ecg basics by dr annapoorna kalia

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addagarla naveen on May 21, 2012 Says :

good one for beginners

gs on Apr 22, 2012 Says :

commendable job. thank u.

harsharan on Jul 22, 2011 Says :

thanks ...it helped me alot..

Syed-Ghazanfar on Mar 28, 2011 Says :

Thankyou, its a very good presentation

nirupam on Mar 07, 2011 Says :

very good presentation.

vinod on Mar 05, 2011 Says :

dat was a nice simplified ecg version thanks

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Slide 1 :

1 Basics of Electrocardiography Dr. Annapoorna Kalia Associate Consultant Dept. of Cardiology

Slide 2 :

2 2 Cardiac Impulse

Slide 3 :

3 Cardiac Impulse Cardiac impulse originates in the SA node Traverses the atria simultaneously – no special conduction wires in atria – so the delay Reaches AV node – the check post – so delay Enters bundle of His and branches – through specialized conducting wires called Purkinje network - activates both ventricles – quick QRS First the septum from L to R, then right ventricle and then the left ventricle and finally the apex Then the ventricles recover for next impulse

Slide 4 :

4 4 Cardiac Conduction

Slide 5 :

5 Important Precautions Correct Lead placement and good contact Proper earth connection, avoid other gadgets Deep inspiration record of L3, aVF Compare serial ECGs if available Relate the changes to Age, Sex, Clinical history Consider the co-morbidities that may effect ECG Make a xerox copy of the record for future use Interpret systematically to avoid errors

Slide 6 :

6 ECG Complex P wave PR Interval QRS complex ST segment T Wave QT Interval RR Interval

Slide 7 :

7 ECG Complex P Wave is Atrial contraction – Normal 0.12 sec PR interval is from the beginning of P wave to the beginning of QRS – Normal up to 0.2 sec QRS is Ventricular contraction –Normal 0.08 sec ST segment – Normal Isoelectic (electric silence) QT Interval – From the beginning of QRS to the end of T wave – Normal – 0.40 sec RR Interval – One Cardiac cycle 0.80 sec

Slide 8 :

8 + + + - - - ECG Bipolar Limb Leads R L F R F L

Slide 9 :

9 Standard ECG is recorded in 12 leads Six Limb leads – L1, L2, L3, aVR, aVL, aVF Six Chest Leads – V1 V2 V3 V4 V5 and V6 L1, L2 and L3 are called bipolar leads L1 between LA and RA L2 between LF and RA L3 between LF and LA ECG Bipolar Limb Leads

Slide 10 :

10 ECG Unipolar Limb Leads + + + Lead aVR Lead aVL Lead aVF R L F

Slide 11 :

11 Standard ECG is recorded in 12 leads Six Limb leads – L1, L2, L3, aVR, aVL, aVF Six Chest Leads – V1 V2 V3 V4 V5 and V6 aVR, aVL, aVF are called unipolar leads aVR – from Right Arm Positive aVL – from Left Arm Positive aVF – from Left Foot Positive ECG Unipolar Limb Leads

Slide 12 :

12 12 ECG Chest Leads

Slide 13 :

13 Precardial (chest) Lead Position V1 Fourth ICS, right sternal border V2 Fourth ICS, left sternal border V3 Equidistant between V2 and V4 V4 Fifth ICS, left Mid clavicular Line V5 Fifth ICS Left anterior axillary line V6 Fifth ICS Left mid axillary line ECG Chest Leads

Slide 14 :

14 The Six Chest Leads TRANSVERSE PLANE

Slide 15 :

15 ECG Graph Paper X- Axis time in seconds Y- Axis Amplitude in mill volts

Slide 16 :

16 16 X-Axis represents time - Scale X-Axis – 1 mm = 0.04 sec Y-Axis represents voltage - Scale Y-Axis – 1 mm = 0.1 mV One big square on X-Axis = 0.2 sec (big box) Two big squares on Y-Axis = 1 milli volt (mV) Each small square is 0.04 sec (1 mm in size) Each big square on the ECG represents 5 small squares = 0.04 x 5 = 0.2 seconds 5 such big squares = 0.2 x 5 = 1sec = 25 mm One second is 25 mm or 5 big squares One minute is 5 x 60 = 300 big squares ECG Graph Paper

Slide 17 :

17 17 Next QRS Rate Determination QRS

Slide 18 :

18 BRADY T ACHY NORMA L Rate Determination

Slide 19 :

19 19 What is the Heart Rate ? Answer on next slide

Slide 20 :

20 To find out the heart rate we need to know The R-R interval in terms of # of big squares If the R-R intervals are constant In this ECG the R-R intervals are constant R-R are approximately 3 big squares apart So the heart rate is 300 ÷ 3 = 100 What is the Heart Rate ?

Slide 21 :

21 21 What is the Heart Rate ? Answer on next slide

Slide 22 :

22 To find out the heart rate we need to know The R-R interval in terms of # of big squares If the R-R intervals are constant In this ECG the R-R intervals are constant R-R are approximately 4.5 big squares apart So the heart rate is 300 ÷ 4.5 = 67 What is the Heart Rate ?

Slide 23 :

23 23 What is the Heart Rate ? Answer on next slide

Slide 24 :

24 To find out the heart rate we need to know The R-R interval in terms of # of Big Squares If the R-R intervals are constant In this ECG the R-R intervals are not constant R-R are varying from 2 boxes to 3 boxes It is an irregular rhythm – Sinus arrhythmia Heart rate is 300 ÷ 2 to 3 = 150 to 100 approx What is the Heart Rate ?

Slide 25 :

25 25 QRS Axis SE NE NW SW

Slide 26 :

26 QRS Axis The QRS electrical (vector) axis can have 4 directions Normal Axis - when it is downward and to the left – southeast quadrant – from -30 to +90 degrees Right Axis – when it is downward and to the right – southwest quadrant – from +90 to 180 degrees Left Axis – when it is upward and to the left – Northeast quadrant –from -30 to -90 degrees Indeterminate Axis – when it is upward & to the right – Northwest quadrant – from -90 to +180

Slide 27 :

27 27 Axis Determination NORMAL RIGHT LEFT MEET LEAVE ALL UPRIGHT

Slide 28 :

28 Axis Determination

Slide :

Slide 30 :

30 ECG With Normal Axis Note the QRS voltages are positive and upright in the leads - L1, L2, L3 and aVF L2, L3 and aVF tell that it is downward L1, aVL tell that it is to the left Downward and leftward is Normal Axis Normal QRS axis

Slide 31 :

31 31 LEAD 1 LEAD 2 LEAD 3 What is the Axis ?

Slide 32 :

32 ECG With Right Axis Note the QRS voltages are positive and upright in leads L2, L3 Negative in Lead 1 L2, L3 tell that it is downward L1 tells that it is not to the left but to right Downward and rightward is Right Axis See the Right –Meet criterion QRS in L1 and L3 meet Right Axis Deviation - RAD

Slide 33 :

33 33 LEAD 1 LEAD 2 LEAD 3 aVR aVL aVF What is the Axis ?

Slide 34 :

34 ECG With Left Axis Note the QRS voltages are positive and upright in leads L1and aVL Negative in L2, L3 and aVF L1, aVL tell that it is leftward L2, L3, and aVF tell that it is not down ward - instead it is upward Upward and Leftward is Left Axis See the Left - Leave criterion QRS in L1 and L3 leave each other Left Axis Deviation - LAD

Slide 35 :

35 35 Normal ECG

Slide 36 :

36 Normal ECG Standardization – 10 mm (2 boxes) = 1 mV Double and half standardization if required Sinus Rhythm – Each P followed by QRS, R-R constant P waves – always examine for in L2, V1, L1 QRS positive in L1, L2, L3, aVF and aVL. – Neg in aVR QRS is < 0.08 narrow, Q in V5, V6 < 0.04, < 3 mm R wave progression from V1 to V6, QT interval < 0.4 Axis normal – L1, L3, and aVF all will be positive ST Isoelectric, T waves ?, Normal T? in aVR,V1, V2

Slide 37 :

37 37 Pediatric ECG

Slide 38 :

38 This is the ECG of a 6 year old child Heart rate is 100 – Normal for the age See V1 + V5 R >> 35 – Not LVH – Normal T? in V1, V2, V3 – Normal in child Base line disturbances in V5, V6 – due to movement by child Pediatric ECG

Slide 39 :

39 Juvenile ECG

Slide 40 :

40 40 Be aware of normal ECG Normal Resting ECG – cannot exclude disease Ischemia may be covert – supply / demand equation Changes of MI take some time to develop in ECG Mild Ventricular hypertrophy - not detectable in ECG Some of the ECG abnormalities are non specific Single ECG cannot give progress – Need serial ECGs ECG changes not always correlate with Angio results Paroxysmal events will be missed in single ECG

Slide 41 :

41 Normal Variations in ECG May have slight left axis due to rotation of heart May have high voltage QRS – simulating LVH Mild slurring of QRS but duration < 0.09 J point depression, early repolarization T inversions in V2, V3 and V4 – Juvenile T ? Similarly in women also T? Low voltages in obese women and men Non cardiac causes of ECG changes may occur

Slide 42 :

42 Early Repolarization This ECG has all normal features The ST-T (J) Junction point is elevated. T waves are tall, May be inverted in LIII, The ST segment initial portion is concave. This does not signify Ischemia

Slide 43 :

43 43 Pseudo Normalization Before Chest pain During Chest pain Chest pain Relieved T? T? T?

Slide 44 :

44 44 Atrial Waves

Slide 45 :

45 45 Left Atrial Enlargement

Slide 46 :

46 46 Left Atrial Enlargement P wave duration is 4 boxes-0.04 x 4 = 0.16

Slide 47 :

47 Always examine V 1 and Lead 1 for LAE Biphasic P Waves, Prolonged P waves P wave 0.16 sec, ? Downward component Systemic Hypertension, MS and or MR Aortic Stenosis and Regurgitation Left ventricular hypertrophy with dysfunction Atrial Septal Defect with R to L shunt Left Atrial Enlargement

Slide 48 :

48 48 Right Atrial Enlargement

Slide 49 :

49 49 Right Atrial Enlargement P wave voltage is 4 boxes or 4 mm

Slide 50 :

50 Always examine Lead 2 for RAE Tall Peaked P Waves, Arrow head P waves Amplitude is 4 mm ( 0.4 mV) - abnormal Pulmonary Hypertension, Mitral Stenosis Tricuspid Stenosis, Regurgitation Pulmonary Valvular Stenosis Pulmonary Embolism Atrial Septal Defect with L to R shunt Right Atrial Enlargement

Slide 51 :

51 51 Ventricular Hypertrophy Ventricular Muscle Hypertrophy QRS voltages in V1 and V6, L 1 and aVL We may have to record to ½ standardization T wave changes opposite to QRS direction Associated Axis shifts Associated Atrial hypertrophy

Slide 52 :

52 52 Right Ventricular Hypertrophy

Slide 53 :

53 Tall R in V1 with R >> S, or R/S ratio > 1 Deep S waves in V4, V5 and V6 The DD is RVH, Posterior MI, Anti-clock wise rotation of Heart Associated Right Axis Deviation, RAE Deep T inversions in V1, V2 and V3 Absence of Inferior MI Right Ventricular Hypertrophy

Slide 54 :

54 54 Is there any hypertrophy ?

Slide 55 :

55 Criteria and Causes of RVH Criteria of RVH Tall R in V1 with R >> S, or R/S ratio > 1 Deep S waves in V4, V5 and V6 The DD is RVH, Posterior MI, Rotation Associated Right Axis Deviation, RAE Deep T inversion in V1, V2 and V3 Cause of RVH Long standing Mitral Stenosis Pulmonary Hypertension of any cause VSD or ASD with initial L to R shunt Congenital heart with RV over load Tricuspid regurgitation, Pulmonary stenosis

Slide 56 :

56 56 What is in this ECG ?

Slide 57 :

57 ECG OF MS with RVH, RAE Classical changes seen are Right ventricular hypertrophy Right axis deviation Right Bundle Branch Block P – Pulmonale - Right Atrial enlargement P – Mitrale – Left Atrial enlargement If Atrial Fibrillation develops – ‘P’ disappears

Slide 58 :

58 58 Left Ventricular Hypertrophy

Slide 59 :

59 High QRS voltages in limb leads R in Lead I + S in Lead III > 25 mm S in V1 + R in V5 > 35 mm R in aVL > 11 mm or S V3 + R aVL > 24 ?, > 20 ? Deep symmetric T inversion in V4, V5 & V6 QRS duration > 0.09 sec Associated Left Axis Deviation, LAE Cornell Voltage criteria, Estes point scoring Left Ventricular Hypertrophy

Slide 60 :

60 60 What is in this ECG ?

Slide 61 :

61 Causes of LVH Pressure overload - Systemic Hypertension, Aortic Stenosis Volume overload - AR or MR - dilated cardiomyopathy VSD - cause both right & left ventricular volume overload Hypertrophic cardiomyopathy – No pressure or volume overload Criteria of LVH High QRS voltages in limb leads R in Lead I + S in Lead III > 25 mm or S in V1 + R in V5 > 35 mm R in aVL > 11 mm or S V3 + R aVL > 24 ?, > 20 ? Deep symmetric T inversion in V4, V5 & V6 QRS duration > 0.09 sec, Associated Left Axis Deviation, LAE Causes and Criteria of LVH

Slide 62 :

62 62 Atrial Ectopics

Slide 63 :

63 Note the premature (ectopic) beats marked as APC (Atrial Premature Contractions) These occurred before the next expected QRS complex (premature) Each APC has a P wave preceding the QRS of that beat – So impulse has originated in the atria The QRS duration is normal < 0.08, not wide Atrial Ectopics

Slide 64 :

64 64 Ventricular Ectopics

Slide 65 :

65 Note the premature (ectopic) beats marked as VPC (Ventricular Premature Contractions) These occurred before the next expected QRS complex (premature) Each VPC has no definite P wave preceding the QRS of that beat – So impulse has originated in the ventricles The QRS complexes are wide with abnormal duration of > 0.12 and their shapes are bizarre Ventricular Ectopics

Slide 66 :

66 66 Complete RBBB

Slide 67 :

67 Complete RBBB Complete RBBB has a QRS duration > 0.12 sec R' wave in lead V1 (usually see rSR' complex) S waves in leads I, aVL, V6, R wave in lead aVR QRS axis in RBBB is -30 to +90 (Normal) Incomplete RBBB has a QRS duration of 0.10 to 0.12 sec with the same QRS features as above The "normal" ST-T waves in RBBB should be oriented opposite to the direction of the QRS

Slide 68 :

68 68 Complete LBBB

Slide 69 :

69 Complete LBBB Complete LBBB has a QRS duration > 0.12 sec Prominent S waves in lead V1, R in L I, aVL, V6 Usually broad, Bizarre R waves are seen, M pattern Poor R progression from V1 to V3 is common. The "normal" ST-T waves in LBBB should be oriented opposite to the direction of the QRS Incomplete LBBB looks like LBBB but QRS duration is 0.10 to 0.12 sec, with less ST-T change. This is often a progression of LVH changes.

Slide 70 :

70 70 Blood Supply of Heart LCA RCA LAD LCX RCA

Slide 71 :

71 Heart has four surfaces Anterior surface – LAD, Left Circumflex (LCx) Left lateral surface – LCx, partly LAD Inferior surface – RCA, LAD terminal portion Posterior surface – RCA, LCx branches Rt. and Lt. coronary arteries arise from aorta They are 2.5 mm at origin, 0.5 mm at the end Coronary arteries fill during diastole Flow - epicardium to endocardium – poverty/plenty Blood Supply of Heart

Slide 72 :

72 72 Ischemia, Injury & Infarction Ischemia produces ST segment depression with or without T inversion Injury causes ST segment elevation with or without loss of R wave voltage Infarction causes deep Q waves with loss of R wave voltage.

Slide 73 :

73 73 Ischemia and Infarction TRANSMURAL Injury ST Elevation

Slide 74 :

74 Ischemic Heart Disease (IHD)

Slide 75 :

75 75 Interpret this ECG

Slide 76 :

76 NSTEMI Non ST ? MI or NSTEMI, Non Q MI Or also called sub-endocardial Infarction Non transmural, restricted to the sub-endocardial region - there will be no ST ? or Q waves ST depressions in anterio-lateral & inferior leads Prolonged chest pain, autonomic symptoms like nausea, vomiting, diaphoresis Persistent ST-segment ?even after resolution of pain

Slide 77 :

77 77 What are these ECGs

Slide 78 :

78 STEMI and QWMI STEMI and QWMI ST ? signifies severe transmural myocardial injury – This is early stage before death of the muscle tissue – the infarction Q waves signify muscle death – They appear late in the sequence of MI and remain for a long time Presence of either is an indication for thrombolysis

Slide 79 :

79 79 Evolution of Acute MI A – Normal ST segment and T waves B – ST mild ? and prominent T waves C – Marked ST ? + merging upright T D – ST elevation reduced, T?,Q starts E – Deep Q waves, ST segment returning to baseline, T wave is inverted F – ST became normal, T Upright, Only Q+

Slide 80 :

80 80 Critical Narrowing of LAD

Slide 81 :

81 81 Normal Q waves Notice the small Normal Q in Lead I

Slide 82 :

82 82 Pathological Q wave Notice the deep & wide Infarction Q in Lead I

Slide 83 :

83 83 Very Striking

Slide 84 :

84 Hyper Acute MI Note the hyper acute elevation of ST The R wave is continuing with ST and the complexes are looking rectangular Some times tall and peaked T waves in the precardial leads may be the only evidence of impending infarct Sudden appearance LBBB indicates MI MI in Dextro-cardia – right sided leads are to be recorded

Slide 85 :

85 85 Severe Chest Pain – Why ?

Slide 86 :

86 Acute Anterio-lateral MI Note the marked ST elevations in chest leads V2 to V5 and also ST? in L1 & aVL T inversions have not appeared as yet R wave voltages have dropped markedly in V3, V4, V5 and V6 Small R in L1 and aVL.

Slide 87 :

87 87 Which wall MI ?

Slide 88 :

88 Note the ST elevations in Inferior leads- namely L2, L3 and aVF T inversions yet to appear aVL lead shows complimentary ST?and T inversion Acute Inferior wall MI

Slide 89 :

89 89 Acute True Posterior MI

Slide 90 :

90 Due to occlusion of the distal Left circumflex artery or posterior descending or distal right coronary artery Mirror image changes or reciprocal changes in the anterior precardial leads Lead V1 shows unusually tall R wave (it is the mirror image of deep Q) V1 R/S > 1, Differential Diagnosis - RVH Acute True Posterior MI

Slide 91 :

91 Thank You!!!

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