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8/16/2019 Intro to ECGs
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An early Electrocardiograph
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Einthoven’s first publishedEKG, 1902
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“I do not however imagine that the
string galvanometer…is likely to
find any very extensive use in thehospital”
August D. Waller, 1909
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The Electrocardiogram
(ECG/EKG)Most Commonly Utilized
Cardiovascular Lab Test100 Million Performed per Year$5 Billion Cost per YearReimbursements have droppedKey to Therapy for ACS/MI
Diagnosis of Arrhythmias
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Indications For An ECGChest or EpigastricPain or Sensation
CHF Signs orSymptoms Abnormal PulseHypotensionUnexplainedWeakness
Altered Mental State(Coma, CVA)
Drug OverdoseChest TraumaSyncope or NearSyncopeSystemic IllnessMetabolic Disease
Screening??
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P’s and Q’s of
Electrocardiography
Atrial
Depolarization
Ventricular
Depolarization
Ventricular
Repolarization
http://medstat.med.utah.edu
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The Electrocardiogram
(ECG/EKG)
Rhythms
ST Segments
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LAD 95%
1
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LAD 95%
1
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1
LAD 95%
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1
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1
LAD 0%
Post PCI
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Basic Principles of ECGInterpretation
Place electrodes correctly (??)Be Careful to Get Correct DataConsider Clinical Context/SettingChest pain? … consider ST segments
Compare to Previous ECGBe Systematic
Rate, Rhythm, ?Pacemaker SpikesQRS duration, Other intervals AxisQ waves
Pattern read
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QRS Prolongation (=>120msec, 3 40 msec boxes)
Ventricular OriginPVCsVentricular TachycardiaVentricular Electronic Pacemaker
SVT with Aberrant ConductionBundle Branch Block
Right (rabbit ears on the right)Left (rabbit ears on the left)
WPW
IntraVentricular Conduction Delay
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Why is QRS Prolongation so
important except for RBBB??? Q waves not diagnostic
ST Depression not diagnostic
Possibly Ventricular Origin
Usually High Risk
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.000
.250
.500
.750
.000
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.
1 (130ms): N=61 (6.6%)
Follow-up (yrs)
S u r v i v
a l
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Rabbit Ears
InvertedTwave
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RBBB
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LBBB
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Rabbit Ears
InvertedTwave
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IVCD
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WPW
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WPW
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RAD
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LAD
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S1S2S3
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Criteria For Infarction Q
WavesEqual or Greater than .04 seconds (onemillimeter box horizontal width, 40
milliseconds)
Q Wave Amplitude must be 25% or
greater of following R Wave
Pathophysiology: no muscle to generateR wave
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Basic Principles of ECGInterpretation
Place electrodes correctly (??)Be Careful to Get Correct DataConsider Clinical Context/Setting
Chest pain? … consider ST segments Compare to Previous ECGBe Systematic
Rate, Rhythm, ?Pacemaker SpikesQRS duration, Other intervals AxisQ waves
Pattern read
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inverted
Qw, P/Tup ordown
Rightventricularinvolvement:RVH, RBBB
Left ventricularinvolvement:LVH, LBBB
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Pattern Reading of the ECG
Diagonal Line Rulebox around aVR (everything inverted)
line thru III, aVL, V1every thing else upright
Parallel Line RuleR waves increase then drop off in V6S waves decrease from greatest in V1Rabbit ears on right side (V1-2) for RBBB,
on left side for LBBB
Th 5 C d f ECG
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The 5 Commandments of ECGInterpretation
• Be systematic
• Put into the clinical context
• Find an old ECG
• Watch out for bad data
– Strive for good data
• Do NOT be afraid to get help
Watch out for bad
data
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RA/LA reversed
V1/V3 reversed
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What happened?
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Intervals, segments, and durations
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Intervals
QRS durationPR interval QT IntervalNormal: .12-.20 sec
(3-5 small boxes)
Normal: .07-
.10 sec
Normal (corrected for
rate or QTc): .440-.470sec
• QT Interval
• PR Interval
• QRS Duration
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Intervals: Conduction
System AbnormalitiesCongenital Syndromes
Electrolyte/Metabolic AbnormalitiesIntrinsic Cardiac DiseaseMedicationsCNS Disorders
Systemic Illnesses
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Electrolyte Abnormalities and
the ECGPotassiumHyper: tall, peaked T waves (also
ischemia), atrial arrestHypo: prominent U waves, low T wave
CalciumHyper: short QT
Hypo: long QT (also Quinidine, ischemia)MagnesiumHyper: short QT interval
Hypo: long QT interval
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L QT i t l
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Long QT intervals(>50% of the RR interval)
• Congenital
HypoMg/CA
anti-arrhythmics
Myocarditis
Hypokalemia
Ischemia
Phenothiazines
Tricyclics
CNS--SubarachnoidHemorrhage
Torsades des Pointes
The QT interval
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The QT intervalLong QT (>50% of the RR interval) CongenitalHypomagnesiumHypocalcemiaIA anti-arrhythmicsIschemiaTorsades de Pointes
PhenothiazinesTricyclicsMyocarditisHypokalemia
Short QT Hypercalcemia
HypermagnesiumHyperkalemiaDigoxinThyrotoxicosis
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Other Patterns
• Atrial Abnormalities
• R>S V1
http://medstat.med.utah.edu
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SANode
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Atrial AbnormalitiesRight (P-pulmonale)Right atrium right heart border, first hump
tall, peaked in inferior leads (>2.5mm)
Left (P-mitrale)Left atrium posterior, second hump
broad P wave (>120msec) with negativecomponent in V1-2 (> 1mm x 1mm)
Normal=2.5x2.5 boxes (100msec x .25Mv)
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P pulmonale or
RAA
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P mitrale or LAA
Computerized LAA with/without P wave prolongation
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0.0
0.2
0.4
0.6
0.8
1.0
0.0 2.0 4.0 6.0 8.0 10.0
a. LAA (-), P duration 120ms n=4,476 (2.0%)
c. LAA (+), P duration 120ms n=407 (4.7%)
p p g
S u
r v i v a l
Years Follow up
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R>S V1RVH
RBBBInferior Posterior MIWPWNormal Variant