% <bc#



_%?%9 E """#$%&$'()%*+#,-$ ;

;<"+-09=0+1 -2" )*78*+"+-, *9 -2" >?@ )*78$"A

A4%*% '*% 21?% ,-0,%5)( )4') "199 4%95 +-C )- 1&%0)12+ )4% &122%*%0) ,-$5-0%0)( -2 )4% 678 ,-$59%:#

Q

Concept #1:

efirst downward deflection is called a Q wave

R

Q

Concept #2: Any upward deflection is called an R wave



_%?%9 E """#$%&$'()%*+#,-$ f

S

R

Q

Concept #3: Any downward deflection that comesafter an R wave and crosses the isoelectricline is called S wave

Concept #4: A second upward deflection is called R prime (R')

R wave R' = R prime

S

RSR'

R R'



_%?%9 E """#$%&$'()%*+#,-$ B

3A:78$"' 0<"+-09=0+1 B C:#",D >?@ )*78$"A",D :+< E C:#",

i'(%& -0 )4% ,-0,%5)( -C)910%& 'R-?%@ "% ,'0 0-" 1&%0)12+ )4% > "'?%(@ 678 ,-$59%:%(@ '0& A "'?%( 10

'0 %:'$59% %:%*,1(%# Z-)1,% )4') )4% (%,-0& "'?% 1( ()%%5 '0& %&3+j 1) 4'( (4'*5%* &%29%,)1-0( )4'0 )4%

-)4%* ,C*?%( '0& )4%*%2-*% 4'( )- R% )4% 678 ,-$59%:#

!"##$% '$(#)*+, ,)-$. "()/)-+#$ 0("1 #2$ %)00$($-# 3+'$. "0 #2$ 4567 82$9 )-#$(.$*# 3)#2 2"():"-#+, ,)-$.)%$-#)09)-/ ;< =>?< +-% 87 @- #2). $A+1B,$ 3$ 2+'$ +,($+%9 )%$-#)0)$% #2$ %)00$($-# 3+'$. 0"( 9"C7

T

QRS

P



_%?%9 E 6C1D """#$%&$'()%*+#,-$ EF

Level 1

QUIZ SECTION

Now it is your turn. If in doubt, start looking for the QRS complex

(focus on sharp deflections!). Also keep in mind that every QRScomplex is followed by the T wave after 200-400ms (equivalent to

5-10mm on this ECG paper).en you should be able to identify the

P wave, as the steepness of its deflection is in between the QRS and

the T wave.

P

QRS

T

P

QRS

T

P

QRS

T

P

QRS

T

ECG 1

ECG 2

ECG 3

ECG 4



_%?%9 K """#$%&$'()%*+#,-$ EE

!"#"$ F' ;+-".#:$ G-07"H :+< :78$0-/<" G#*$-:1"H 7":,/."7"+-,/0 )41( ,4'5)%*@ +-C "199 9%'*0 'R-C) )4% &C*')1-0 '0& '$591)C&%( -2 )4% ?'*1-C( "'?%( '0& 4-" )-

$%'(C*% )4%$#

G-C ,'0 $%'(C*% 10 )"- &1$%0(1-0( -0 )4% <bc 5'5%*# A4% YV:R1& (4-"( :78*1$0A%& U1#%#@ )"*$:2%X@ "419%

)4% ZV:R1& (4-"( $17%#

D$+.C()-/ ). -"# +,3+9. -$*$..+(9 )- "(%$( #" *"1$ CB 3)#2 #2$ ()/2# %)+/-".).7 ?"1$

%).$+.$. EC.# ($FC)($ B+##$(- ($*"/-)#)"- G$7/7< +*C#$ 19"*+(%)+, )-0+(*#)"-H< 32),$ "#2$(.

($FC)($ 1$+.C($1$-#. G$7/7< '$-#()*C,+( 29B$(#("B29< IC-%,$ I(+-*2 I,"*J.< $#*7H7

E2" IJ:A0,6:78$0-/<" 7":,/."7"+-

e$591)C&% -* ?-9)'3% 1( $%'(C*%& -0 )4% GH':1(j +J77 *%5*%(%0) + 71**1)"*$ ?7[@ "1)4 ()'0&'*&

,'91R*')1-0#



_%?%9 K """#$%&$'()%*+#,-$ EK

5""A $" L#"F, k,,'(1-0'99+@ ,'91R*')1-0 1( (%) ') &-CR9% ()'0&'*& UKF$$ l E$gX -* 4'92 ()'0&'*& U]$$ l

E$gX# O-"%?%*@ )41( 1( -09+ *'*%9+ &-0%# 8- mC() *%$%$R%* )4') +J77 \ +7[ '0& +-C[99 R% 210% 10 BB#Bn

-2 ,'(%(#

O%*%[( 4-" +-C ,'0 )%99 12 )4% <bc 1( '&mC()%& )- ()'0&'*& ,'91R*')1-0# e9$-() %?%*+ <bc 5*10)-C) '9(- 4'(

' *%,)'03C9'* ,'91R*')1-0 (130'9 -0 1)# /2 )4% $',410% 1( (%) )- ()'0&'*& ,'91R*')1-0 UEF$$ l E$gX@ )41(

,'91R*')1-0 (130'9 "199 R% %:',)9+ EF$$ 4134 '( (4-"0 10 )4% %:'$59%#

E2" KJ:A0,6-07" 7":,/."7"+-

L-() <bc $',410%( 5*10) ') ' (5%%& -2 K]$$ 5%* (%,-0&# A4%*%2-*%@ ' =I77 &1()'0,% -0 )4% JH':1(

,-**%(5-0&( )- ' &C*')1-0 -2 + &%."#A#

=I77 "# $3% ZV:R1& \ + &%."#A

I77 ?*:/2% G"R@ "# ZV:R1& \ +]I "9 : &%."#A "/ J;= &%."#A&

+77 ?&7:** G"R@ "# ZV:R1& \ +]I "9 J;= &%."#A& "/ J;JD &%."#A&

5""A $" L#"F, k,,'(1-0'99+@ 5'5%* (5%%& 1( (%) ') ]F$$T(%,-0& 10 "41,4 ,'(% '99 <bc 10)%*?'9( '*% )"1,%

'( 9-03 '( 0-*$'9 U9'*3% R-: l F#E( 10()%'& -2 F#K(@ ($'99 R-: l F#FK( 10()%'& -2 F#F.(X# 8- "4%0%?%* '99

10)%*?'9( 9--Y )-- 9-03@ ,4%,Y 2-* '0 10,*%'(% -2 5'5%* (5%%& )- ]F$$T(#

L":,/.0+1 0+-".#:$,

Z-" 1)[( )1$% )- ,'**+ -C) (-$% $%'(C*%$%0)(# A4% A0/:$1"# -2 ' "'?% 1( $%'(C*%& 2*-$ 1)( 101)1'9

&%?1')1-0 2*-$ )4% 1(-%9%,)*1, 910% C0)19 )4% 5-10) "4%*% 1) *%)C*0( )- )4% 1(-%9%,)*1, 910% '3'10# A4%

:78*1$0A% -2 )4% "'?% 1( )4% &1()'0,% R%)"%%0 )4% 1(-%9%,)*1, 910% '0& )4% 5%'Y -* 0'&1* -2 )4') "'?%#

K"C .2"C,% #(9 #" $'+,C+#$ +-% 1$+.C($ $+*2 456 )- + .9.#$1+#)* 3+9< "-$ .#$B +0#$( #2$

"#2$(7 @- ,+#$( *2+B#$(. 3$ 3),, )-#("%C*$ .C*2 +- +BB("+*2< 32)*2 3$ *+,, #2$ L456

5""JI""J7M

EF$$

O" /%7%7G%/,



_%?%9 K """#$%&$'()%*+#,-$ EP

O%*% 1( 4-" )- $%'(C*% )4% &122%*%0) 10)%*?'9(=

D$+.C($1$-# "0 ; 3+'$ %C(+#)"- .#+(#. +# #2$

B")-# 32$($ #2$ ; 3+'$ ,$+'$. #2$ )."$,$*#()*

,)-$ C-#), )# ($#C(-. #" #2$ )."$,$*#()* ,)-$ +/+)-7

D$+.C($1$-# "0 #2$ =8 )-#$('+, .#+(#. +# #2$ I$/)--)-/"0 #2$ =>? *"1B,$A C-#), #2$ $-% "0 #2$ 8 3+'$7

D$+.C($1$-# "0 +1B,)#C%$.N

.#+(# 1$+.C()-/ +# #2$ )."$,$*#()*

,)-$ C-#), #2$ -+%)( "( B$+J "0 #2$

*C('$7

7

D$+.C($1$-# "0 =>? %C(+#)"- .#+(#. +# #2$ B")-#

32$($ #2$ =>? *"1B,$A ,$+'$. #2$ )."$,$*#()* ,)-$

C-#), )# ($#C(-. #" #2$ )."$,$*#()* ,)-$ +/+)-7



_%?%9 K 6C1D """#$%&$'()%*+#,-$ E.



_%?%9 K 6C1D """#$%&$'()%*+#,-$ E]



_%?%9 P """#$%&$'()%*+#,-$ EN

!"#"$ M' N2"+ -2" -070+1 0, *996-2" 9*/+<:-0*+, *9 0+-".#:$

0+-".8."-:-0*+/0 )41( ,4'5)%*@ +-C '*% 3-103 )- 9%'*0 'R-C) )4% 0-*$'9 ?'9C%( -2 )4% &122%*%0) )1$% 10)%*?'9( '0& "4') 1)

$%'0( 12 )4%+ '*% -22#

(/.:-0*+ *9 -2" B C:#"-%8"*:/1W:$1"# -2 )4% ')*1' U1#%#@ > "'?% &C*')1-0X C(C'99+ )'Y%( *%&& $3:# J;+J &%."#A&# /2 )4% 9%2) ')*1C$ 1(

&19')%& U%09'*3%&X@ &%5-9'*1D')1-0 )'Y%( 9-03%* '0& X F:)% A0/:$1"# F1** 1#./%:&% $" ^ J;+=&#

A4% 5*-9-03%& > "'?% (%%0 10 ')*1'9 %09'*3%$%0) 4'( ' V&-CR9% 5%'YW 10 9%'& / '0& 9%'& // '0& 1( ,'99%& X

71$/:*% U(%% 1$'3%X# Q% '*% 3-103 )- 9%'*0 $-*% 'R-C) 1) 10 _%?%9 EE#



_%?%9 P """#$%&$'()%*+#,-$ E;

(/.:-0*+ *9 -2" B? 0+-".#:$

A4% XQ 1#$%/):* *%5*%(%0)( )4% &C*')1-0 )4% 1$5C9(% )'Y%( )- )*'?%9 2*-$ )4% ')*1' )- )4% ?%0)*1,9%(# /)[(

$%'(C*%& 2*-$ )4% R%3100103 -2 )4% > "'?% C0)19 )4% R%3100103 -2 )4% 678 ,-$59%:# _"/7:* ):*0%& '*%

R%)"%%0 J;+= :#A J;= &%."#A&# e0+ &C*')1-0 R%9-" -* 'R-?% )41( *'03% 1( *%3'*&%& '( 'R0-*$'9#

N2"+ -2" B? 0+-".#:$ 0, O PQF ,")*+<,

Q4%0 )4% >7 10)%*?'9 1( 9-03%* )4'0 F#K (%,-0&( eZM 12 )4%*%[( ' 678 ,-$59%: '2)%* %',4 > "'?%@ "% 4'?%

"4')[( ,'99%& ' 91/&$ A%2/%% T[ G*".L U-* eg R9-,Y /X@ '( (%%0 -0 )4% 1$'3%#

4A+1B,$ "0 + 0)(.# %$/($$ OP I,"*J GOP I,"*J @H7 @- #2). *+.$< #2$ ;> )-#$('+, ). Q7RS. +-% #2$($ ). + =>?

*"1B,$A +0#$( $+*2 ; 3+'$7

N2"+ -2" B? 0+-".#:$ 0, R PQ&F ,")*+<,'

Q4%0 )4% >7 10)%*?'9 1( (4-*)%* )4'0 F#EK (%,-0&(@ &%5-9'*1D')1-0 -2 )4% ?%0)*1,9%( -,,C*( %'*91%* )4'0

0-*$'9# A41( (1)C')1-0 1( ,'99%& 8/%%R.1$:$1"# U-* 8/%%R.1$:$1"# &H#A/"7%X# /0 )4%(% (+0&*-$%(@ '0

'&&1)1-0'9 RC0&9% ,-0&C,)( )4% 1$5C9(% &-"0 2*-$ )4% ')*1' )- )4% ?%0)*1,9%(# A4% ,-0&C,)1-0 (5%%& 10

)4% '&&1)1-0'9 RC0&9% 1( 2'()%* )4'0 10 )4% eg 0-&%I(- )4% 1$5C9(% *%',4%( )4% ?%0)*1,9%( %'*91%* )4'0

0-*$'9 '0& )4% >7 10)%*?'9 1( (4-*)%0%&#



_%?%9 P """#$%&$'()%*+#,-$ Ef

A4%*% '*% )"- 1$5-*)'0) 5*%%:,1)')1-0 (+0&*-$%( )4') +-C (4-C9& *%$%$R%*# A4% ("F#V5:#"#2V(%)1#%

&H#A/"7% ?(5( &H#A/"7%@ 1( ,4'*',)%*1D%& R+ ' 678 ,-$59%: )4') 1$$%&1')%9+ 2-99-"( )4% > "'?%# A4%

'55%'*'0,% '0& &C*')1-0 -2 )4% 678 ,-$59%:%( '*% 0-*$'9#

A4% -)4%* 2-*$ -2 5*%%:,1)')1-0 1( ,'99%& C"*99VX:/L1#&"#VC31$% &H#A/"7% ?CXC &H#A/"7%@# e (9C**%&

C5()*-Y% -2 )4% 678 ,-$59%: 1$$%&1')%9+ 2-99-"( )4% > "'?%j 1) 1( '9(- Y0-"0 '( ' V&%9)' "'?%@W '( 1)

*%(%$R9%( )4% c*%%Y 9%))%* &%9)'# A4% &C*')1-0 -2 )4% 678 1( C(C'99+ 9%03)4%0%& )- o F#EK(#



_%?%9 P """#$%&$'()%*+#,-$ EB

>?@ </.:-0*+

`0&%* 0-*$'9 ,1*,C$()'0,%(@ &%5-9'*1D')1-0 -2 )4% ?%0)*1,9%( )'Y%( C5 )- F#EF (%,-0&(# M19')')1-0 -2 )4%

?%0)*1,9%( $'+ ,'C(% ' (9134) 9%03)4%0103 -2 )4% 678 Uo F#E )- p F#EK (X# e (130121,'0)9+ 5*-9-03%& PQO

A0/:$1"# "9 ^ J;+=&@ 4-"%?%*@ 10&1,')%( )4') %1)4%* )4% *134) -* 9%2) RC0&9% R*'0,4 1( R9-,Y%&# A41(

(1)C')1-0 1( ,'99%& ' ."78*%$% G0#A*% G/:#.3 G*".L# Q%[99 4%'* $-*% 'R-C) 1) 10 _%?%9 ]#

A4%*% '*% '9(- -)4%* *%'(-0( 2-* R*-'& 678 ,-$59%:%(# e( "% 4'?% mC() 9%'*0%&@ -0% (C,4 %:'$59% 1( )4%

Q>Q (+0&*-$%@ 10 "41,4 ' &%9)' "'?% 1( '&&%& ') )4% R%3100103 -2 )4% 678 ,-$59%:# k)4%* *%'(-0( "199

R% 10)*-&C,%& 10 9')%* ,4'5)%*(#



_%?%9 P 6C1D """#$%&$'()%*+#,-$ KF

Level 3

QUIZ SECTION

e following examples may seem familiar to you, but at this

time not only the measurements but also the correct diagnoses

are required. Note that there may be more than only one

abnormality in a single example!

ECG 1

ECG 2

ECG 3

N o n e o f t h e

a n s w e r s p r o v i d e d

C o m p l e t e b u n d l e

b r a n c h b l o c k

W P W

s y n d r o m e

L G L s y n d r o m e

I ° A V b l o c k

P m i t r a l e

I

I

I



_%?%9 P 6C1D """#$%&$'()%*+#,-$ KE

ECG 4

ECG 5

ECG 6

ECG 7

N o n e o f t h e

a n s w e r s p r o v i d

e d

C o m p l e t e b u n d

l e


W P W

s y n d r o m

e


I ° A V b l o c k

P m i t r a l e

V5

II

I

V1

II



_%?%9 . """#$%&$'()%*+#,-$ KK

!"#"$ S' E2" 8.")*.<0:$ $":<,6C2:- +*T*<= "#". -"$$, =*//0 )41( ,4'5)%* +-C "199 9%'*0 "4%*% )- 5C) )4% 5*%,-*&1'9 9%'&( '0& "4') )4%+ )%99 +-C 'R-C) )4% 4%'*)#

A4% 5*%,-*&1'9 9%'&( (4-" )4% %9%,)*1,'9 ',)1?1)+ -2 )4% 4%'*) 10 )4% 3"/1W"#$:* 8*:#%# L-() ,-$$-09+@ (1:

5*%,-*&1'9 9%'&( '*% *%,-*&%&# A4% 5*%,-*&1'9 9%'&( '*% *%31()%*%& 10 ,-$R10')1-0 "1)4 )4% 91$R 9%'&(# G-C

'*% 3-103 )- 9%'*0 $-*% 'R-C) )4% 91$R 9%'&( 10 _%?%9 B -2 )41( )*'10103#

U*C -* 8$:)" -2" 8.")*.<0:$ $":<,

;("B$( B,+*$1$-# "0 #2$ B($*"(%)+, ,$+%. PT #2("C/2 PU7

A4% 5*%,-*&1'9 9%'&( '*% 59',%& ') 5*%&%210%& 5-(1)1-0( -0 )4% ,4%()# O%*%[( 4-" )- 3- 'R-C) 1)=

O$%8 += G-C 4'?% )- 210& )4% (%,-0& *1R '0& )4% (%,-0& 10)%*,-()'9 (5',% 21*()# A4%0 ,-C0) &-"0 )-

)4% 2-C*)4 10)%*,-()'9 (5',%# e))',4 [+ 1# $3% 9"0/$3 1#$%/."&$:* &8:.% "# $3% /123$ &1A% "9

$3% &$%/#07 '0& :$$:.3 [= 1# $3% 9"0/$3 1#$%/."&$:* &8:.% "# $3% *%9$ &1A% "9 $3%

&$%/#07#

O$%8 == e2)%* +-C[?% '))',4%& gE '0& gK@ '))',4 g. ') )4% 10)%*(%,)1-0 -2 )4% $1&,9'?1,C9'* 910%

'0& )4% 212)4 10)%*,-()'9 (5',%#

O$%8 B= e))',4 gP %:',)9+ 4'92 "'+ 10 R%)"%%0 gK '0& g.# q*-$ g. -0@ "% &-0[) 0%%& )- "-**+

'R-C) )4% 10)%*,-()'9 (5',%( '0+$-*%j )4% (CR(%^C%0) 9%'&( '*% '))',4%& ') )4% ('$%

4-*1D-0)'9 9%?%9 '( g.#

O$%8 D= g] 1( 59',%& 10 )4% '0)%*1-* ':199'*+ 910% U('$% 9%?%9 '( g.X#

O$%8 I= gN 1( 59',%& 10 )4% $1&H':199'*+ 910% U('$% 9%?%9 '( g.X#

k,,'(1-0'99+@ )"- '&&1)1-0'9 9%'&( Ug; h gfX '*% '9(- '))',4%&# g; 1( 9-,')%& ') )4% 5-()%*1-* ':199'*+ 910%U('$% 9%?%9 '( g.X@ '0& gf 1( '))',4%& ') )4% (,'5C9'* 910% U('$% 9%?%9 '( g.X#



_%?%9 . """#$%&$'()%*+#,-$ KP

U*C -* 90+< :+< )*/+- -2" 0+-".)*,-:$ ,8:)", )*..")-$=

A4% %'(1%() "'+ )- 210& )4% 2-C*)4 10)%*,-()'9 (5',% 1( )-

9--Y 2-* )4% ()%*0'9 '039%# A4% &$%/#:* :#2*% 1( ' 91))9% %&3%

10 )4% C55%* )41*& -2 )4% ()%*0C$ U(%% 1$'3%X@ "41,4 ,'0 R%

2-C0& 10 '9$-() '0+ 5')1%0)# A4% (%,-0& *1R 10(%*)( *134)

0%:) )- )4% ()%*0'9 '039%# i%9-" )4% (%,-0& *1R 1( )4%

(%,-0& 10)%*,-()'9 (5',%# A4%0 +-C mC() ,-C0) &-"0 )- )4%

2-C*)4 '0& 212)4 10)%*,-()'9 (5',%(@ *%(5%,)1?%9+#

8(9 #" 0)-% #2$ .$*"-% ()I "- 9"C(.$,0 C.)-/ #2). +BB("+*2<

+-% 9"CV,, .$$ #2+# )#V. $+.97 82$- *"C-# #2$ )-#$(*".#+,

.B+*$.W

N2:- :+:-*70):$ ."10*+, :." <"80)-"< T= C2:- $":<,V<',4 5*%,-*&1'9 9%'& &%51,)( ' ,%*)'10 *%31-0 -2 )4% 4%'*)# 8-$% 9%'&( %?%0 &%51,) $-*% )4'0 -0% *%31-0#

_%)[( ('+ +-C (%% 8A %9%?')1-0( -0 )4% <bcI' (130 -2 $+-,'*&1'9 102'*,)1-0# rC() R+ 9--Y103 ') )4% '22%,)%&

9%'&(@ +-C[99 R% 'R9% )- )%99 "4%*% )4% 102'*,)1-0 1( 9-,')%&#

@0 *2+-/$. +($ .$$- )- ,$+%. PT< PS +-% PR< #2$ ()/2# '$-#()*,$ ). +00$*#$%7



_%?%9 . """#$%&$'()%*+#,-$ K.

@0 "-,9 PS +-% PR .2"3 *2+-/$.< )#V. #2$ I+.+, .$B#C1 #2+# 2+. #2$ B("I,$17

@0 *2+-/$. *+- I$ .$$- )- PS< PR +-% PX< #2$- #2$ +-#$()"( 3+,, "0 #2$ ,$0# '$-#()*,$ G+-% #2$ .$B#C1H +($+00$*#$%7



_%?%9 . """#$%&$'()%*+#,-$ K]

PY +-% PU .2"3 #2$ ,+#$(+, 3+,, "0 #2$ ,$0# '$-#()*,$7

Z2$($+. P[ +-% P\ %$B)*# #2$ B".#$()"( 3+,, "0 #2$ ,$0# '$-#()*,$7



_%?%9 . """#$%&$'()%*+#,-$ KN

52+-/$. #2+# +($ .$$- )- #2$ +-#$()"( O]! #2$ ,+#$(+, 3+,,. +($ *+,,$% "#$%&'()$%&)( 7

52+-/$. #2+# +($ .$$- )- #2$ ,+#$(+, +-% B".#$()"( 3+,,. +($ *+,,$% *'+$%&'()$%&)( 7

52+-/$. #2+# +($ .$$- )- #2$ +-#$()"( 3+,, +-% #2$ .$B#C1 +($ *+,,$% "#$%&'+%,$)(-

E2" +*.7:$ 8:--".+

<',4 5*%,-*&1'9 9%'& 4'( ' )+51,'9 <bc 5'))%*0# A*+ )- *%$%$R%* )41( 51,)C*% -2 0-*$'9 ,4%() 9%'&(=

E2" ?W@ .:-0* GX? -* @ .:-0*YH

e( )4% 0'$% 1$591%(@ )4% 7T8 *')1- ,-$5'*%( )4% (1D% -2 )4% 7 "'?% )- )4% (1D% -2 )4% 8 "'?% 10 %',4 9%'&#

_%)[( 9--Y ') 2-C* %:'$59%(# >9%'(% ,-$59%)% )4% ,'9,C9')1-0( 2-* %:'$59%( P '0& .#

./)0,(% 1 ./)0,(% 2 ./)0,(% 3 ./)0,(% 4

> G1PH Q7X T7X

? G1PH S7Q T7X

>^? Q7X^S7Q _ T^Y _ Q7S T7X ^ T7X _ T

V1 V2 V3 V4

V5 V6



_%?%9 . """#$%&$'()%*+#,-$ K;

O ,"# "0 0",J. -$/,$*# #2$ > #" ? (+#)"7 `C# 9"C .2"C,%-V#W

@* C2= 0, -2" ?W@ .:-0* 078*.-:+-V

A4%*% '*% )"- ?%*+ 1$5-*)'0) 9'"( )4') '559+ C0&%* 0-*$'9 ,1*,C$()'0,%( U1#%#@ "4%0 )4% $C(,9% $'(( -2

)4% 9%2) ?%0)*1,9% %:,%%&( )4') -2 )4% *134) ?%0)*1,9%X# _'" 0C$R%* E ('+(=



_%?%9 . """#$%&$'()%*+#,-$ Kf

82$ #(+-.)#)"-+, :"-$ C.C+,,9 "**C(. +# ,$+%. PR "( PX7

e0& 9'" 0C$R%* K ('+(=

a+3 S 3),, I$ ($+,,9 )1B"(#+-# 32$- 3$ ,$+(- +I"C# 19"*+(%)+, )-0+(*#)"-W 82).

)-0"(1+#)"- 1)/2# *"1$ )- 2+-%9 %C()-/ 9"C( -$A# -)/2# "- *+,,7



_%?%9 . """#$%&$'()%*+#,-$ KB

N2"+ -2" -.:+,0-0*+:$ Z*+" 0, *99

e( "% 9%'*0%& 'R-?%@ )4% )*'0(1)1-0'9 D-0% U)4% &-))%& 910% (%5'*')103 *134) 2*-$ 9%2) ?%0)*1,9%X C(C'99+

-,,C*( ') gP -* g.@ '( &%51,)%& 10 )41( 1$'3%=

iC) 0-) %?%*+ 4%'*) 1( )4% ('$%# 8-$%)1$%(@ )4% 4%'*) 1( V*-)')%&W 10 ' ,9-,Y"1(% -* ,-C0)%*H,9-,Y"1(%

2'(41-0 '9-03 1)( 9-031)C&10'9 ':1( U3-103 2*-$ )4% '5%: )- )4% R'(% -2 )4% 4%'*)X#

Q4%0 )4% 4%'*) 1( *-)')%& 10 ' ,9-,Y"1(% 2'(41-0@ )4% )*'0(1)1-0'9 D-0% (412)( )-"'*&( g] -* gN=

e0& "4%0 )4% 4%'*) 1( *-)')%& 10 ' ,-C0)%*H,9-,Y"1(% 2'(41-0@ )4% )*'0(1)1-0'9 D-0% -,,C*( ') gE -* gK=



_%?%9 . """#$%&$'()%*+#,-$ PF

K"CV,, -$$% #" I$ +I,$ #" #$,, )0 + B($*"(%)+, ,$+% %$B)*#. #2$ ()/2# "( #2$ ,$0# '$-#()*,$7

b-"3,$%/$ +I"C# ("#+#)"- ). #2$($0"($ *()#)*+,7



_%?%9 . 6C1D """#$%&$'()%*+#,-$ PE

Level 4

QUIZ SECTION

Which leads provide information on the... V1 V2 V3 V4 V5 V6 V7 V8

Right ventricle

Upper part of the septum

Left ventricle

Anterior wall of the LV

Lateral wall of the LV

Posterior wall of the LV

Which ventricle is represented by theseleads under normal circumstances?

Right ventricle

Left ventricle

Now it’s time for some exercises.ey will help you to

repeat and remember the most important information

covered in this level.





_%?%9 ] """#$%&$'()%*+#,-$ PP

82$ 5 ,)$$%&# ). C.C+,,9 FC)#$ $+.9 #" .$$ G9$,,"3H7 Z2$- #2$ %$,+9 )- %$B",+():+#)"- "0 #2$ '$-#()*,$. ).

,$.. "I')"C.< #2$- #2+#V. *+,,$% #'$678#97

A4%(% ,4'03%( 10 7 "'?% $-*54-9-3+ 10&1,')% )4') &%5-9'*1D')1-0 -2 )4% ?%0)*1,9%( 1( &%9'+%&# A41( &%9'+

$'+ R% ,'C(%& R+ )%#$/1.0*:/ 3H8%/$/"83HU )%#$/1.0*:/ A1*:$:$1"#U -* G0#A*% G/:#.3 G*".L#

/0 RC0&9% R*'0,4 R9-,Y@ ,-0&C,)1-0 )4*-C34 )4% 9%2) -* *134) RC0&9% R*'0,4 1( ,-$59%)%9+ R9-,Y%&#

M%5-9'*1D')1-0 -2 )4% ?%0)*1,9%( )4%*%2-*% )'Y%( 9-03%* )4'0 0-*$'9 '0& )4% 678 ,-$59%: 1( 9%03)4%0%& )-

F#EK (%,-0&( -* 9-03%*#

/0 -*&%* )- 210& -C) 12 )4% 9%2) -* )4% *134) RC0&9% R*'0,4 1( '22%,)%&@ "% 0%%& )- 9--Y ') )4% ,4%() 9%'&(=

@- *"1B,$#$ ,$0# IC-%,$ I(+-*2 I,"*J Ga```H< #2$ =>? %C(+#)"- ). c Q7TS .$*"-%. +-% +- DdB+##$(-

G-"#*2)-/H ). .$$- "'$( #2$ ,$0# '$-#()*,$ GPY "( PUH7

Q4%0 )4% 678 &C*')1-0 1( R%)"%%0 F#EF '0& F#EK (%,-0&(@ )4%0 )4')[( ,'99%& 1#."78*%$% G0#A*% G/:#.3

G*".L@ "41,4 '9(- ,'C(%( 0-),4103 -2 )4% 678 ,-$59%:# /0,-$59%)% RC0&9% R*'0,4 R9-,Y $'+ R% ,'C(%& R+

&19')1-0 -* 4+5%*)*-54+ -2 )4% ?%0)*1,9%(#

M-form

notching

M shape

M shape over the

left ventricle



_%?%9 ] """#$%&$'()%*+#,-$ P.

@- *"1B,$#$ ()/2# IC-%,$ I(+-*2 I,"*J G>```H< #2$ =>? %C(+#)"- ). c Q7TS .$*"-%. +-% +- DdB+##$(- G"(

-"#*2)-/H ). .$$- "'$( #2$ ()/2# '$-#()*,$ GPT "( PSH7

O# #2). B")-# 3$ -$$% #" #+J$ + FC)*J .)%$d.#$Be

A4%*%[( -0% 1$5-*)'0) 5')4-9-3+ )4') ,-C9& R% ,-02C(%& "1)4 RC0&9% R*'0,4 R9-,Y R%,'C(% 678 &C*')1-0

1( '9(- 9%03)4%0%&# Q% 4'?% '9*%'&+ 9%'*0%& 'R-C) )41( &1(%'(% 10 9%?%9 P# O%*%[( '0 %:'$59%# b'0 +-C (5-)

)4% 5*-R9%$S

@- #2). $A+1B,$< #2$ =>? %C(+#)"- ). ,$-/#2$-$% #" c Q7TS .$*"-%. +-% #2$($V. -"#*2)-/ )- ,$+% PT7 @. #2). +

*+.$ "0 ()/2# IC-%,$ I(+-*2 I,"*Jf

K"C 1)/2# 2+'$ +,($+%9 ($+,):$% 32+#V. 3("-/ 3)#2 #2). 4567 82$($ +($ + 0$3 B("I,$1.N

#2$ =>? ). ,$-/#2$-$%< #2$ ;> )-#$('+, ). #"" .2"(#< O]! #2$ I$/)--)-/ "0 #2$ =>? ,""J.

J)-% "0 0C--97

V1 V2 V3 V4 V5 V6





_%?%9 ] 6C1D """#$%&$'()%*+#,-$ PN

V2 V3 V4 V5 V6V1

ECG 3

Level 5

QUIZ SECTION

And now it’s time for some exercises ...

V2 V3 V4 V5 V6V1

ECG 1

V2 V3 V4 V5 V6V1

ECG 2

Diagnosis Diagnostic criteria

C o m p l e t e r i g h t b u n d l e b r a n c h b l o c k

C o m p l e t e l e f t b u n d l e


V o l u m e o v e r l o a d r i

g h t v e n t r i c l e

V o l u m e o v e r l o a d l e f t v e n t r i c l e

W P W

s y n d r

o m e

D u r a t i o n o f t h e Q R S c o m p l e x

( V 1 ) Q R S s h a p e

( V 6 ) Q R S s h a p e

D u r a t i o n o f t h e P

R i n t e r v a l

D e l t a w a v e i n

l e a d s :



_%?%9 ] 6C1D """#$%&$'()%*+#,-$ P;

V2 V3 V4 V5 V6V1

ECG 6

V1 V2

I

V1 V2 V3 V4 V5 V6

III III

V2 V3 V4 V5 V6V1 V2V1

V2 V3 V4 V5 V6V1

ECG 4

ECG 5

ECG7

Diagnosis Diagnostic criteria

C o m p l e t e r i g h t b u n d l e b r a n c h b l o c k

C o m p l e t e l e f t b u n d l e b r a n c h b l o c k

V o l u m e o

v e r l o a d r i g h t v e n t r i c l e

V o l u m e o v e r l o a d l e f t v e n t r i c l e

W

P W

s y n d r o m e

D u r a t i o n o f t h e Q R S c o m p l e x

( V 1 ) Q R S s h a p e

( V 6 ) Q R S s h a p e

D u r a t i o n o f t h e P R i n t e r v a l

D e l t a w a v e i n l e a d s :



_%?%9 N """#$%&$'()%*+#,-$ Pf

V1, V2

!"#"$ ]' N2:- =*/ .":$$= +""< -* ^+*C :T*/- #"+-.0)/$:.

2=8".-.*82=A4% <bc 1( '0 1$5-*)'0) )--9 2-* )4% 1&%0)121,')1-0 -2 9%2) ?%0)*1,C9'* 4+5%*)*-54+# /0 )41( ,4'5)%*@ +-C[99

9%'*0 "4') )- 9--Y 2-*#

Q% 9%'*0%& 10 _%?%9 . )4') 7 "'?%( 10,*%'(% '( "% 3- 2*-$ *134) UgEX )- 9%2) UgNX# A4% (1D% -2 )4% 7 "'?% 1(

' *%29%,)1-0 -2 )4% $+-,'*&1'9 $'(( C0&%*0%')4 )4% 9%'&# A4')[( "4+ )4% 7 "'?%( -?%* )4% )410H"'99%&

*134) ?%0)*1,9% UgE '0& gKX '*% ($'99%* )4'0 )4% 7 "'?%( -?%* )4% $C(,C9'* 9%2) ?%0)*1,9% Ug] '0& gNX#

A4% "'?%( -2 )4% <bc '*% ' 5*-&C,) -2 %9%,)*1,'9 &%5-9'*1D')1-0# /2 &%5-9'*1D')1-0 $-?%( )-"'*& ' 9%'&@

)4% *%(5%,)1?% (%3$%0) -2 )4% <bc "'?% "199 R% 5-(1)1?%# /2 &%5-9'*1D')1-0 $-?%( '"'+ 2*-$ )4% 9%'&@ )4%

&%29%,)1-0 "199 R% 0%3')1?%#

@0 #2$ $,$*#()*+, '$*#"( B")-#. #"3+(% + ,$+%< #2$

($.B$*#)'$ .$/1$-# "0 #2$ 456 3),, I$ B".)#)'$7

@0 #2$ $,$*#()*+, '$*#"( B")-#. +3+9 0("1 + ,$+%< #2$ 456 3+'$. 3),, I$ -$/+#)'$7

/) 2-99-"( )4') ' ()*-03 %9%,)*1,'9 ?%,)-* )4') 5-10)( 10 )4% &1*%,)1-0 -2 g] '0& gN 5*-&C,%( ' 9'*3% 7 "'?%

10 g] -* gN '0& ' &%%5 8 "'?% 10 )4% -55-(1)% 9%'&( gE '0& gK# /0 -)4%* "-*&(@ )4% 8 "'?% 10 gE '0& gK 1(

$-*% -* 9%(( ' $1**-* 1$'3% -2 )4% 7 "'?% 10 g] '0& gN#

V5, V6



_%?%9 N """#$%&$'()%*+#,-$ PB

E3% 3123%/ $3% Q F:)% ")%/ $3% *%9$ )%#$/1.*%U $3% *:/2%/ $3% 70&.0*:/ 7:&& "9 $3% *%9$ )%#$/1.*%

?: A1/%.$ &12# "9 *%9$ )%#$/1.0*:/ 3H8%/$/"83H@;

E3% A%%8%/ $3% O F:)% ")%/ $3% /123$ )%#$/1.*%U $3% *:/2%/ $3% 70&.0*:/ 7:&& "9 $3% *%9$ )%#$/1.*%

?:# 1#A1/%.$ &12# "9 *%9$ )%#$/1.0*:/ 3H8%/$/"83H@;

E2" @*^*$*C 0+<"A

`0&%* 0-*$'9 ,1*,C$()'0,%( )4% 9%2) ?%0)*1,9% 4'( ' 4134%* $C(,C9'* $'(( )4'0 )4% *134) ?%0)*1,9%# /0

-*&%* )- '((%(( "4%)4%* U'R0-*$'9X 9%2) ?%0)*1,C9'* 4+5%*)*-54+ 1( 5*%(%0)@ )4% O"L"*"F 1#A%R ,'0 R%

C(%&# /) R'(1,'99+ )'Y%( )4% 5*%,%&103 )"- ()')%$%0)( '0& )C*0( )4%$ 10)- 0C$R%*(# O%*%[( 4-" 1)[( &-0%=

E# A'Y% )4% 7 U$gX 10 g] -* gN U"41,4%?%* -0% 1( )'99%*X#

K# e&& )4% 8 U$gX 10 gE -* gK U"41,4%?%* -0% 1( &%%5%*X#

P# /2 )4% *%(C9)103 0C$R%* 1( -?%* P#]$g@ 9%2) ?%0)*1,C9'* 4+5%*)*-54+ 1( 5*-R'R9+ 5*%(%0)#

8-$%)1$%( )4% 7 "'?% 10 ' 9%2) ?%0)*1,C9'* 9%'& '9-0% %:,%%&( K#] $gj )41( ,'0 '9(- R% 10)%*5*%)%& '( '

(130 -2 _gO#

A4% 2-99-"103 %:'$59% 199C()*')%( 4-" )- C(% )4% 8-Y-9-" 10&%:=

Z$V,, C.$ #2$ > )- PY I$*+C.$ )#V. #+,,$( #2+- #2$ > )- PU7 82$ +1B,)#C%$ "0 #2+# > 3+'$ ). S7S1P7 82$- 3$V,,

1$+.C($ #2$ ? )- PS I$*+C.$ )#V. %$$B$( #2+- #2$ ? )- PT7 82+# ? 3+'$ ). R7T1P7 82$- 3$ +%% CB #2".$

-C1I$(.N S7S g R7T _ Y7R1P7 ?)-*$ Y7R ). ,+(/$( #2+- R7Y< ,$0# '$-#()*C,+( 29B$(#("B29 ). B("I+I,9 B($.$-#7

h"3$'$(< #2). #$*2-)FC$ .2"C,% I$ C.$% 3)#2 *+C#)"-7 i+,.$ B".)#)'$ +-% 0+,.$ -$/+#)'$

($.C,#. 1+9 "**C(7 O,."< #2). 1$#2"% ). -"# .C)#+I,$ 0"( B+#)$-#. C-%$( #2$ +/$ "0 RY

9$+(.7 O ,"# "0 B$"B,$ )- #2). +/$ /("CB 3),, $A*$$% #2$ #2($.2",% "0 R7Y1P 3)#2"C#2+')-/ ,$0# '$-#()*C,+( 29B$(#("B29 G32)*2 1$+-. 2)/2 (+#$. "0 0+,.$ B".)#)'$.WH7

O" /%7%7G%/,





_%?%9 N 6C1D """#$%&$'()%*+#,-$ .E

Level 6

QUIZ SECTION

V1 V2 V3 V4 V5 V6

V1 V2

V1 V2 V3 V4 V5 V6

ECG 1

ECG 2

R (mV)

S (mV)

R/S ratio

R (mV)

S (mV)

R/S

Rotation

L e f t v e n t r i c u l a r

h y p e r t r o p h y

R i g h t v e n t r i c u l a r

h y p e r t r o p h y

L e f t v e n t r i c u l a r

v o l u m e o v e r l o a d

R i g h t v e n t r i c u l a r

v o l u m e o v e r l o a d

C o u n t e r c l o c k w i s e

C l o c k w i s e

N o r m a l

t r a n s i t i o n z o n e

Use the above method to complete the following examples. Fill in your measurements

(R waves, S waves and R/S ratios) on the lines below the leads. You don’t need to mark

the measurements below every lead – just the ones that are relevant. It should be quite

obvious from what we’ve discussed in this level what the relevant leads are. After you’ve

performed the measurements, choose from the four possible diagnoses given on the right

side of each example. Use the method taught in Level 4 for the assessment of rotation.



_%?%9 N 6C1D """#$%&$'()%*+#,-$ .K



_%?%9 N 6C1D """#$%&$'()%*+#,-$ .P



_%?%9 ; """#$%&$'()%*+#,-$ ..

!"#"$ b' @E <"8.",,0*+ :+< E +"1:-0#0-=6: ,078$" :88.*:)28A &%5*%((1-0 '0& A "'?% 0%3')1?1)+ '*% ,-$$-09+ '((-,1')%& "1)4 &%R191)')103 '0& 5-)%0)1'99+ 912%H

)4*%')%0103 &1(%'(%(# <?%*+ <bc ()C&%0) (4-C9& R% 'R9% )- *%,-301D% '0& 10)%*5*%) )4%$# 8- 5'+ ,9-(%

'))%0)1-0#

_%)[( ()'*) -22 "1)4 )"- (1$59% 5*10,159%(=

`9 %$0)-)#)"-< #2$ )."$,$*#()* ,)-$ ). ,"*+#$% +# #2$ ,$'$, "0 #2$ 456 *C('$ #2+# *"1$. +0#$( #2$ 8 3+'$<

I$0"($ #2$ -$A# ; 3+'$7

V1 V2

V4 V5 V6

V3

Principle #1:

The ST segment isnormally located atthe level of the

isoelectric line

Principle #2:

Except for V1, the T wave is

normally positive



_%?%9 ; """#$%&$'()%*+#,-$ .]

k0,% +-C *%,-301D% )4% 5*%(%0,% -2 8A &%5*%((1-0( -* A "'?% 10?%*(1-0(@ +-C (4-C9& 9--Y ') )"- )4103(=

E# A4%1* 9-,')1-0 U"41,4 9%'&( '*% '22%,)%&X#

K# A4%1* (4'5%#

E:$^0+1 :T*/- $*):-0*+a/0 9%?%9 .@ +-C 9%'*0%& "4') 9%'&( &%51,) "41,4 5'*)( -2 )4% ?%0)*1,9%# 8- 12 8A &%5*%((1-0 1( 5*%(%0) 10 g]

'0& gN 2-* %:'$59%@ +-C Y0-" )4') 1)[( )4% 9')%*'9 "'99 )4') 4'( ' 5*-R9%$#

E:$^0+1 :T*/- ,2:8"a

E2" <099"."+- 9*.7, *9 @E <"8.",,0*+,

/0 -C* %:5%*1%0,%@ +-C ,'0 )%99 ' 9-) 'R-C) )4% C0&%*9+103 5')4-9-31%( 12 +-C Y0-" 4-" )4%+ ,4'03% )4%

$-*54-9-3+ -2 )4% 8A (%3$%0)# O%*% '*% (-$% %:'$59%(=

4R:78*% T= e &%(,%0&103 8A &%5*%((1-0 1( C(C'99+ '((-,1')%& "1)4 ?%0)*1,C9'* 4+5%*)*-54+#

4R:78*%& bU ! :#A -= A4%(% '*% -09+ *%9%?'0) -?%* )4% 9%2) ?%0)*1,9% Uk0% %:,%5)1-0 )- )41( *C9% '*% $1**-*

1$'3%( -2 ' 5-()%*1-* "'99 8A %9%?')1-0 $+-,'*&1'9 102'*,)1-0@ "41,4 "199 '9(- 5*-&C,% (1$19'* 8A

&%5*%((1-0( 10 gE@ gK@ '0& gP# L-*% 'R-C) )4') 10 9%?%9 B#X

4R:78*% b= 8A &%5*%((1-0 "1)4 ' ('33103 $-*54-9-3+I)41( $'+ R% ,'C(%& R+ ,-*-0'*+ 10(C221,1%0,+

U'0310'X@ &13-:10@ -* 4+5-Y'9%$1'#

4R:78*% != O-*1D-0)'9 8A &%5*%((1-0@ )+51,'99+ (%%0 10 5')1%0)( "1)4 ,-*-0'*+ 10(C221,1%0,+ U1#%#@

(+$5)-$')1, ,-*-0'*+ 4%'*) &1(%'(%X#

4R:78*%& b :#A != b-$$-09+ (%%0 10 5')1%0)( "1)4 %:%*,1(%H10&C,%& '0310' C0&%*3-103 ()*%(( )%()#

4R:78*% -= e(,%0&103 8A &%5*%((1-0 $'+ R% ,'C(%& R+ 4134 (+$5')4%)1, )-0%@ RC) '9(- R+ 54+(1,'9

',)1?1)+# MC*103 54+(1,'9 ',)1?1)+@ '(,%0&103 8A &%5*%((1-0( &- 0-) 0%,%(('*19+ $%'0 )4') 1(,4%$1' 1(

5*%(%0)#

4R:78*% 4= M%%5 4-*1D-0)'9 8A &%5*%((1-0( '*% -2)%0 (%%0 10 (%?%*'9 ,-**%(5-0&103 9%'&( 10 )4% (%))103 -2

(%?%*% 1(,4%$1'#

NORMAL A

1. ventricular hypertrophy

B

2. digoxin

3. hypokalemia

C

5. coronaryinsu!ciency

D

6. sympathetic tone

7. coronaryinsu!ciency

(possible)

E

8. severe ischemia

4. coronary insu!ciency

ST depression





_%?%9 ; 6C1D """#$%&$'()%*+#,-$ .;

L e v e l 7

Q U I Z S E C T I O N

I n t h e f o l l o w i n g e x e r c i s e s , p

l e a s e d e s c r i b e t h e p a t t e r n o f

S T

s e g m e n t c h a n g e s ( e . g . , h o r i z o n t a l , d e s c e n d i n g , e t c . ) a s w

e l l a s

T w a v e c h a n g e s ( e . g . , s y m m

e t r i c , a s y m m e t r i c , b i p h a s i c ,

e t c . )

a n d d e c i d e w h a t t h e u n d e r l y i n g d i a g n o s i s c o u l d b e .

V 1

V 2

V 3

V 4

V 5

V 6

E C G 1

S T

d e p r e s s i o n

T

n e g a t i v i t y

D i a g n o s i s

C o r o n a r y T w a v e i n v e r s i o n

C o r o n a r y S T d e p r e s s i o n

W P W s y n d r o m e

C o m p l e t e r i g h t b u n d l e b r a n c h

C o m p l e t e l e f t b u n d l e b r a n c h

L e f t v e n t r i c u l a r h y p e r t r o p h y R i g h t v e n t r i c u l a r h y p e r t r o p h y

P o s . / n e g . b i p h a s i c

N o n e

S y m m e t r i c a l l y n e g a t i v e

A s y m m e t r i c a l l y n e g a t i v e

N e g . / p o s . b i p h a s i c

F l a t

A s c e n d i n g

N o n e

H o r i z o n t a l

S a g g i n g O R U - s h a p e d

D e s c e n d i n g



_%?%9 ; 6C1D """#$%&$'()%*+#,-$ .f

V 1

V 2

V 3

V 4

V 5

V 6

E C G 3

V 1

V 2

V 3

V 4

V 5

V 6

E C G 2

S T

d e p r e s s i o n

T

n e g a t i v i t y

D i a g n o s i s






L e f t v e n t r i c u l a r h y p e r t r o p h y

R i g h t v e n t r i c u l a r h y p e r t r o p h y


N o n e




F l a t

A s c e n d i n g

N o n e

H o r i z o n t a l


D e s c e n d i n g



_%?%9 ; 6C1D """#$%&$'()%*+#,-$ .B

V 1

V

2

V 3

V 4

V 5

V 6

E C G 5

V 1

V 2

V 3

V 4

V 5

V 6

V 1

E C G 4

S T

d e p r e s s i o n

T

n e g a t i v i t y

D i a g n o s i s









N o n e




F l a t

A s c e n d i n g

N o n e

H o r i z o n t a l


D e s c e n d i n g



_%?%9 ; 6C1D """#$%&$'()%*+#,-$ ]F

V 1

V 2

V 3

V 4

V 5

V 6

E C G 7

V 1

V 2

V 3

V 4

V 5

V 6

V 1

V

E C G 6

S T

d e p r e s s i o n

T

n e g a t i v i t y

D i a g n o s i s









N o n e




F l a t

U p s h a p i n g

N o n e

H o r i z o n t a l


D o w n s h a p i n g



_%?%9 f """#$%&$'()%*+#,-$ ]E

!"#"$ c' N2:- "#".=T*<= */12- -* ^+*C :T*/- 7=*):.<0:$

0+9:.)-0*+ :+< -2" >?@ )*78$"A/0 )41( 9%?%9@ +-C '*% 3-103 )- 9%'*0 4-" $+-,'*&1'9 102'*,)1-0 '22%,)( )4% '55%'*'0,% -2 )4% 678#

(.*C+0+1 0+ +"1:-0#0-=A4%*%[( -0% R13 1&%' )4') +-C 4'?% )- Y%%5 10 $10& 10 -*&%* )- *%$%$R%* "4') $+-,'*&1'9 102'*,)1-0 &-%(

)- )4% 678 ,-$59%:# e0& )41( R13 1&%' 1(= A/"F#1#2 1# #%2:$1)1$H;

M*-"0103 $%'0( )4') ,%*)'10 5'*)( -2 )4% 678 R%,-$% 0%3')1?% U6 "'?%(X "419% -)4%* 5'*)( "199 &%,*%'(%

10 (1D% U7 "'?%(X# /0 -)4%* "-*&(@ -0% -* $-*% -2 )4% 2-99-"103 )4103( ,'0 4'55%0=

• e 5*%%:1()103 Q F:)% &%,*%'(%( 10 (1D%

• e 5*%%:1()103 P F:)% 3%)( &%%5%*

• e 0%" P F:)% &%?%9-5(

A4% *%(C9)103 5'))%*0 1( 41349+ &%5%0&%0) -0 )4% 101)1'9 2-*$ -2 )4% 678 ,-$59%:# e( "%[?% ('1& R%2-*%@ 12

+-C Y0-" "4') )4% 678 ,-$59%: 10 %',4 9%'& 9--Y( 91Y%@ +-C[99 '9(- Y0-" "4%0 (-$%)4103[( "*-03#



_%?%9 f """#$%&$'()%*+#,-$ ]K

with infarctionwithout infarction



_%)[( 4'?% ' 9--Y ') (-$% %:'$59%(=

4R:78*% T, /0 )41( %:'$59%@ )4%*%[( '0 101)1'9 6

"'?% %?%0 "1)4-C) $+-,'*&1'9 102'*,)1-0# A41(

,-C9& R% g] -* gN "4%*% "% "-C9& )+51,'99+

(%% ' ($'99 6 %?%0 10 0-*$'9 5')1%0)(# Q4%0

$+-,'*&1'9 102'*,)1-0 &%?%9-5(@ )4% 6 3%)($C,4 &%%5%* )4'0 R%2-*%I4%*% 1)[( ETP )4%

(1D% -2 )4% 7 "'?%#

?1+,, = 3+'$. *+- I$ B($.$-# )-

,$+%. PY< PU< @< +Pa< @@< +-% @@@ "0

2$+,#29 B+#)$-#.7

4R:78*% b, O%*% "% 4'?% ' ($'99 101)1'9 7

"'?%# A41( 1( )4% )+51,'9 '55%'*'0,% -2 9%'&( gE

-* gK# Q4%0 $+-,'*&1'9 102'*,)1-0 &%?%9-5(@

)4% 7 3%)( 9-() '0& "% %0& C5 "1)4 -0% &%%5

68 ,-$59%:#

4R:78*% !, /0 )41( %:'$59%@ )4% 7 "'?% 1(

'9*%'&+ 5*%))+ )'99 U9%2) (1&%@ "1)4-C)

102'*,)1-0X@ "419% )4% 8 1( ()199 2'1*9+ &%%5 U7T8

*')1- p EX# 8- )41( $C() R% '0 '*%' C0&%* 9%'&(

gK )- g.# /0 )4%(% 9%'&( "% C(C'99+ &-0[) (%%

'0+ 6 "'?%(# iC) "4%0 $+-,'*&1'9 102'*,)1-0

&%?%9-5(@ )4%*%[( ' 0%" 6 "'?% ') )4%

R%3100103 -2 )4% 678I)4% 101)1'9 7 "'?% 1( 9-()#

82$.$ *2+-/$. +BB$+( "'$( #2$

B+(#. "0 #2$ '$-#()*,$ #2+# +($

+00$*#$% I9 19"*+(%)+,

)-0+(*#)"-< 32)*2 1+J$.

,"*+,):+#)"- "0 #2$ +00$*#$% +($+

0+)(,9 $+.97



_%?%9 f """#$%&$'()%*+#,-$ ]P

normal

V4 V5 V6

Q waves increase

5""A $" L#"F= A4%(% ,4'03%( )- )4% 678 ,-$59%: ,'0 R% (%%0 10 ',C)% eZM -9& $+-,'*&1'9 102'*,)1-0(#

Q4%0 +-C -R(%*?% )4%$ 10 ' 5')1%0) "4- &-%( 0-) 4'?% '0+ (+$5)-$( -2 ',C)% $+-,'*&1'9 102'*,)1-0@

)41( 5*-R'R9+ $%'0( )4') +-C '*% &%'9103 "1)4 '0 -9& 102'*,)#

B:-2*$*10) *. +*- 8:-2*$*10)6-2:- 0, -2" d/",-0*+

/) ,'0 (-$%)1$%( R% )*1,Y+ )- &122%*%0)1')% R%)"%%0 0-*$'9 6 "'?%( '0& 5')4-9-31, 6 "'?%(# >')4-9-31,

6 "'?%( 10 )4% (%))103 -2 $+-,'*&1'9 102'*,)1-0 '*% C(C'99+ &%%5%* '0& "1&%* )4'0 0-*$'9 6 "'?%(# A4%./1$%/1: 9"/ 8:$3"*"21. P F:)%& '*%=

• A4% &%5)4 -2 )4% 6 "'?% 1( s ET. )4% (1D% -2 )4% 7 "'?% 10 )4% ('$% 9%'&#

-*

• A4% 6 "'?% &C*')1-0 1( o F#F. (%,-0&( UE ($'99 R-: -0 )4% <bc 5'5%*X#

A4%*% '*% ' ,-C59% -2 '&&1)1-0'9 ,*1)%*1' RC) )4%(% '*% )4% -0%( +-C (4-C9& *%$%$R%* 2-* 0-"#

k0% -)4%* )*1,Y )4') +-C ,'0 C(% 10 )4% 5*%,-*&1'9 9%'&( 1( )- 9--Y ') )4% 6 "'?% 5*-3*%((1-0 10 9%'&( g. )-gN# `0&%* 0-*$'9 ,-0&1)1-0(@ )4% &%5)4 -2 )4% 6 "'?% 10,*%'(%( '( "% 3- 2*-$ g. )- gN@ '( (%%0 -0 )4%

2-99-"103 %:'$59%=

O-"%?%*@ "4%0 )4%*%[( '0 102'*,) 10 )4% '*%' -2 g. '0& g]@ 6 "'?%( "199 &%,*%'(% 10 (1D% '( "% 3- 2*-$ g.

)- gN@ '( (%%0 10 )4% 2-99-"103 %:'$59%=



_%?%9 f """#$%&$'()%*+#,-$ ].

V1 V2 V3 V4 V5 V6

Normal appearance of precordial leads

A4% 2-99-"103 1$'3% (4-"( '0 102'*,) ') )4% '0)%*-9')%*'9 *%31-0# /0 )41( %:'$59%@ )4%*% "199 R% 5')4-9-31,

6 "'?%( 10 g. '0& g] )4') "199 R% R133%* '0& $-*% 5*-0-C0,%& )4'0 )4% ($'99 6 "'?% 10 9%'& gN#

C3%# P F:)%& 2%$ &7:**%/ 9/"7 [D $" [<U 7H".:/A1:* 1#9:/.$1"# 1& 8/"G:G*H 8/%&%#$;

Z-" 9%)[( 4'?% ' 9--Y ') )4% 0-*$'9 '55%'*'0,% -2 )4% 5*%,-*&1'9 9%'&( '3'10=

O" /%7%7G%/,



_%?%9 f """#$%&$'()%*+#,-$ ]]

small initial R seen in

V1 and V2

EC* 078*.-:+- -.0)^, 9*. =*/. -**$T*A

Q%[99 4'?% )- 9%'*0 )"- 1$5-*)'0) 2',)( )4') '*% 1$5-*)'0) 2-* <bc $'()%*+=

q',) tE ('+(= (%:A& [+U [=U :#A [B 0&0:**H &$:/$ F1$3 :# 1#1$1:* Q F:)%;

gE ,'0 (-$%)1$%( ,-$% "1)4-C) '0 101)1'9 7 "'?% RC) 2*-$ gK -0"'*& "% '9$-() '9"'+( (%% 1)# /0 gP )4%

7 1( C(C'99+ '9*%'&+ 5*%))+ R13#

Z-" )'Y% ' 9--Y ') )41( %:'$59%=

A41( 678 '9(- 4'( ' ($'99 7 "'?%@ RC) )4%*%[( ' ($'99 6 "'?% 5*%,%&103 1)# /2 +-C (%% (-$%)4103 91Y% )41( 10

9%'&( gE@ gK@ -* gP@ +-C (4-C9& '9"'+( *%$%$R%* q',) tE# L+-,'*&1'9 102'*,)1-0 1( ?%*+ 91Y%9+ 10 )4%(%

,'(%(#

q',) tK ('+(= _"/7:**H Q F:)% :78*1$0A%& 1#./%:&% :& F% 2" 9/"7 [+ $" [<;

/2 7 "'?% '$591)C&% &-%( ZkA 10,*%'(% 2*-$ gE )- gP k7 12 7 "'?% '$591)C&% %?%0 &%,*%'(%(@ "% '9(-4'?% )- )410Y 'R-C) )4% 5-((1R191)+ -2 $+-,'*&1'9 102'*,)1-0 10 )4% '0)%*1-* "'99#

Small initial Q wave.

Beware of anything

that looks like this in

leads V1, V2 or V3!



_%?%9 f """#$%&$'()%*+#,-$ ]N

Z-" "%[99 9--Y ') (-$% %:'$59%(=

4R:78*% :, A4%*% '*% 'R0-*$'9 6 "'?%( 10 9%'&( g. )- gN# e9(-@ 7 "'?% '$591)C&% &%,*%'(%( 2*-$ gP )-

g.# A4%(% '*% ,9%'* (130( -2 $+-,'*&1'9 102'*,)1-0 -2 )4% '0)%*-9')%*'9 *%31-0 Ug. l '0)%*1-* "'99@ g] '0&

gN l 9')%*'9 "'99X#

4R:78*% G= A4% 7 "'?% (%%0 10 gE 3%)( ,-$59%)%9+ 9-() 10 gK "4%*% "% (%% ' 9'*3% 68 ,-$59%:#

qC*)4%*$-*%@ 5')4-9-31, 6 "'?%( ,'0 R% (%%0 10 gP '0& g.# A41( 1( ' ,9%'* ,'(% -2 '0 '0)%*1-* "'99

$+-,'*&1'9 102'*,)1-0 UgK )- g. l '0)%*1-* "'99X#

4R:78*% .= O%*% )4% (130( -2 $+-,'*&1'9 102'*,)1-0 '*% $-*% (CR)9% )4'0 10 )4% 5*%?1-C( %:'$59%(# 7 "'?%

'$591)C&% &%,*%'(%( '( "% 3- 2*-$ gE )- gK '0& ()'+( )4% ('$% 2*-$ gK )- gP# 7 "'?% 5*-3*%((1-0 10 g.

1( 0-*$'9 '3'10# A41( 1( 5*-R'R9+ ' ,'(% -2 $+-,'*&1'9 102'*,)1-0 -2 )4% R'('9 (%5)C$ UgK '0& gP l R'('9(%5)C$X#

V1 V2 V3 V4 V5 V6

normal

a

b

c



_%?%9 f 6C1D """#$%&$'()%*+#,-$ ];

L e v e l 8


V 1

V 2

V 3

V 4

V 5

V 6

V 2

V 3

V 1

V 2

V 3

V 4

V 5

V 6

V 1

V

2

V 1

V 2

V 3

V 4

V 5

V 6

V 1

E C

G 1

E C

G 3

E C G 2

C h a n g e s i n Q R S m o r p h o

l o g y r e l a t e d t o

m y o c a r d i a l i n f a r c t i o n ( p a t h o l o g i c Q

w a v e ,

Q S p a t t e r n , r e d u c e d i n i t i a l R w a v e )

c a n b e f o u n d i n

l e a d s

I n f a r c t i o n L o c a l i z a t i o n

W h i c h a d d i t i o n a l E C G

c h a n g e s c a n b e f o u n d ?

( w r i t e t h e m d

o w n )

V 1

V 2

V 3

V 4

V 5

V 6

V 7

V 8

A n t e r o s e p t a l

A n t e r i o r w a l l

L a t e r a l w a l l

A n t e r o l a t e r a l r e g i o n

P o s t e r i o r w a l l

P o s t e r o l a t e r a l r e g i o n

N o w

i t ’ s t i m e f o r s o m e e x e r c i s e s

a g a i n !



_%?%9 f 6C1D """#$%&$'()%*+#,-$ ]f

V 2

V 3

V 4

V

5

V 6

V 7

V 8

E C

G 4

V 1

V 2

V 3

V 4

V 5

V 6

E C

G 5

V 1

V 2

V 3

V 4

V 5

V 6

V 7

E C G 6

C h a n g e s i n Q R S m o r p h o

l o g y r e l a t e d t o

m y o c a r d i a l i n f a r c t i o n ( p a t

h o l o g i c Q

w a v e ,

Q S p a t t e r n , r e d u c e d i n

i t i a l R w a v e )

c a n b e f o u n d i n

l e a d s

I n f a r c t i o n L o c a l i z a t i o n

W h i c h a d d i t i o n a l E C G

c h a n g e s c a n b e f o u n d ?

( w r i t e t h e m d

o w n )

V 1

V 2

V 3

V 4

V 5

V 6

V 7

V 8

A n t e r o s e p t a l

A n t e r i o r w a l l

L a t e r a l w a l l






_%?%9 B """#$%&$'()%*+#,-$ ]B

!"#"$ e' ;+9".0*. C:$$ 7=*):.<0:$ 0+9:.)-0*+68":.$, :+< 80-9:$$,/0 )4% 5*%?1-C( ,4'5)%*(@ "% 2-,C(%& -0 )4% 5*%,-*&1'9 9%'&( U,4%() 9%'&(X# _%'*0103 )4% <bc "-*Y( R%() 12

+-C 4'?% ' )4-*-C34 C0&%*()'0&103 -2 )4% 5*%,-*&1'9 9%'&( I$0"($ 9%'*0103 'R-C) )4% 91$R 9%'&(# iC) 0-"

1)[( )1$% )- $-?% -0#

E2" $07T $":<,

82$ ,)1I ,$+%. +-% #2$ B($*"(%)+, ,$+%. L,""JM +# #2$ 2$+(# 0("1 #3" %)00$($-#

B$(.B$*#)'$.7

A4% 5*%,-*&1'9 9%'&( $-*% -* 9%(( (4-" )4% 4-*1D-0)'9 59'0%@ "4%*%'( )4% *17G *%:A& (4-" )4% 9/"#$:*

8*:#%#

cut plane

Precordial Leads: Horizontal Plane

cut plane

Limb Leads: Frontal Plane



_%?%9 B """#$%&$'()%*+#,-$ NF

A4% 91$R 9%'&( ,-0(1() -2=

• A4*%% ()'0&'*& 9%'&( ,'99%& >@ >>@ '0& >>>

• A4*%% 'C3$%0)%& 9%'&( ,'99%& :[Q U*134) '*$X@ :[( U9%2) '*$X@ '0& :[c U2--)X

q-C* "1*%( '*% 0%%&%& 10 -*&%* )- *%,-*& )4%(% 9%'&(=

•

A4% /%A F1/% 3-%( -0)- )4% /123$ :/7;

• A4% H%**"F F1/% 3-%( -0)- )4% *%9$ :/7;

• A4% 2/%%# F1/% 3-%( -0)- )4% *%9$ 9""$#

• A4% G*:.L F1/% 3-%( -0)- )4% /123$ 9""$;

G-C ,'0 *%$%$R%* )41( (%^C%0,% R+ 51,)C*103 ' )*'221, 9134) "1)4 ' *%& 9134) -0 )-5@ ' +%99-" 9134) 10 )4%

$1&&9%@ '0& ' 3*%%0 9134) -0 )4% R-))-$=

`(103 )4%(% "1*%(@ +-C ,'0 0-" *%,-*& )4% 91$R 9%'&(# e( "% ('1&@ )4%(% 9%'&( V9--Y ')W )4% %9%,)*1,'9

',)1?1)+ -2 )4% 4%'*) 10 ' 2*-0)'9 59'0%=



_%?%9 B """#$%&$'()%*+#,-$ NE

A4% 213C*% (4-"( )4') ,4'03%( -2 )4% 9')%*'9 "'99 U*%& '*%'X@ 91Y% $+-,'*&1'9 102'*,)1-0@ '*% &%51,)%& R+

9%'&( / '0& 'g_# b4'03%( 10 )4% 102%*1-* "'99 U3*%%0 '*%'X '*% &%51,)%& R+ 9%'&( //@ ///@ '0& 'gq#

e( "% '9*%'&+ 9%'*0%&@ 5*%,-*&1'9 9%'&( g] '0& gN '9(- &%51,) )4% 9')%*'9 "'99# 8- "% &-0[) 'R(-9C)%9+

0%%& 9%'&( / '0& 'g_ )- $'Y% )4% &1'30-(1( -2 5*-R9%$( -2 )4% 9')%*'9 "'99 91Y% $+-,'*&1'9 102'*,)1-0#

b-0?%*(%9+@ )4% 5*%,-*&1'9 9%'&( &-0[) (4-" )4% 102%*1-* "'99I') 9%'() 0-) &1*%,)9+# 8- "% 0%%& 9%'&( //@ ///@

'0& 'gq )- %?'9C')% )4% 102%*1-* "'99#

k,,'(1-0'99+@ 9%'&( //@ ///@ '0& 'gq "199 0-) &%)%,) 102%*1-* "'99 102'*,)1-0@ %(5%,1'99+ "4%0 1)[( ($'99# A4')[(

"4%0 ' 91))9% )*1,Y ,-$%( 10 4'0&+#

!**^0+1 :- 70..*. 07:1",

A4% &1*%,) %9%,)*1,'9 V1$'3%W -2 '0 102%*1-* "'99 $+-,'*&1'9 102'*,)1-0 1( ?1(C'91D%& 10 //@ ///@ '0& 'gq# _%'&(

gE@ gK@ '0& gP V9--Y ')W )4% 4%'*) 2*-$ )4% -55-(1)% (1&% '0& ,'0 )4%*%2-*% 5*-&C,% (-H,'99%& $1**-*

1$'3%(=

4A+1B,$ "0 +- )-0$()"( 3+,, 19"*+(%)+, )-0+(*#)"-7 !)($*# *2+-/$. *+- I$ .$$- )- ,$+%. @@< @@@< +-% +PiN %$$B

+-% I("+% = 3+'$< ?8 $,$'+#)"-< +-% -$/+#)'$ 8 3+'$7 O 1)(("( )1+/$ *+- I$ .$$- )- ,$+%. PT< PS< +-% PRN

I("+% > 3+'$< ?8 %$B($..)"-< +-% B".)#)'$ 8 3+'$7

?" 3$ 2+'$ #" CB%+#$ "C( J-"3,$%/$ +I"C# #2$ B($*"(%)+, ,$+%.7 PT< PS< +-% PR -"# "-,9

/)'$ 9"C )-0"(1+#)"- +I"C# #2$ ()/2# '$-#()*,$ +-% #2$ I+.+, .$B#C1 IC# +,." +I"C# #2$

)-0$()"( 3+,,e)- #2$ 0"(1 "0 1)(("( )1+/$.7 O ,"# "0 B$"B,$ %"-V# J-"3 +I"C# #2).W





_%?%9 B """#$%&$'()%*+#,-$ NP

Question Answer Diagnosis

1. Rhythm

2. Heart rate

3. P waves

4. PR interval a) > 0.2 sec (if PR interval constant for all beats & each P wave is

followed by a QRS complex)

I° AV block

b) < 0.12 sec & QRS complex normal LGL syndrome

c) < 0.12 sec & visible delta wave WPW syndrome

5. QRS axis

6. QRS duration complete bundle

branch block

b) > 0.1 and < 0.12 sec with typical bundle branch block appea-

rance (notching)

incomplete bundle

branch block

7. Rotation

myocardium is located at V1-V3 and left ventricular myocardium is at

V5-V6.

clockwise rotation

counter-clockwise rotation

in the setting of myocardial

bundle branch block

8. QRS amplitude a) QRS amplitude <0.5 mV in all standard leads low voltage

b) Positive criteria for left ventricular hypertrophy left ventricular hypertrophy

c) Positive criteria for right ventricular hypertrophy right ventricular hypertrophy

9. QRS infarction signs myocardial infarction -

10. ST-T segment

11. QT duration,

T-U waves

B$":," C"$)*7" QQQ -2" 345 )**^T**^h

Z-"@ 1)[( )1$% )- 10)*-&C,% +-C )- -C* 4!5 .""LG""L# A4% ,--YR--Y "199 5*-?1&% +-C "1)4 ' ()%5HR+H()%5

'55*-',4 2-* %?'9C')103 '0 ',)C'9 <bc "1)4-C) $1((103 '0+)4103# A4%*% '*% ' )-)'9 -2 EE ()%5( 10 )4%

,--YR--Y# G-C (4-C9& R% 'R9% )- ,-$59%)% ] -2 )4%$ "1)4 )4% Y0-"9%&3% +-C[?% ',^C1*%& (- 2'*# Q%[99

'&& $-*% ()%5( )- )4% ,--YR--Y '( "% 5*-3*%((# Q% *%,-$$%0& )4') +-C $'Y% 1) ' 4'R1) )- 3- )4*-C34'99 )4% ()%5( -2 )4% ,--YR--Y "4%0 %?'9C')103 '0 <bc# A4') "'+ +-C[99 $'Y% (C*% 0-) )- $1(( '0+)4103@

+-C[99 1$5*-?% )4% -&&( -2 ,-$103 C5 "1)4 )4% *134) &1'30-(1(@ eZM +-C[99 &%?%9-5 ' 4'R1)@ "41,4 "199

R%,-$% (%,-0& 0')C*% "1)410 ' (4-*) 5%*1-& -2 )1$%#

8- "1)4-C) 2C*)4%* '&-@ 4%*%[( )4% ,--YR--Y\#



_%?%9 B 6C1D """#$%&$'()%*+#,-$ N.

L e v e l 9

Q U I Z S E C T I O

N

V 1

V 2

I

I I

I I I

R

L

F

V 1

V 2

V 3

V 4

V 5

V 6

V 1

V 4

V 5

V 6

V 2

V 3

E C G 1

E C G 2

P R

Q R S

d u r a t i o n

R o t a t i o n

H y p e r -

t r o p h y

I n f a r c t i o n

I ° A V b l o c k W P W - s y n d r o m e

L G L - s y n d r o m e

C o m p l e t e R B B B

C o m p l e t e L B B B

D i l a t e d r i g h t v e n t r i c l e

D i l a t e d l e f t v e n t r i c l e

C l o c k w i s e r o t a t i o n

N o r m a l t r a n s i t i o n z o n e

C o u n t e r c l o c k w i s e r o t a t i o n



A n t e r o s e p t a l r e g i o n A n t e r i o r w a l l


L a t e r a l r e g i o n



I n f e r i o r w a l l

A n d n o w i t ’ s t i m e f o r s o m e e x e r c i s e s u s i n g o u r c o o k b

o o k .



_%?%9 B 6C1D """#$%&$'()%*+#,-$ N]

V 1

V 2

V 3

V 4

V 5

V 6

I

I I

I I I

R

L

F

V 1

V 2

V 3

V 4

V 5

V 6

V 1

V 2

E C G 3

E C G 4

P R

Q R S

d u r a t i o n

R o t a t i o n

H y p e r -

t r o p h y

I n f a r c t i o n




















_%?%9 B 6C1D """#$%&$'()%*+#,-$ NN

V 1

V 2

V 3

V 4

V 5

V 6

I

I I

I

I I

I I I

R

L

F

E C G 5



c o m p l e t e R B B B

c o m p l e t e L B B B

d i l a t e d r i g h t v e n t r i c l e

d i l a t e d l e f t v e n t r i c l e

c l o c k w i s e r o t a t i o n

n o r m a l t r a n s i t i o n z o n e

c o u n t e r c l o c k w i s e r o t a t i o n

r i g h t v e n t r i c u l a r h y p e r t r o p h y

l e f t v e n t r i c u l a r h y p e r t r o p h y

a n t e r o s e p t a l r e g i o n a n t e r i o r w a l l

a n t e r o l a t e r a l r e g i o n

l a t e r a l r e g i o n

p o s t e r o l a t e r a l r e g i o n

p o s t e r i o r w a l l

i n f e r i o r w a l l

P

R

Q R S

d u r a t i o n

R o t a t i o n

H y p e r -

t r o p h y

I n f a r c t i o n

I ° A V b l o c k W P W s y n d r o m e



















_%?%9 EF """#$%&$'()%*+#,-$ N;

!"#"$ &P' i)/-" )*.*+:.= ,=+<.*7",67:,-".0+1 -2" @E ,"17"+-/0 )4% 5*%?1-C( ,4'5)%*( "% &1(,C((%& "4') 4'55%0( )- )4% 678 ,-$59%: 10 )4% (%))103 -2 $+-,'*&1'9

102'*,)1-0# G-C 9%'*0%& )4') )4% 678 V&*-"0( 10 0%3')1?1)+W "4%0 $+-,'*&1'9 102'*,)1-0 -,,C*(@ "41,4

$%'0( )4') 7 "'?% '$591)C&%( &%,*%'(% '0& 6 "'?%( %$%*3%#

A4%(% 678 ,4'03%( '*% (130( -2 $+-,'*&1'9 0%,*-(1( '0&T-* (,'**103# 8,'*( '*% C(C'99+ 1**%?%*(1R9%# 8-

)4%(% ,4'03%( )- )4% 678 ,-$59%: '*% '9(- 1//%)%/&1G*%#

iC) $+-,'*&1'9 102'*,)1-0 0-) -09+ '22%,)( )4% 678 ,-$59%: RC) '9(- )4% 8A (%3$%0)@ '0& )4%(% ,4'03%(

'*% C(C'99+ $/:#&1%#$#

e,C)% $+-,'*&1'9 102'*,)1-0 1( 5'*) -2 )4% (-H,'99%& T.0$% !"/"#:/H OH#A/"7%& Ueb8X# e,C)% b-*-0'*+

8+0&*-$%( *%(C9) 2*-$ U5'*)9+X -,,9C&%& ,-*-0'*+ '*)%*1%( %1)4%* R+ ' )4*-$RC( -* *C5)C*%& 59'^C%#

/2 +-C "'0) )- R%,-$% ' )*C% $'()%* -2 )4% 8A (%3$%0)@ +-C[99 0%%& ' )4-*-C34 C0&%*()'0&103 -2 )4%

&122%*%0) e,C)% b-*-0'*+ 8+0&*-$%(# 8- 4%*% )4%+ '*%#

e 2%" )4103( )- *%$%$R%*=

E# i-)4 OE4d>& :#A _OE4d>& '*% ,4'*',)%*1D%& R+ '0 %*%):$1"# "9 $/"8"#1# 10 )4% R9--&# A*-5-010 1(

%9%?')%& R%,'C(% $+-,'*&1'9 ,%99( '*% &+103 -22#

K# e( )4% 0'$% 1$591%(@ OE4d> ,-$%( "1)4 '0 %*%):$1"# "9 $3% OE &%27%#$ U&C4dX@ "41,4

&1(,*1$10')%( 1) 2*-$ Z8A<L/ '0& C0()'R9% '0310'#

P#

/0 _OE4d> :#A 0#&$:G*% :#21#:@ ,4'03%( )- )4% 8A (%3$%0) ,'0 R% (CR)9%j )4%*% ,'0 R% OEA%8/%&&1"#U E F:)% 1#)%/&1"#U -* R-)4#

.# 8A ,4'03%( '*% ?%*+ (1$19'* 10 C0()'R9% '0310' '0& Z8A<L/# O-"%?%*@ 10 0#&$:G*% :#21#:U

$/"8"#1# U'0& -)4%* ,'*&1', %0D+$%(X '*% _eE %*%):$%A#



_%?%9 EF """#$%&$'()%*+#,-$ Nf

A4% 213C*% R%9-" (4-"( )4% &122%*%0) ()'3%( -2 ',C)% ,-*-0'*+ (+0&*-$%(#

A4% )%*$( V8A<L/@W V',C)% $+-,'*&1'9 102'*,)1-0@W '0& Veb8 "1)4 8A %9%?')1-0W '*%

(-$%)1$%( C(%& 10)%*,4'03%'R9+# O-"%?%*@ eb8 &-%(0[) 0%,%(('*19+ 9%'& )- $+-,'*&1'9

102'*,)1-0 U1#%#@ 0%,*-(1(X# A4%*%2-*%@ +-C (4-C9& )410Y -2 8A %9%?')1-0 '( ' (130 -2 ',C)%

1(,4%$1' *')4%* )4'0 102'*,)1-0#

@0-/:-0*+, ; :+< ;;6i4@ C0-2 @E "$"#:-0*+

8A %9%?')1-0 ,'0 -,,C* "1)4 -* "1)4-C) 6 "'?%(#

_%)[( 21*() )'Y% ' 9--Y ') 8A %9%?')1-0( "1)4 6 "'?%( U(1)C')1-0 / 10 )4% 5*%?1-C( 199C()*')1-0X=

• e( (+$5)-$( &%?%9-5@ OE &%27%#$ %*%):$1"# :88%:/& U1(,4%$1'X#

•

e 2%" 4-C*( '2)%* )4% R%3100103 -2 $+-,'*&1'9 1(,4%$1'@ 5')4-9-31, P F:)%& :88%:/ '( ' (130 -2

0%,*-(1( U/e 10 )4% 199C()*')1-0X#

III B

III A

ACS without ST elevation

symptoms

no symptoms

I II

IV

ACS with ST elevation

A

B

C

D



_%?%9 EF """#$%&$'()%*+#,-$ NB

• e( $%0)1-0%& 'R-?%@ 8A %9%?')1-0 1( ' )*'0(1%0) 54%0-$%0-0# A4% 5*-,%(( 2*-$ 8A %9%?')1-0 )-

1)( *%(-9C)1-0 1( ,'99%& OE &%27%#$ /%&"*0$1"## /) ()'*)( "1)4 )4% 8A (%3$%0) 3-103 &-"0 '0& )4% A

"'?% R%,-$103 0%3')1?% U/iX#

• /0 )4% (CR',C)% 54'(% -2 $+-,'*&1'9 102'*,)1-0 U/bX@ )4% OE &%27%#$ /%$0/#& $" $3% 1&"%*%.$/1. *1#%U

'0& $3% E F:)% G%."7%& #%2:$1)%# /0 (-$% 5')1%0)(@ )41( 5'))%*0 5%*(1()( 2-*%?%*#

• /0 )4% ,4*-01, 54'(% -2 $+-,'*&1'9 102'*,)1-0 U/MX@ )4% A "'?% R%,-$%( 5-(1)1?% '3'10# A4%*% 1( 0-

*%(1&C'9 (130 -2 102'*,)1-0 10 )4% 8A (%3$%0) -* A "'?%# A4% $+-,'*&1'9 (,'* 1( -09+ ?1(1R9% '( ' 6

"'?% -* 68 ,-$59%:#

• A1$% C0)19 ,-$59%)% 8A (%3$%0) *%(-9C)1-0 1( ?'*1'R9%# /) ()*-039+ &%5%0&( C5-0 )1$% )-

*%?'(,C9'*1D')1-0# `(C'99+@ )4% 8A (%3$%0) ()'*)( )- 3- &-"0 1$$%&1')%9+ '2)%* ,-$59%)%

*%?'(,C9'*1D')1-0# /0 -)4%* ,'(%( 8A %9%?')1-0 &1('55%'*( -09+ '2)%* (%?%*'9 &'+(# >%*(1()%0,% -2 8AH

(%3$%0) %9%?')1-0( -?%* "%%Y( '2)%* $+-,'*&1'9 102'*,)1-0 1( '9'*$103 '( 1) 1( -2)%0 ,'C(%& R+ '

9%2) ?%0)*1,C9'* '0%C*+($#

A4% )1$% &%5%0&%0) 5'))%*0 -2 ,4'03%( (%%0 10 )4% 8A (%3$%0) '0& A "'?% ,'0 '9(- R% -R(%*?%& 10 0-0a

6 "'?% 102'*,)1-0 U'0& 10 5')1%0)( "1)4 5%*1$+-,'*&1)1(XI)41( 1( (1)C')1-0 // 10 )4% 199C()*')1-0#

@0-/:-0*+ ;;;6i4@ C0-2*/- @E "$"#:-0*+

/0 Z8A<L/ '0& C0()'R9% '0310'@ (+$5)-$( '*% '((-,1')%& "1)4 8A &%5*%((1-0 U/// e 10 )4% 199C()*')1-0X -* A

"'?% 10?%*(1-0 U/// iX# /0 -*&%* )- &122%*%0)1')% R%)"%%0 Z8A<L/ '0& C0()'R9% '0310'@ +-C[99 4'?% )- 9--Y

"4%)4%* ,'*&1', %0D+$%( '*% %9%?')%&#

?)-*$ ."1$ B+#)$-#. 3)#2 *"("-+(9 +(#$(9 %).$+.$ 2+'$ -$/+#)'$ 8 3+'$. $'$- 32$- #2$9+($ +.91B#"1+#)*< )#V. '$(9 )1B"(#+-# #" ,""J 0"( *2+-/$. )- ?8d8 3+'$ 1"(B2","/9

%C()-/ .91B#"1.7

]?84D@ )- #2$ #$(()#"(9 "0 #2$ ,$0# +-#$()"( %$.*$-%)-/ +(#$(9 GaO!H7 a$+%. PS< PR< +-% PX +($ +00$*#$%7

myocardial aneurysm

V1

NSTEMI or non Q wave infarction

V2 V3 V4 V5 V6

NSTEMI or non-Q wave infarction



_%?%9 EF """#$%&$'()%*+#,-$ ;F

ascending part of the QRS complex

concave

Perimyocarditis

descending part of the QRS complex

convex

STEMI

@0-/:-0*+ ;j6B.0+Z7"-:$ :+10+:' : ,8")0:$ ):,"

A4%*% 1( ' 2-*$ -2 $+-,'*&1'9 1(,4%$1' )4')[( ,-$$-09+ '((-,1')%& "1)4 8A %9%?')1-0# A41( &1(%'(% 1(

,'99%& [:/1:#$ :#21#: -* X/1#W7%$:* :#21#:# b4%() 5'10 1( )+51,'99+ -2 (4-*) &C*')1-0 UE] )- KF $10C)%(X

'0& '55%'*( ') *%() -* %?%0 &C*103 (9%%5# `091Y% -)4%* 2-*$( -2 '0310'@ 8A %9%?')1-0 *%)C*0( )- R'(%910%

1$$%&1')%9+ '2)%* (+$5)-$( &1('55%'*# b-*-0'*+ -,,9C(1-0 1( )4-C34) )- R% ,'C(%& R+ ,-*-0'*+ (5'($ 10

)4%(% ,'(%(#

Return to baseline after

symptom resolution

B".07=*):.<0-0,

/0 5%*1$+-,'*&1)1(@ )4% 8A (%3$%0) 1( C(C'99+ '9(- %9%?')%&# >%*1$+-,'*&1)1( 1( ' &122C(% &1(%'(% '0&@ C091Y%

102'*,)1-0@ 1)[( 0-) 91$1)%& )- )4% 5%*2C(1-0 )%**1)-*+ -2 -0% ,-*-0'*+ '*)%*+#

Z2$-$'$( 9"C .$$ ?8 $,$'+#)"-. )- +($+. #2+# +($ -"# .CBB,)$% I9 "-$ .)-/,$ +(#$(9< 9"C

.2"C,% #2)-J "0 ;$()19"*+(%)#).7

A+51,'99+@ )4% 8A %9%?')1-0 1( 0-) ,-0?%:@ '( 10 $+-,'*&1'9 102'*,)1-0 RC) *')4%* ,-0,'?% U'( (%%0 -0 )4%2-99-"103 1$'3%X# qC*)4%*$-*%@ )4% 8A (%3$%0) C(C'99+ -*1310')%( 2*-$ )4% '(,%0&103 5'*) -2 )4% 678

,-$59%: 10 5%*1$+-,'*&1)1(@ "4%*%'( 10 8A<L/@ 1) C(C'99+ -*1310')%( 2*-$ )4% &%(,%0&103 5'*) -2 )4% 678#

@- ;$()19"*+(%)#). 9"C *+- +,." .$$ #2$ #)1$d%$B$-%$-# *2+-/$. .$$- )- O5? 3)#2 ?8

$,$'+#)"-< ?8 ($.",C#)"-< 8 3+'$ )-'$(.)"-< $#*7



_%?%9 EF """#$%&$'()%*+#,-$ ;E

j:1*-*+0:

e0& 210'99+@ )4%*%[( -0% $-*% 2-*$ -2 8A (%3$%0) %9%?')1-0 )4')[( *')4%* 100-,%0) ,-$5'*%& )- )4%

5*%?1-C( -0%(# A41( )+5% -2 8A %9%?')1-0 ,'0 R% (%%0 10 )4% (%))103 -2 ):2"$"#1: U1#%#@ '0 10,*%'(% 10 ?'3'9

)-0%X# A4% %9%?')1-0 1( C5 )- F#K $g 10 '$591)C&%@ '0& 1)[( C(C'99+ ',,-$5'01%& R+ ' )'99 '0& 5%'Y%& A

"'?%@ '( "%99 '( ' 9-" 4%'*) *')% -2 p NF R%')( 5%* $10C)%#

5+.$ "0 '+/"#"-)+ 3)#2 ?8 $,$'+#)"- +-% + #+,,< B$+J$% 8 3+'$7

Z)#2 #2). J-"3,$%/$ )- 1)-%< 3$ *+- -"3 +%% #2$ $'+,C+#)"- "0 #2$ ?8 .$/1$-# #" #2$

.#$B. "0 "C( *""JI""J7 ]"#$ #2+# #2$ ?8 .$/1$-# .2"C,% +,3+9. I$ $'+,C+#$% )-

*"1I)-+#)"- 3)#2 #2$ =>? *"1B,$A7

V1 V 2 V3 V4 V5 V6



_%?%9 EF """#$%&$'()%*+#,-$ ;K


1. Rhythm

2. Heart rate

3. P waves



I° AV block



5. QRS axis


branch block


rance (notching)

incomplete bundle

branch block

7. Rotation


V5-V6.

clockwise rotation



bundle branch block




9. QRS infarction signs myocardial infarction -



_%?%9 EF """#$%&$'()%*+#,-$ ;P

10. ST-T segment

tall T wave ST depression ST depression ST elevation negative T

vagotonia

probably ischemia

abnormality

perimyocarditis

Variant angina

STEMI in resolution

STEMI in resolution

STEMI acute and in resolution

left ventricular hypertrophy

In these situations an ST

segment deviation is almost

always present and cannot be

interpreted in and of itself.

It has to be left out in the

ECG report

11. QT duration,

T-U waves

QRS normal

QRS normal

QRS normal

QRS normal

QRS: left ventricular

hypertrophy

QRS: right ventricular

hypertrophy, bundle

branch block or WPW

syndrome

QRS with Q wave

QRS normal

QRS normal





_%?%9 EF 6C1D """#$%&$'()%*+#,-$ ;]

V 1

V 2

V 3

V 4

V 5

V 6

V 1

V 2

V 1

V 2

V 3

V 4

V 5

V 6

I

I I

I I I

R

L

F

E C G 3

E C G 4

P a t h o l o g

y

P h a s e

W h i c h a d d i t i o n a l

p a t h o l o g i e s c a n b e f o u n d ?

( u s e o u r c o o k b o o k )

Q w a v e S T E M I

N o n - Q w a v e S T E M I

A c u t e c o r o n a r y s y n d r o m e / N S T E M I

P e r i m y o c a r d i t i s

N o n e o f t h e p a t h o l o g i e s m e n t i o n e d

A c u t e

I n r e s o l u t i o n

C h r o n i c ( o n l y a p p l i e s t o S T E M I )

N o m e n c l a t u r e c a n n o t b e a p p l i e d



_%?%9 EF 6C1D """#$%&$'()%*+#,-$ ;N

V 1

V 2

V 3

V 4

V 5

V 6

V

1

V 2

V 3

V 4

V 5

V 6

I

I I

I I I

R

L

F

I

I I

V 1

V 2

V 3

V 4

V 5

V 6

V 1 I

E C G 5

E C G 6

E C G 7

P a t h o l o g y

P h a s e




Q w a v e S T E M I





A c u t e






_%?%9 EF 6C1D """#$%&$'()%*+#,-$ ;;

V 1

V 2

V 3

V 4

V 5

V 6

I

I I

I I I

I

I I

I I

I

I

I I

I I I

R

L

F

E C G 8

P a t h o l o g y

P h a s e




Q w a v e S T E M I





A c u t e




J u n e 1

J u n e 4

J u n e 6



_%?%9 EE """#$%&$'()%*+#,-$ ;f

!"#"$ &&' E2" 345 -.0*6):.<0:) :A0,D :-.0:$ 2=8".-.*82=D :+<

$*CJ#*$-:1"/0 )41( 9%?%9@ +-C '*% 3-103 )- 9%'*0 '0 %'(+ '0& 2'() $%)4-& 2-* 4-" )- &%)%*$10% )4% ,'*&1', ':1(# A4%

3--& 0%"( 1(@ 1)[( $C,4 %'(1%* )4'0 %?%*+-0% )%99( +-C#

E2" ,2*)^0+1 -./-2 :T*/- -2" ):.<0:) :A0,

/2 +-C[*% 91Y% $-() <bc ()C&%0)(@ +-C 210& )4% %?'9C')1-0 -2 )4% ,'*&1', ':1( C))%*9+ ,-02C(103@ '0& +-C '*%

0-) (C*% "4+ +-C 4'?% )- 9%'*0 1) ') '99# 6C1)% 2*'0Y9+@ +-C '*% 'R(-9C)%9+ *134)#

Q4%0 +-C ,-$5'*% )4% '$-C0) -2 )1$% $-() 2-9Y( (5%0& ()C&+103 )4% ':1( '0& )4% ',)C'9 ?'9C% 1) '&&( )-

)4%1* *%5-*)(@ +-C[99 0-)1,% )4') )4% *%)C*0 -0 )4%1* )1$% 1( 4C$R9%# A4% 3--& 0%"( 1( )4') )4%*% '*% -09+ '

,-C59% -2 )4103( )4') '*% *%'99+ 1$5-*)'0) 'R-C) )4% ':1(# /0 )41( (%,)1-0@ "%[99 )%',4 +-C "4') )4%+ '*%#

Q1)4 )4% ,-$591,')%& 3%-$%)*+ -2 )4% ?%0)*1,9%(@ +-C ,'0 1$'310% )4') ') %',4 5-10) 10 )1$% )4%*% '*%

?%,)-*( -2 &122%*%0) '$591)C&%( 5-10)103 10 &122%*%0) &1*%,)1-0( 10(1&% )4% 4%'*)# q*-$ '99 )4%(% $-$%0)'*+?%,)-*(@ '0 '?%*'3% ?%,)-* ,'0 R% ,-0()*C,)%& 2-* %',4 5-10) 10 )1$%#

Z$ J-"3 #2+# '$-#()*C,+( %$B",+():+#)"- #+J$. +I"C# \Q #" TQQ 1.$* Gj Q7T .$*H7 @- #2). )1+/$ 3$ 2+'$

1+(J$% + 0$3 "0 #2$.$ )-.#+-#+-$"C. +'$(+/$ '$*#"(.N ON '$*#"( +# Y 1.$*k `N '$*#"( +# RQ 1.$*k 5N

'$*#"( +# UQ 1.$*k !N '$*#"( +# \Q 1.$*7 82$ %+.2$% ,)-$ *"--$*#)-/ #2$ #)B. "0 #2$.$ '$*#"(. ($B($.$-#.

#2$ ?%,)-* 9--5 < 32)*2 C.$% #" I$ C.$% )- '$*#"(*+(%)"/(+B297 `C# %"-l# 3"((9< 3$ 3"-l# /" )-#" 0C(#2$(

%$#+),.7



_%?%9 EE """#$%&$'()%*+#,-$ ;B

A4% ()*-03%() U1#%#@ 9-03%()X -2 )4%(% '?%*'3% ?%,)-*( 1( ,'99%& )4% 7:1# )%.$"/j 1) 1( )4% -0% )4')

&%)%*$10%( )4% %9%,)*1,'9 ':1( -2 )4% 4%'*) 10 )4% 2*-0)'9 59'0%# /0 -)4%* "-*&(@ )4% ,'*&1', ':1( *%5*%(%0)(

)4% &1*%,)1-0 -2 )4% $'10 %9%,)*1,'9 ?%,)-* 10 )4% 2*-0)'9 59'0%#

A4% $-() %:',) "'+ )- &%)%*$10% )4% ':1( 10 )4% 2*-0)'9 59'0% "-C9& R% )- %:',)9+ ,'9,C9')% )4% &1*%,)1-0

-2 )4% $'10 ?%,)-*# O-"%?%*@ )4')[( )-- )1$% ,-0(C$103 '0& 0-) "-*)4 )4% %22-*) R%,'C(% )4%*% '*% -09+

' 2%" (1)C')1-0( "4%*% Y0-"9%&3% -2 )4% ':1( *%'99+ $'Y%( ' &122%*%0,%# G-C[99 9%'*0 "4') )4%+ '*% ' 91))9%9')%*#

Q4') "% (4-C9& R% 'R9% )- &- 1( )- 210& )4% $-() 1$5-*)'0) 'R0-*$'91)1%( -2 )4% %9%,)*1,'9 ':1(# i%9-" "%

-C)910% ' (1$59% )*1,Y 2-* &-103 (-#

7%$%$R%* )4') ' 9%'& *%,-*&( ' 8"&1$1)% F:)% "4%0 )4% )%.$"/ 8"1#$& 1#$" $3%

A1/%.$1"# "9 $3:$ *%:A# Q4%0 )4% )%.$"/ 8"1#$& :F:H 9/"7 $3:$ *%:A@ )4% &%29%,)1-0 "199

R% $'109+ #%2:$1)%#

q1*()@ "% 4'?% )- 9%'*0 )4% 9-,')1-0 -2 )4% 9%'&( U/@ //@ /// '0& 'g7@ 'g_@ 'gqX -0 )4% b'R*%*' ,1*,9% U-*

b'R*%*' (+()%$X# A41( (+()%$ 5*-?1&%( ' ,-0?%0)1-0 2-* *%5*%(%0)103 )4% %:)*%$1)+ 9%'&( 10 ' 9-31,'9

(%^C%0,%# A4% 9-,')1-0 -2 %',4 9%'& ,'0 R% (%%0 10 )4% 1$'3% R%9-"#

+90°

0°

-90°

180°

aVR aVL

aVF

I

IIIII



_%?%9 EE """#$%&$'()%*+#,-$ fF

_%) C( 0-" ,-0(1&%* "4') )41( $%'0( 2-* 9%'& /=

_%)[( (%% "4') 4'55%0( "4%0 9%'&( / '0& // '*% $'109+ 5-(1)1?%=

The area between -30° and +90° is called a “normal axis”

M%29%,)1-0 1( #%2:$1)%

"4%0 ?%,)-*( 5-10)

:F:H 9/"7 9%'& /

M%29%,)1-0 1( 8"&1$1)%

"4%0 ?%,)-*( 5-10) 1# $3%

A1/%.$1"# -2 9%'& /



_%?%9 EE """#$%&$'()%*+#,-$ fE

8- "% Y0-" )4') 12 9%'&( / '0& // '*% 5-(1)1?%@ )4% ?%,)-* 5-10)( ') )4% '*%' R%)"%%0 HPFv )- wBFv# L-()

%9%,)*1,'9 ?%,)-*( 10 4C$'0( '*% 9-,')%& 10 )4') (%,)-* '0& )4')[( "4+ "% ,'99 1) ' #"/7:* :R1&# A4%

)%*$10-9-3+ ?'*1%( 10 &122%*%0) $%&1,'9 (,4--9( '0& ,-C0)*1%(# Q% "199 C(% )4% )%*$( $-()9+ C(%& 10 i*1)1(4

'0& e$%*1,'0 )%:)R--Y(#

Z-" 9%)[( (%% "4') 4'55%0( "4%0 9%'& / 1( 5-(1)1?% '0& 9%'& // 1( 0%3')1?%=

The area between -30° and -90° is called “left axis deviation”

/2 9%'& / 1( 0%3')1?%@ +-C (4-C9& 9--Y ') 9%'& 'gq 10()%'& -2 9%'& // 10 -*&%* )- &%)%*$10% )4% ':1(#



_%?%9 EE """#$%&$'()%*+#,-$ fK

Z-" 9%)[( (%% "4') 4'55%0( "4%0 9%'& / 1( 0%3')1?% '0& 'gq 1( 5-(1)1?%=

The area between +90° and +-180° is called “right axis deviation”



_%?%9 EE """#$%&$'()%*+#,-$ fP

e0& "4')[( )4% $'))%* "4%0 R-)4 9%'&( / '0& 'gq '*% 0%3')1?%S

The area between -90° and +-180° is called a “North-West axis”

G-C (4-C9& -09+ ,'*% 'R-C) 9%2) ':1( &%?1')1-0 '0& *134) ':1( &%?1')1-0 2-* 0-"# Q4+S i%,'C(% "4%0 )4%

':1( 1( 0-*$'9@ )4') "-0[) *%'99+ 4%95 +-C 10 *%210103 +-C* &1'30-(1(# e Z-*)4HQ%() ':1( 1( %:)*%$%9+ *'*%I

+-C "-0[) %0,-C0)%* 1) $C,4 '( ' 0-?1,%# iC) +-C "199 %0,-C0)%* 9%2) ':1( &%?1')1-0 '0& *134) ':1(

&%?1')1-0@ '0& )4%+ "199 4%95 +-C 10 +-C* &1'30-(1(#

The main vector has to point at theIntersection of the grey and red areas



_%?%9 EE """#$%&$'()%*+#,-$ f.

8- 4%*%[( '0 -?%*?1%"=

8- 4-" ,'0 +-C &%)%*$10% )4% ,'*&1', ':1( *%'99+ %'(19+S O%*%[( 4-"\

e99 +-C 4'?% )- &- 10 -*&%* )- &%)%*$10% )4% ,'*&1', ':1( 1( )- 4-9& )4% <bc 5*10)-C) 10 +-C* 4'0&(# G-C*

9%2) )4C$R (4-C9& R% 0%:) )- 9%'& /# >9 *%:A > 1& 8"&1$1)%U *%:A >> &3"0*A G% #%R$ $" H"0/ /123$ $307G; >9 *%:A

> 1& 7:1#*H #%2:$1)%U *%:A :[c &3"0*A G% #%R$ $" H"0/ /123$ $307G=

If both leads are mainly positive,

it’s a normal axis

If the left lead is mainly positive and the right lead

is mainly negative, it’s a left axis deviation



_%?%9 EE """#$%&$'()%*+#,-$ f]

K"CV,, /$# B,$-#9 "0 "BB"(#C-)#)$. #" +..$.. #2$ +A). )- #2$ $A$(*).$.W

Z-" 9%)[( )C*0 )- )4% ,9101,'9 (1)C')1-0( "4%*% Y0-"9%&3% -2 )4% ,'*&1', ':1( $'Y%( ' &122%*%0,%#

@0-/:-0*+ k&

q-* ?%0)*1,C9'* &%5-9'*1D')1-0@ 1$5C9(%( '*% ,-0&C,)%& &-"0 10)- )4% ?%0)*1,9%( )4*-C34 )4% (-H,'99%&

RC0&9% R*'0,4%(# A4%*%[( ' *134) RC0&9% R*'0,4 '0& ' 9%2) RC0&9% R*'0,4# A4% 9%2) RC0&9% R*'0,4 1( (CRH

&1?1&%& 10)- ' 9%2) '0)%*1-* 2'(,1,9% U_eqX '0& ' 9%2) 5-()%*1-* 2'(,1,9% U_>qX '( (4-"0 10 )4% 1$'3%=

right bundle branch

(RBB)

left bundle branch(LBB)

anterior fascicle(LAF)

posterior fascicle(LPF)

HIS bundle

If the right lead is mainly positive and

the left lead is mainly negative, it’s

right axis deviation

If both leads are mainly negative, it’s a

North West axis



_%?%9 EE """#$%&$'()%*+#,-$ fN

Q% 4'?% '9*%'&+ 9%'*0%& )4') )4% 678 ,-$59%: R*-'&%0( "4%0 %1)4%* )4% *134) -* 9%2) RC0&9% R*'0,4%(

'*% R9-,Y%&# 8-$%)1$%( "4') 4'55%0( 10 *134) RC0&9% R*'0,4 R9-,Y 1( )4') -0% -2 )4% 9%2) 2'(,1,9%( 1( '9(-

R9-,Y%&# A4')[( ,'99%& ' R1H2'(,1,C9'* R9-,Y# /)[( ' 5*%))+ &'03%*-C( (1)C')1-0@ (10,% )4%*%[( -09+ -0% 2'(,1,9%

)4')[( 9%2) 2-* )4% 1$5C9(% )- *%',4 )4% ?%0)*1,9%(# /2 )41( 9'() 2'(,1,9% 3%)( R9-,Y%& '( "%99@ )4% 5')1%0) %0&(

C5 10 ,-$59%)% 4%'*) R9-,Y@ ' 5-)%0)1'99+ 912%H)4*%')%0103 (1)C')1-0#

O-" ,'0 +-C )%99 12 R1H2'(,1,C9'* R9-,Y 1( 5*%(%0)S Q%99@ 12 +-C 4'?% ' )+51,'9 51,)C*% -2 ' *134) RC0&9%R*'0,4 R9-,Y 10 )4% 5*%,-*&1'9 9%'&( eZM +-C '9(- 4'?% 9%2) ':1( &%?1')1-0@ )4% 5')1%0) 4'( R1H2'(,1,C9'*

R9-,Y 10?-9?103 )4% 9%2) '0)%*1-* 2'(,1,9% U'9(- ,'99%& V*134) RC0&9% R*'0,4 R9-,Y "1)4 9%2) '0)%*1-*

4%$1R9-,YWX=

A4% 'RR*%?1')1-0 2-* )4% 9%2) '0)%*1-* 2'(,1,9% 1( _eq# 8- )4%*%[( ' ()*'134)H2-*"'*& $0%$-01, 2-* )41(

(1)C')1-0=

(%9$ :R1& A%)1:$1"# \ (Tc?E@ G*".L

Q4%0 )4% 5')1%0) 4'( *134) RC0&9% R*'0,4 R9-,Y 59C( *134) ':1( &%?1')1-0@ (4% 5*-R'R9+ '9(- 4'( R1H

2'(,1,C9'* R9-,Y "1)4 10?-9?%$%0) -2 )4% 9%2) 5-()%*1-* 2'(,1,9%=

right bundle branch block

left axis deviation

right bundle branch block

right axis deviation

right bundle branch

block with block of the

left anterior fascicle

right bundle branch

block with block of the

left posterior fascicle



_%?%9 EE """#$%&$'()%*+#,-$ f;

@0-/:-0*+ kF

Q4%0%?%* +-C (C(5%,) /123$ )%#$/1.0*:/ 3H8%/$/"83H 2*-$ 9--Y103 ') )4% 5*%,-*&1'9 9%'&(@ 1) -2)%0 4%95(

)- 9--Y 2-* )4% 5*%(%0,% -2 *134) ':1( &%?1')1-0@ "41,4 "-C9& *%102-*,% +-C* (C(51,1-0# 8- "4%0%?%* )4%

788 ,*1)%*1' '*% 5-(1)1?% U%#3#@ +-C 4'?% ' 5')1%0) "1)4 ' )'99 7 10 gE '0& ' &%%5 8 10 g]X@ '0& )41( 5')1%0)

'9(- 4'( /123$ :R1& A%)1:$1"#@ )4%0 +-C ,'0 R% '9$-() ,%*)'10 )4') &"7%$31#2f& F/"#2 F1$3 $3% /123$ 3%:/$=

@0-/:-0*+ kM

Q4%0 )4%*% '*% &12#& "9 *%9$ )%#$/1.0*:/ 3H8%/$/"83H 10 )4% <bc '0& )4% 5')1%0) '9(- 4'( /123$

:R1& A%)1:$1"#@ +-C (4-C9& )410Y -2 G1)%#$/1.0*:/ 3H8%/$/"83H# e( )4% 0'$% 1$591%(@ )41( 1( '

(1)C')1-0 "4%*% R-)4 )4% 9%2) '0& )4% *134) ?%0)*1,9%( '*% 4+5%*)*-541,#

6($+#W ]"3 9"C J-"3 32$- J-"3,$%/$ "0 #2$ *+(%)+* +A). ($+,,9 1+J$. + %)00$($-*$7

K"C .2"C,% -"3 )-#$/(+#$ #2$ $'+,C+#)"- "0 *+(%)+* +A). )-#" #2$ .#$B. "0 #2$ *""JI""J7

5"-/(+#.< 9"CV'$ +,1".# 1+%$ )# #2("C/2 #2$ K$,,"3 ̀ $,# 8(+)-)-/W

signs of right

ventricular

hypertrophy in

precordial leads

right axis

deviation

increases likelihood

of right ventricular

hypertrophy+



_%?%9 EE """#$%&$'()%*+#,-$ ff

i-.0:$ 2=8".-.*82=

O+5%*)*-54+ -2 )4% ')*1' ,'0 R% %?'9C')%& R+ 9--Y103 ') )4% > "'?%( 10 )4% ()'0&'*& 9%'&(#

!"9- :-.0:$ 2=8".-.*82=

A4% > "'?% 4'( )"- 5%'Y(@ '0& C(C'99+ )4% (%,-0& 5%'Y 1( )'99%* )4'0 )4% 21*() -0%# > "'?% &C*')1-0 1(

'R-?% F#E (%,-0&(# A4%(% ,4'03%( '*% $-() 5*-0-C0,%& 10 9%'&( / '0& //# A41( )+5% -2 > "'?% 1( ,'99%& X

71$/:*%=

> $1)*'9% ,'0 '9(- R% 01,%9+ &%51,)%& 10 9%'& gE@ "4%*% "% "-C9& )+51,'99+ (%% ' R154'(1, U1#%#@ 5-(1)1?%H

0%3')1?%X > "'?%# A4% 0%3')1?% 5'*) -2 )4% > "'?% ,-**%(5-0&( )- )4% %09'*3%& 9%2) ')*1C$# /2 )4% 0%3')1?%

5'*) 1( 9-03%* )4'0 E ($'99 R-: U-* o F#F.(X@ )4%0 > $1)*'9% 1( 5*%(%0)=

?012- :-.0:$ 2=8".-.*82=

A41( 1( R%() (%%0 10 9%'&( //@ ///@ '0& 'gq# A4% > "'?% 1( 5%'Y%& '0& %:,%%&( F#K]$g 10 '$591)C&%# A4%(%

5%'Y%& > "'?%( '*% ,'99%& X 80*7"#:*%#

UF#F.(X



_%?%9 EE """#$%&$'()%*+#,-$ fB

O%*% '*% )4% ,*1)%*1' '3'10=

Z)#2 #2). J-"3,$%/$ )- 1)-%< 9"C .2"C,% -"3 +%% #2$ $'+,C+#)"- "0 ; 3+'$. #" 9"C(

*""JI""J +BB("+*2W

!*C #*$-:1"

_-" ?-9)'3% *%2%*( )- ' (1)C')1-0 10 "41,4 0-0% -2 )4% 678 ,-$59%:%( 10 )4% ()'0&'*& 9%'&( U1#%#@ 9%'&( /@ //@

'0& ///X 1( 4134%* )4'0 F#]$g# >-((1R9% *%'(-0( 2-* )41( 210&103 '*% 5%*154%*'9 %&%$'@ 5C9$-0'*+

%$54+(%$'@ 9'*3% 5%*1,'*&1'9 %22C(1-0@ -* (%?%*% $+-,'*&1'9 &'$'3%@ '$-03 -)4%*(# A4% <bc ,'00-)

5*-?1&% +-C "1)4 ' &%2101)1?% &1'30-(1(j 1) ,'0 mC() 31?% +-C ' 410) )4') 2C*)4%* "-*YC5( '*% 0%,%(('*+#

Normal

P pulmonale

V1 II criteria

P > 2,5mm in II

left atrialenlargement

negative P inV1 > 0.04s and/or Pwave duration >0.12sin most cases

right atrial

enlargement

P mitrale

P > 2.5mm in II

negative P inV1 > 0.04s and/or Pwave duration > 0.12sin most cases



_%?%9 EE """#$%&$'()%*+#,-$ BF


1. Rhythm

2. Heart rate

3. P waves Large P wave amplitude (> 2.5mm in II, III, or aVF) Right atrial enlargement

Prolonged negative part of P wave in V1 (>1mm) and P wave with 2

peaks in II, P wave duration > 0.12 sec

Left atrial enlargement



I° AV block



5. QRS axis Determine the axis according to Leads I, II, and aVF Normal axis

Left axis deviation

Right axis deviationNorth-West axis


branch block


rance (notching)

incomplete bundle

branch block

7. Rotation


V5-V6.

clockwise rotation



infarction, WPW syndrome or

bundle branch block




9. QRS infarction signs abnormal Q waves, QS waves, missing R wave progression myocardial infarction -



_%?%9 EE """#$%&$'()%*+#,-$ BE

10. ST-T segment


hyperkalemia,

vagotonia

probably ischemia

abnormality

acute ischemia,

perimyocarditis

Variant angina

STEMI in resolution

STEMI in resolution

NSTEMI, perimyocarditis








ECG report

11. QT duration,

T-U waves

QRS normal

QRS normal

QRS normal

QRS normal


hypertrophy


hypertrophy, bundle

branch block or WPW

syndrome

QRS with Q wave

QRS normal

QRS normal



_%?%9 EE 6C1D """#$%&$'()%*+#,-$ BK

L e v e

l 1 1


A n d n

o w i t ’ s t i m e f o r s o m e e x e r c i s e s . . .

I

V 1

V 2

V 3

V 4

V 5

V 6

I I

I I I

R

L

F

V 1

V 2

I

I I

V 1

V 2

V 3

V 4

V 5

V 6

I

I I

I I I

R

L

F

V 1

V

I

E C G 1

E C G 2

E l e c t r i c a l a x i s

W h i c h

a d d i t i o n a l c h a n g e s

c a n b e f o u n d ?

( u s e o u r c o o k b o o k ! )

N o r m a l a x i s

L e f t a x i s d e v i a t i o n

R i g h t a x i s d e v i a t i o n

N o r t h - W e s t a x i s / e x t r e m e a x i s d e v i a t i o n





_%?%9 EE 6C1D """#$%&$'()%*+#,-$ B.

V 1

V 2

V 3

V 4

V 5

V 6

I

I I

I I I

R

L

F

I

V 1

V 3

V 5

I

I I

I I I

I V 1

E C G 5

E C G 6

E l e c t r i c a

l a x i s

W h i c h

a d d i t i o n a l c h a n g e s

c

a n b e f o u n d ?

( u s e

o u r c o o k b o o k ! )

N o r m a l a x i s

L e f t a x i s d e v i a t i o n

R i g h t a x i s d e v i a t i o n

N o r t h - W e s t a x i s / e x t r e m e a x i s d e v i a t i o n



_%?%9 EK """#$%&$'()%*+#,-$ B]

A

B

normal

hyperkalemia hypokalemia

T U

T

QT

QU

U

!"#"$ &F' i ,2*.- ,-*.= :T*/- "$")-.*$=-", :+< 2":.- .:-"A4% <bc ,'0 4%95 +-C &%)%,) ?'*1-C( Y10&( -2 %9%,)*-9+)% &1()C*R'0,%(# 8-$% -2 )4%$ '*% 5-)%0)1'99+ 912%H

)4*%')%0103#

U=8".^:$"70:

gH8%/L:*%71: U'( (%%0 10 *%0'9 2'19C*%X 1( ,4'*',)%*1D%& R+ ' $:** :#A h$%#$%Ai E F:)% UeX# 8-$%)1$%( )4%

<bc ,'0 9%'& )- ' &1'30-(1( -2 ,4*-01, *%0'9 2'19C*% %?%0 10 5')1%0)( "4- 4'?%0[) &%?%9-5%& '0+ (+$5)-$(

+%)# /0 $-*% (%?%*% ,'(%( UiX@ )4% X F:)% 2%$& *"&$ '0& PQO ."78*%R 2%$& G/":A%/#

>$1$1I$( #2+# )- '+/"#"-)+ 3$ *+- +,." .$$ #+,, 8 3+'$.7 `C# #2$.$ 8 3+'$. +($ -"# +.

#+,, +-% .2+(B +. #2$ "-$. .$$- )- 29B$(J+,$1)+7 D$+.C($1$-# "0 B"#+..)C1 ,$'$,. 3),,

/)'$ 9"C #2$ +-.3$(7

U=8*^:$"70:

<bc ,4'03%( (%%0 10 4+5-Y'9%$1' '*% ' (130 -2 ,%99C9'* 5-)'((1C$ 9-((# A4%+ '*% (%%0 %?%0 R%2-*% R9--&

9%?%9( ()'*) )- &*-5# A4')[( "4+ <bc ,4'03%( '((-,1')%& "1)4 4+5-Y'9%$1' ,-**%9')% 9%(( "%99 "1)45-)'((1C$ 9%?%9( )4'0 ,4'03%( '((-,1')%& "1)4 4+5%*Y'9%$1'#



_%?%9 EK """#$%&$'()%*+#,-$ BN

CALCIUM

CALCIUM

CALCIUM

Normal

Hypocalcemia

Hypercalcemia

E3% $H81.:* 4!5 .3:#2%& &%%# 1# 3H8"L:*%71: :/%,

• q9'))%0103 -2 )4% A "'?%

• e55%'*'0,% -2 ' ` "'?%

• 8A &%5*%((1-0

gH8%/L:*%71: \ $:** E

gH8"L:*%71: \ &7:** E

e ` "'?% 1( ' (%,-0& 5-(1)1?% &%29%,)1-0 )4') ,-$%( '2)%* )4% A "'?% Ue '0& i 10 )4% 199C()*')1-0 ') )4%R%3100103 -2 )41( 9%?%9X# Z-)% )4') 4+5-Y'9%$1' &-%( 0-) 9%'& )- ' 5*-9-03')1-0 -2 )4% 6A 10)%*?'9# A4% PE

1#$%/):* ()'*)( ') )4% R%3100103 -2 )4% 678 ,-$59%: '0& %0&( ') )4% %0& -2 )4% A "'?%#

C'#D$ 6'#@;+% $7% EF 8#$%&>)( G8$7 $7% EH 8#$%&>)(I

U=8*):$)"70: l U=8".):$)"70:

/0 4+5%*,'9,%$1'@ )4% 6A 10)%*?'9 ,'0 R% (4-*)%0%&@

"4%*%'( 10 4+5-,'9,%$1'@ )4% 6A 10)%*?'9 ,'0 R%

5*-9-03%&#

e0& 4-" "199 +-C Y0-" 12 ' 5')1%0)[( 6A 10)%*?'9 1(

0-*$'9 -* 0-)S Q%99@ )4% 0-*$'9 6A )1$% ?'*1%( "1)4

4%'*) *')%# C3%# 3%:/$ /:$% 1& 9:&$U $3% PE $17%

&3"/$%#&; C3%# 3%:/$ /:$% 1& &*"FU PE $17% G%."7%&

*"#2%/; 8- )4%*%[( 0- (1039% 0-*$'9 ?'9C%#

8- 4-" ,'0 +-C Y0-" 12 +-C* 5')1%0)[( 6A 10)%*?'9 1(

0-*$'9 -* 0-)S A4%*% '*% )"- '55*-',4%( )4') +-C

(4-C9& Y0-" 2-* 0-"=

E# L-() <bc $',410%( "199 ,'9,C9')% )4% PE. $17% 2-* +-C# A4')[( )4% ,-**%,)%& 6A 10)%*?'9

0-*$'91D%& 2-* ' 4%'*) *')% -2 NFT(%,# A4% 6A, 1( 5*-9-03%& 12 1)[( o F#.. (%,-0&( 10 $%0 '0& oF#.N (%,-0&( 10 "-$%0#

K# e0& )4% ^C1,Y '0& &1*)+ $%)4-& 3-%( 91Y% )41(=

O" /%7%7G%/,



_%?%9 EK """#$%&$'()%*+#,-$ B;

1 2 3 4 5

8+J$ +- >> )-#$('+, +-% L*C#M )# )- 2+,07 @0 #2$ 8 3+'$ $-%. )- #2$ 0)(.# 2+,0 "0 #2$ >> )-#$('+, G+. )- #2$ #"B

$A+1B,$H< #2$ =8 )-#$('+, ). -"(1+,7 @0 #2$ 8 3+'$ $-%. )- #2$ .$*"-% 2+,0 "0 #2$ >> )-#$('+, G+. )- #2$ ,"3$(

$A+1B,$H< #2$ =8 #)1$ ). B(","-/$%7 @0 #2$ =8 )-#$('+, ). B(","-/$%< 9"C .2"C,% #2$- *+,*C,+#$ #2$ =8* )-

"(%$( #" '$()09 9"C( .C.B)*)"-7

U":.- .:-" d/0)^ -08

e0 %'(+ "'+ )- '((%(( 4%'*) *')% 1( )- &1?1&% PFF R+ )4% 0C$R%* -2 R13 R-:%( R%)"%%0 )"- 678

,-$59%:%(=

82$ %).#+-*$ 0("1 "-$ =>? *"1B,$A #" #2$ -$A# ). :%$G%%# 4 )#< J :'/%+ )- ,$-/#27 RQQ^X 3"C,% I$ [Y

I$+#. B$( 1)-C#$k RQQ^Y 3"C,% I$ UQ I$+#. B$( 1)-C#$7 ?" #2$ 2$+(# (+#$ ). I$#3$$- [Y +-% UQ GB("I+I,9

+("C-% UY I$+#. B$( 1)-C#$H7

G-C (4-C9& 0-" '&& )4% %?'9C')1-0 -2 4%'*) *')%@ A "'?%(@ ` "'?%(@ '0& )4% 6A 10)%*?'9

10)- +-C* ,--YR--Y '55*-',4d



_%?%9 EK """#$%&$'()%*+#,-$ Bf


1. Rhythm

2. Heart rate


Prolonged negative part of P wave in V1 (>1mm) and P wave with 2

peaks in II, P wave duration > 0.12 sec




I° AV block




Left axis deviation

Right axis deviationNorth-West axis


branch block


rance (notching)

incomplete bundle

branch block

7. Rotation


V5-V6.

clockwise rotation



infarction, WPW syndrome or

bundle branch block







_%?%9 EK """#$%&$'()%*+#,-$ BB

10. ST-T segment


hyperkalemia,

vagotonia

probably ischemia

abnormality

acute ischemia,

myopericarditis

Variant angina

STEMI in resolution

STEMI in resolution

NSTEMI, myopericarditis



In these situations an ST seg-

ment deviatiation is almost




ECG report

11. QT duration,

T-U waves

a) QT shortening Hypercalcemia

b) QT prolongation Hypocalcemia

c) tall and peaked T wave Hyperkalemia

these

Hypokalemia

QRS normal

QRS normal

QRS normal

QRS normal


hypertrophy


hypertrophy, bundle

branch block or WPW

syndrome

QRS with Q wave

QRS normal

QRS normal



_%?%9 EK 6C1D """#$%&$'()%*+#,-$ EFF

L e v e

l 1 2

Q U

I Z S E C T I O N

P l e a s e u s e t h e u p d a t e d c o o k b o o k f o r t h e f o l l o w i n g e x e r c i s e s a n d

g o

t h r o u

g h a l l t h e s t e p s t h a t w e h a v e

c o v e r e d s o f a r . e n u m b e r s i n t h e

t a b l e

t o t h e r i g h t o f t h e E C G s c o r r e

s p o n d t o t h e s t e p s i n t h e c o o k b o o k .

I f a t o

n e s t e p d u r i n g y o u r e v a l u a t i o n y o u fi n d t h a t s o m e t h i n g i s

w r o n g

( e . g . ,

P R i n t e r v a l , Q R S w i d t h , e t c . )

, j u s t t i c k o ff t h e r e s p e c t i v e n

u m b e r .

Y o u s h o u l d e s t i m a t e t h e h e a r t r a t e

a n d t h e a x i s f o r e a c h E C G .

I

V 1

V 2

V 3

V 4

V 5

V 6

I I

I I

I I I

E C G 1

2

3

4

5

6

7

8

9

1 0

1 1

a

b

a

b

c

a

b

a

b

c

____________

_____

/ m i n

__________________

_______________________

D i a g n o s i s :



_%?%9 EK 6C1D """#$%&$'()%*+#,-$ EFE



_%?%9 EK 6C1D """#$%&$'()%*+#,-$ EFK



_%?%9 EK 6C1D """#$%&$'()%*+#,-$ EFP



_%?%9 EK 6C1D """#$%&$'()%*+#,-$ EF.



_%?%9 EP """#$%&$'()%*+#,-$ EF]

!"#"$ &M' ?2=-27 &P&6-2" +*.7:$ ,0+/, .2=-27

b$$B /")-/W K"CV'$ +,1".# 1+%$ )# #2("C/2 #2$ K$,,"3 `$,# ?$*#)"-W

/2 +-C "'0) )- R% 'R9% )- &1'30-(% *4+)4$ 5*-R9%$(@ +-C[99 21*() 4'?% )- 9%'*0 "4') ,-0()1)C)%( ' 0-*$'9

(10C( *4+)4$# /0 (10C( *4+)4$ )4%*%[( ' *%3C9'* (%^C%0,% -2 > "'?%( '0& 678 ,-$59%:%(#

e99 -2 )4% 2-99-"103 9"0/ ./1$%/1: 0%%& )- R% $%) 10 -*&%* 2-* (10C( *4+)4$ )- R% 5*%(%0)=

E# > "'?%( '*% 5-(1)1?% 10 9%'&( / '0& //#

K# <?%*+ > "'?% 1( 2-99-"%& R+ ' 678 ,-$59%:#

P#

A4% &1()'0,% R%)"%%0 %',4 > "'?% '0& )4% 2-99-"103 678 1( ,-0()'0)#

.# A4% &1()'0,% R%)"%%0 )4% 678 ,-$59%:%( 1( ,-0()'0)

_%)[( ,4%,Y )4% %:'$59% R%9-" 2-* )4% 5*%(%0,% -2 (10C( *4+)4$#

]"#$ #2+# +B+(# 0("1 #2$ ,)1I ,$+%.< 3$ +,." .2"3 9"C ,$+% K1 2$($7 82). ,$+% ). ,"*+#$% )- *,".$ B("A)1)#9

#" #2$ ()/2# +#()C1 +-% ). #2$($0"($ 8<%)((B +;8$%< @'& $7% )++%++0%#$ '@ )$&8)( <%,'()&8L)$8'#7 82$ ; 3+'$

). C.C+,,9 I)B2+.)* )- PT< #2$ )-)#)+, B".)#)'$ %$0,$*#)"- *"(($.B"-%. #" ()/2# +#()+, %$B",+():+#)"-< +-% #2$

.$*"-% G-$/+#)'$H B+(# *"(($.B"-%. #" ,$0# +#()+, %$B",+():+#)"-7

Q% 4'?% 0-" ,-?%*%& '99 )4% ()%5( -2 )4% ,--YR--Yd



_%?%9 EP """#$%&$'()%*+#,-$ EFN


1. Rhythm Criteria for sinus rhythm:

1. Are the P waves positive in I and II?

2. Is there a QRS after each P wave?

3. Are the PR intervals constant?

4. Are the RR intervals constant?

Sinus rhythm or

no sinus rhythm?

2. Heart rate Estimate heart rate: 300 / number of large boxes between two QRS

complexes

Heart rate in beats per min.


Prolonged negative part of P wave in V1 (>1mm) and P wave with 2peaks in II, P wave duration > 0.12 sec




I° AV block




Left axis deviation

Right axis deviation

North-West axis


branch block


rance (notching)

incomplete bundle

branch block

7. Rotation


V5-V6.

clockwise rotation


in the setting of myocardialinfarction, WPW syndrome or

bundle branch block







_%?%9 EP """#$%&$'()%*+#,-$ EF;

10. ST-T segment


hyperkalemia,

vagotonia

probably ischemia

(DD: Digitalis)

abnormality

acute ischemia,

perimyocarditis

Variant angina

STEMI in resolution

STEMI in resolutionNSTEMI, perimyocarditis





always present and cannot beinterpreted in and of itself.


ECG report

11. QT duration,

T-U waves

a) QT shortening Hypercalcemia

b) QT prolongation Hypocalcemia

c) tall and peaked T wave Hyperkalemia

these

Hypokalemia

QRS normal

QRS normal

QRS normal

QRS normal


hypertrophy


hypertrophy, bundlebranch block or WPW

syndrome

QRS with Q wave

QRS normal

QRS normal

Z-" 1)[( +-C* )C*0 '3'10# A*+ )- 210& -C) 12 (10C( *4+)4$ 1( 5*%(%0) 10 )4% 2-99-"103 %:%*,1(%(# /2 1) 1(

5*%(%0)@ ,'**+ -C) ' ,-$59%)% %?'9C')1-0 C(103 )4% ()%5( -2 -C* ,--YR--Y#



_%?%9 EP """#$%&$'()%*+#,-$ EFf

M'#9&)$;()$8'#+N B'; 7)>% 0)<% 8$ $7&';97 $7% O%(('G P%($ +%6$8'#- Q&%)$ R':IO'; )&% #'G ):(% $' +,%)= $7% .MQ ()#9;)9%- O'; ;#<%&+$)#< $7% 0'+$

80,'&$)#$ ,&8#68,(%+ )#< )&% ):(% $' 6)&&B ';$ ) :)+86 %>)(;)$8'# '@ $7% .MQ- PB

#'GN B'; )&% G%(( %S;8,,%< $' (%)&# 0'&% .MQ'('9B '# $7% R':- T'G%>%&N 8@ B';

G)#$ $' $)=% $7% %/,&%++ ()#% $' .MQ 0)+$%&BN 67%6= ';$ ';& P(;% P%($ +%6$8'# )+

G%((- H7%&%N B'; G8(( (%)&# $7% #;$+ )#< :'($+ '@ &7B$70 0)+$%&B- UD0 (''=8#9

@'&G)&< $' +%%8#9 B'; $7%&%- T)>% @;# )#< %#R'B $7% (%)&#8#9 %/,%&8%#6%I



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EFB

L e v e

l 1 3

Q U I Z D i s c l o s u r e

S t a r t

b y m a r k i n g t h e P w a v e s a n d t h e Q R S c o m p l e x e s ,

t h e n d

e c i d e i f s i n u s r h y t h m i s

p r e s e n t o r n o t .

D e t e r m i n e

t h e h e

a r t r a t e i n e a c h e x a m p l e .

I I I I I I

V 1

I I I

E C G 1

S i n u s r h y t h m

H e a r t r a t e

I f t h e r e i s s i n u s r h y t h m m

a k e

a d d i t

i o n a l d i a g n o s e s a c c o r d i n g

t o o u r c o o k b o o k .

y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EEF

I I I I I I

V 1

I I I I I I

E C G 2

S i n u s r h y t h

m

H e a r t r a t e


a k e

a d d i t i o n a l d i a g n o s e s a c c o r d i n g


y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EEE

I I I I I I

V 1

E C G 3

S i n u s r h y t h

m

H e a r t r a t e


a k e



y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EEK

I I I I I I

E C G 4

S i n u s r h y t h

m

H e a r t r a t e


a k e



y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EEP

I I I I I I

V 1

E C G 5

S i n u s r h y t

h m

H e a r t r a t e

I f t h

e r e i s s i n u s r h y t h m m

a k e



y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EE.

I I I

I I I

E C G 6

S i n u s r h y t h

m

H e a r t r a t e


a k e



y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EE]

I I I

I I I

E C G 7

S i n u s r h y t h

m

H e a r t r a t e


a k e



y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EEN

I I I

I I

I

E C G 8


H e a r t r a t e

I f t h

e r e i s s i n u s r h y t h m m

a k e



y e s

n o

P

Q R S T



_%?%9 EP 6C1D """#$%&$'()%*+#,-$ EE;

I

I I I

I I

E C G 9


H e a r t r a t e


a k e

a d d i t

i o n a l d i a g n o s e s a c c o r d i n g


y e s

n o

P

Q R S T



S i n u s r h y t h

m

H e a r t r a t e


a k e



y e s

n o

Documents

ECG Mastery Yellow Belt Workbook