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basic interpretation of common ecg patterns for general practitioners in simple way.
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DR. RAGHOBA
• DR. RAGHOBA T. GAONKAR
• JUNIOR PHYSICIAN
• NORTH DISTRICT HOSPITAL – GOA
SCOPE OF ECG DR. RAGHOBA
1. ECG LEADS
2. NORMAL ECG
3. TACHY ARRYTHMIAS
4. BRADY ARRYTHMIAS
5. ISCHAEMIC HEART DISEASE
6. BUNDLE BRANCH BLOCK
7. ECTOPICS
8. CHAMBER ENLARGEMENT
9. POTASSIUM DISTURBANCES
10.MISCELLANIOUS
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ORIENTATION OF THE 12 LEAD ECG
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AXIS OF ECG
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COMPONENTS OF NORMAL ECG COMPLEX DR. RAGHOBA
NORMAL ECG VALUES
P waves : P amplitude < 2.5 mm and width < 2.5 mm. May see notched. Best seen in lead II
PR Interval: 0.12 - 0.20 sec i.e. max one big square
q-waves :are narrow (<0.04s duration) and small (<25% the amplitude of the R wave). They are
often seen in leads I and aVL when the QRS axis is to the left of +60°, and in leads II, III, aVF when
the QRS axis is to the right of +60°.
Septal q waves should not be confused with the pathologic Q waves of myocardial infarction.
QRS Duration: 0.06 - 0.10 sec i.e. around max three small squares
QT Interval (QTc ≤ 0.40 sec)
Bazett's Formula: QTc = (QT)/Sq Root RR (in seconds)
ST segment: is a misnomer, because a discrete ST segment distinct from the T wave is usually
absent. More often the ST-T wave is a smooth, continuous waveform beginning with the J-point
(end of QRS), slowly rising to the peak of the T and followed by a rapid descent to the isoelectric
baseline or the onset of the U wave. This gives rise to an asymmetrical T wave. In some normal
individuals, particularly women, the T wave is symmetrical and a distinct, horizontal ST segment
is present.
Normal ST segment elevation: this occurs in leads with large S waves (e.g., V1-3), with concavity
upwards; this is often called early repolarization
T wave :The normal T wave is usually in the same direction as the QRS except in the right precordial leads. In the normal ECG the T wave is always upright in leads I, II, V3-6, and always inverted in lead aVR.
DR. RAGHOBA
QRS axis : The normal QRS axis range (+90° to -30° ); this implies that the QRS be mostly
positive (upright) in leads II and I
Precordial leads:
• Small r-waves begin in V1 or V2 and progress in size to V5.
• In reverse, the s-waves begin in V6 or V5 and progress in size to V2.
• Small "septal" q-waves may be seen in leads V5 and V6.
U Wave : amplitude is usually < 1/3 T wave amplitude in same lead. Direction is the same as T wave direction in that lead
Rate : 60 – 100 per min i.e. 3 -5 big squares
Correlate with old ECGs
Amplitude of complexes will be affected by thickness of chest wall
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NORMAL
Sinus rhythm PR interval max 0ne square
R-R interval between 3-5 squares
QRS max 3 small squares
ST segment normal t waves upright except aVR Normal axis
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DR. RAGHOBA
SINUS TACHYCARDIA
Sinus rhythm R-R interval < 3 squares
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SVT
Regular Narrow QRS complex Tachycardia No definite P waves
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ATRIAL FIBRILLATION
Irregular Narrow QRS complex Tachycardia Irregular R-R interval
Baseline wavy No definite P waves
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ATRIAL FLUTTER
Narrow QRS complex Tachycardia Irregular or regular R-R interval
Baseline saw toothed No definite P waves
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MULTIFOCAL ATRIAL TACHYCARDIA (MAT)
Narrow QRS complex Tachycardia Irregular or regular R-R interval multifocal P' waves at least 3 different P wave morphologies in a given lead
Varying PR interval Commonly seen in COPD
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VENTRICULAR TACHYCARDIA
Regular broad QRS complex Tachycardia No P & QRS relation
Capture & fusion beats may be seen
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VENTRICULAR FIBRILLATION
Irregular broad QRS complex Tachycardia Chaotic rhythm
No definite P or QRS
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TACHYCARDIA
NARROW/NORMAL QRS BROAD QRS
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NARROW/NORMAL QRS TACHYCARDIA
DEFINITE P WAVES
REGULAR
PRESENT
ABSENT
SINUS TACHYCARDIA
SVT
MAT/PAT
DEFINITE P WAVES
IRREGULAR
PRESENT
ABSENT
BASELINE
IRREGULAR
SAW TOOTHED
ATRIAL FLUTTER
ATRIAL FIBRILLATION
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BROAD QRS TACHYCARDIA
EACH QRS PRECEEDED BY P WAVE
NO P &QRS RELATION
SINUS RHYTHM WITH BROAD QRS
ALMOST REGULAR R-R
INTERVAL
IRREGULAR R-R
INTERVAL / CHAOTIC RYTHM
VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILLATION
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SINUS BRADYCARDIA
Sinus rhythm R-R distance > 5 squares
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FIRST DEGREE HEART BLOCK
Sinus rhythm P-R interval > one square
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2 nd DEGREE A-V BLOCK
Sinus rhythm Some P waves not followed by QRS complex
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COMPLETE HEART BLOCK
bradycardia
No association between p and qrs i.e. pr interval is varying
Constant pp and rr interval
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NODAL RHYTHM
Bradycardia No P waves
Regular narrow QRS
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SICK SINUS SYNDROME
Sinus pauses i.e. Missed p waves Seen in elderly
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BRADYCARDIA
P WAVES ABSENT P WAVES SEEN
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P WAVES SEEN
MISSED QRS
PRESENT
ABSENT
P & QRS RELATION
ABSENT CONSTANT
COMPLETE HEART BLOCK
SINUS BRADYCARDIA
A V BLOCK
DR. RAGHOBA
ABSENT P WAVES
SICK SINUS SYNDROME
NO SINUS PAUSES
INTERMITTENT SINUS PAUSE
NODAL RYTHM
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ANTERIOR WALL MI
ST elevation in V1 - V6 Reciprocal ST depression in inferior leads
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EVOVLED ANTERIOR WALL MI
T waves inverted
Q waves developed
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INFERIOR & LATERAL WALL MI
ST elevation in II, III and Avf, V5 V6 Reciprocal ST depression in anterior leads
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POSTERIOR WALL MI
ST depression in V1 V2
May have ST elevations in V5 V6 i.e. lateral leads
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UNSTABLE ANGINA
Horizontal ST Depression Anginal symptoms
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DR. RAGHOBA
RIGHT BUNDLE BRANCH BLOCK
Broad QRS M pattern in right sided leads i.e. V1 V2 Reciprocal T inversion usually present in
right sided leads
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LEFT BUNDLE BRANCH BLOCK
Broad QRS M pattern in left sided leads i.e. V5 V6
Reciprocal T inversion usually present in left sided leads
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DR. RAGHOBA
ECTOPICS
VPC APC
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VPC
Early onset broad QRS No preceding P wave
Usually associated with T inversion Complete compensatory pause
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APC
Early onset narrow QRS Deformed P wave
Incomplete compensatory pause No reciprocal T wave inversion
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VENTRICULAR BIGEMINY
Alternating normal QRS and ventricular ectopic
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LEFT VENTRICULAR HYPERTROPHY WITH STRAIN
LVH – S wave in V1 + R wave in V5 or 6 > 35 mm i.e. 7 squares R + S in any leads > 45 mm Downsloping ST depression in lateral leads V5,V6,I,AvL
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ATRIAL ENLARGEMENT
P wave height > 2.5 small square P wave width >2.5 small square
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P PULMONALE DR. RAGHOBA
RIGHT VENTRICULAR HYPERTROPHY
R/S ratio < 1 May be associated with p pulmonale, RBBB Right axis deviation i.e. deep s in lead I
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HYPOKALAEMIA
usual triad of: ST depression, low T waves or inversion, and large U waves
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HYPERKALAEMIA
Tall peaked broad based t waves Suspect in kidney failure patients
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WRONG LEAD PLACEMENT
Positive QRS in aVR Deep S wave and small R in lead I
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EARLY REPOLARISATION DR. RAGHOBA
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COMMON NONSIGNIFICANT ABNORMALITIES
1. T inversion in V1-3 in females
2. Isolated T inversion or q wave in lead III
3. Minor conduction defects in limb leads
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DR. RAGHOBA