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A blend of poetry and clinical practice

.Muhammad Raza
Dr
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Basics of ECG
Before starting interpretation of ECG, these basic details I think important to understand ECG (skip to
page 5, if you know that).

ECG Electrodes

ECG standard leads

There are three of these leads, I, II and III.

Lead I: is between the right arm and left arm electrodes, the left arm being positive.
Lead II: is between the right arm and left leg electrodes, the left leg being positive.
Lead III: is between the left arm and left leg electrodes, the left leg again being positive.

Chest Electrode Placement

V1: Fourth intercostal space to the right of the sternum.
V2: Fourth intercostal space to the Left of the sternum.
V3: Directly between leads V2 and V4.
V4: Fifth intercostal space at midclavicular line.
V5: Level with V4 at left anterior axillary line.
V6: Level with V5 at left midaxillary line. (Directly under the midpoint of the armpit)

ECG Leads - Views of the Heart

Chest Leads View
V1 & V2 Right Ventricle
V3 & V4 Septum/Lateral Left Ventricle
V5 & V6 anterior/Lateral Left Ventricle

The ECG records the electrical activity that results when the
heart muscle cells in the atria and ventricles contract.
 Atrial contractions show up as the P wave.
 Ventricular contractions show as a series known as the QRS
complex.
 The third and last common wave in an ECG is the T wave.
This is the electrical activity produced when the ventricles
are recharging for the next contraction (repolarizing).
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ECG Interpretation

The graph paper that the ECG records on is standardized to run at 25mm/second, and is marked at 1
second intervals on the top and bottom. The horizontal axis correlates the length of each electrical event
with its duration in time. Each small block (defined by lighter lines) on the horizontal axis represents 0.04
seconds. Five small blocks (shown by heavy lines) is a large block, and represents 0.20 seconds.

Duration of a waveform, segment, or interval is determined by counting the blocks from the beginning
to the end of the wave, segment, or interval.

P-Wave: represents atrial depolarization - the time necessary for an electrical impulse from the
sinoatrial (SA) node to spread throughout the atrial musculature.

 Location: Precedes QRS complex

Amplitude: Should not exceed 2 to 2.5 mm in height Duration: 0.06 to 0.11 seconds

P-R Interval: represents the time it takes an impulse to travel from the atria through the AV node,
bundle of His, and bundle branches to the Purkinje fibres.

 Location: Extends from the beginning of the P wave to the beginning of the QRS complex

Duration: 0.12 to 0.20 seconds.

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QRS Complex: represents ventricular depolarisation. The QRS complex consists of 3 waves: the Q wave,
the R wave, and the S wave.

 The Q wave is always located at the beginning of the QRS complex.

It may or may not always be present.

The R wave is always the first positive deflection.

The S wave, the negative deflection, follows the R wave

 Location: Follows the P-R interval
Amplitude: Normal values vary with age and sex

Duration: No longer than 0.10 seconds

Q-T Interval: represents the time necessary for ventricular depolarization and repolarization.

 Location: Extends from the beginning of the QRS complex to the end of the T wave
(includes the QRS complex, S-T segment, and the T wave)

Duration: Varies according to age, sex, and heart rate

T Wave: represents the repolarization of the ventricles. On rare occasions, a U wave can be seen
following the T wave. The U wave reflects the repolarization of the His-Purkinje fibres.

 Location: Follows the S wave and the S-T segment

Amplitude: 5mm or less in standard leads I, II, and III; 10mm or less in precordial leads V1-V6.

Duration: Not usually measured

S-T Segment: represents the end of the ventricular depolarization and the beginning of ventricular
repolarization.

 Location: Extends from the end of the S wave to the beginning of the T wave
Duration: Not usually measured
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Approach to ECG Interpretation:

I will introduce an approach that removes the need to examine each component of the ECG for
abnormalities and instead simply scan the ECG looking for a small number of clinically significant findings
including bundle branch block, acute myocardial ischemia and arrhythmias.

Scan the ECG....Are you Sure?

What does "Scanning the ECG" involve? There are three steps to the procedure summarized by the
mnemonic PQRST or P - QRS - ST:
1. Step 1: Begin by looking for P waves:
Is there a normal looking P wave before each QRS complex? If not are the P waves absent or
are there too many P waves?
2. Step 2: Next look carefully for widening of the QRS and identify the ventricular rate
3. Step 3: Finally, (provided the QRS width is normal) examine the ST segment for evidence of
ischemia

Just in case you need a little more help to remember this approach I have created the following jingle
for you sing on your way to work each day:
 Scan the ECG .......And look at the P
 Move on to the QRS .......And finally the ST
A blend of poetry and clinical practice - I bet you did not expect that

The Journey Begins–The P wave

The ECG waveform begins with the P wave. The P wave reflects depolarization of the atrium. In the normal
heart the depolarization begins in the SA node and is rapidly transmitted through the atrium triggering
depolarization of the atrium and giving us the P wave. Major disturbances to the normal conduction
process in the heart can often be identified by examining the P wave or recognizing that it is missing.

Looking for the P wave

Finding the P wave is not always easy!
At times the P wave can be difficult to locate or identify with certainty: "Is that little hump/bump a P wave or not?
Below are a few tips on uncovering a difficult to find P wave:
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1. Begin your search for the P wave in the leads where it is most positive (and hence most visible).
These are Leads II and aVF.
2. Look in the area before the QRS where you most expect to see the P wave: i.e. between 3 – 5 little
squares from the beginning of the QRS complex.
3. If there is still no obvious P wave “hump” look in all the other leads for a possible P wave. Lead V1
is a good place to start the search and then look across the other precordial leads.
4. If you see something that looks like a P wave in a lead, look to see if the same P wave hump appears
before the other QRS complexes in other leads.
5. If you are reasonably confident you have identified a P wave in one lead, cast your eye to the leads
above and below looking in exactly the same spot before the QRS as you found the P wave and
then do it for the other leads in the ECG. If it is a P wave its' location will be the same in every other
lead so you should be able to find at least one other lead where it is present.

What do you think (Question)?

One of the most important ECG clues to the presence of a clinically significant arrhythmia is the absence
of a P wave: i.e. there is simply no visible P wave activity.

In which one of the following arrhythmias should P waves still be visible?

o Ventricular tachycardia
o Complete heart block
o Atrial fibrillation
o Supraventricular tachycardia (SVT

answer: Complete heart block

Rationale: P waves are visible in complete heart bock however the P waves do not appear in regular
place before each QRS complex. This is termed AV Dissociation and implies that the atrium and the
ventricles beat independent on one another.

Step1:Scan the ECG......Look for the P

Begin by looking for a P wave. If there is a normal looking P wave before each QRS complex you are finished
and can move on to Step 2, looking at the ventricular rate and QRS width.

If you cannot find normal P waves before each QRS complex or there seem to be too many P waves
(compared to the number of QRS complexes) ... we have a problem!
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No P wave:
If you are unable to find a P wave it may be that the P wave is absent. This is an important clue to the
presence of an arrhythmia. Common causes of absent P waves include:
1. Atrial fibrillation (AF): look for an irregular rhythm:

2. Supraventricular Tachycardia (SVT): look for the narrow QRS complex:

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3. Ventricular Tachycardia (VT): look for the wide QRS complex:

Too Many P waves:

There should be one P wave for each QRS complex. If there are more P waves than QRS complexes this
is a clue to the presence of AV block. There are two clinically significant arrhythmias to consider
1. Atrial flutter: this is characterized by a very fast (300 / min) atrial rhythm and a much slower
ventricular rhythm (usually 100 - 150 / minute). The characteristic finding is atrial flutter waves
which are very fast P waves usually about one square apart. It really is a very beautiful ECG to
view.
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2. Second or Third Degree Heart Block:

o In Second degree AV block there are frequent non-conducted P waves resulting in dropped beats.
They do not occur with every P wave (this happens in complete heart block) but only with some
P waves.

o In Complete heart block (Third Degree heart block) there is no AV nodal conduction and all atrial
impulses are blocked from passing to the ventricles resulting in "AV Dissociation". The P waves
are generally easily visible but they have no fixed relationship to the QRS complex.
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What do you think (Question)?

Look at the following ECG. Examine for the P wave. What is the correct diagnosis?

o Supraventricular tachycardia (SVT)

o Atrial fibrillation
o Normal P wave before each QRS complex
o Complete heart block
o Atrial flutter

answer: Atrial fibrillation

Rationale: The ECG shows the characteristic findings of atrial fibrillation : There are no P waves visible on
this ECG and the rhythm is irregular.

Remember: Begin by looking for a P wave. If there is a normal looking P wave before each QRS complex you are
finished and can move on to Step 2, looking at the ventricular rate and QRS width.

If you cannot find normal P waves before each QRS complex or there seem to be too many P waves
(compared to the number of QRS complexes) ... we have a problem!
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What do you think (Question)?

Look at the following ECG. Examine for the P wave. What is the correct diagnosis?

o Ventricular tachycardia (VT)

o Supraventricular tachycardia (SVT)
o Atrial fibrillation (AF)
o Sinus tachycardia

answer: Supraventricular tachycardia (SVT)

Rationale: The ECG shows a regular rhythm. There are no visible P waves (at least none that I can see).
The QRS complex width is normal. The ECG therefore shows a narrow complex regular tachycardia with
no P waves. It cannot be a sinus rhythm - there are no P waves. It cannot be VT - the QRS width is normal.
It cannot be AF -the rhythm is regular. The arrhythmia must therefore be an SVT. See not too hard!
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Step 2: Move on to the QRS....

The QRS complex reflects depolarization of the ventricles and normally has a width of less than 0.12 secs
(equivalent to less than 3 small squares).

The QRS complex provides us with information about the heart rate and about abnormal conduction
through the electrical wiring of the heart (referred to in anatomical terms as the His-Purkinjie system).

1. Determine the Ventricular Rate

When we talk about heart rate what we really mean is the ventricular rate represented on the ECG by the
QRS complex. Many ECG machines report the ventricular rate on the ECG printout. In adult’s bradycardias
are associated with depolarization rates < 60 / min and tachycardia’s with rates > 100 / min.

You can determine the ventricular rate / minute manually by measuring the number of large squares
between two QRS complexes (the R - R interval) and dividing this number into 300. Rates for a range of
R-R intervals are shown below.

R-R interval Ventricular rate R-R interval Ventricular rate

6 squares = 50 / min 3 squares = 100 / min

5 squares = 60 / min 2 squares = 150 / min

4 squares = 75 / min 1.5 squares = 200 / min

2. Look for a Widened QRS

Many machines report the QRS width. A width of > 0.12 secs (120 msecs) indicates widening in the QRS
complex.

Four important diagnoses to consider when you see a widened QRS complex are:

1. Sinus rhythm with bundle branch block: This is recognized by (normal) P waves before each QRS
complex. There is no need to worry about whether the bundle branch block is right or left sided at
this stage. The key thing is to look for the P waves to ensure it is not a Ventricular tachycardia.
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2. Atrial fibrillation with bundle branch block: This is easily identified by an irregular rhythm and a
fibrillating or flat baseline with no P waves.
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3. Ventricular Tachycardia: One of the most serious arrhythmias with a risk for rapid deterioration
toward circulatory shock or cardiac arrest. It is easily recognized by as a regular (wide complex)
rhythm with no P waves. In the example notice that the patient develops VT as the ECG is being
performed.

4. Hyperkaliemia: One the most feared biochemical abnormalities, severe hyperkaliemia is life-
threatening. Early ECG features (peaking of T waves, diminishing P wave height) are often difficult
to detect and in most cases not associated with significant cardiac toxicity. More severe
hyperkaliemia markedly slows depolarization in the heart resulting in the QRS becoming gradually
wider and wider and eventually blending into the T wave to form a characteristic sine wave pattern
indicating severe cardiac toxicity and impending cardiac arrest.
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What do you think (Question)?

Which of the following most accurately describes the following ECG?

o Ventricular rate = 100 / min. Sinus rhythm with bundle branch block
o Ventricular rate = 150 / min. Ventricular tachycardia
o Ventricular rate = 200 / min. Supraventricular tachycardia
o Ventricular rate = 125 / min. Moderate to severe hyperkaliemia

answer: Ventricular rate = 150 / min. Ventricular tachycardia

Rationale: The R - R width is 2 large squares: 300 / 2 = 150 / minute. The QRS width > 0.12 secs with no P
waves. This is Ventricular tachycardia (VT).

Remember:

The QRS complex reflects depolarization of the ventricles and normally has a width of less than 0.12 secs
(equivalent to less than 3 small squares).

1. Determine the ventricular rate

2. Look for a widened QRS

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What do you think (Question)?

Look at the following ECG. Follow the "P" and QRS steps. What is the correct diagnosis?

o Ventricular tachycardia (VT)

o Hyperkaliemia
o Atrial fibrillation with bundle branch block
o Sinus rhythm with Bundle branch block

answer: Sinus rhythm with Bundle branch block

Rationale: If we follow the "P" then the QRS approach to examining this ECG we note that there is in fact
an identifiable P wave before each QRS complex. This is hard to see though in some leads but is definitely
visible in lead II, the lead we are most likely to see a P wave in. This is a sinus rhythm.
The QRS width is wide. We do not need to worry about whether it is left or right bundle branch block only
that it cannot be VT (there are P waves) nor AF (the rhythm is regular). Could it be hyperkaliemia - you
could always check the potassium however the presence of P waves makes it very unlikely that this is
hyperkalemia. (There are other findings that would make hyperkaliemia unlikely but we won't go into this
now).
One more point of interest is to look at the ST and T waves especially in V1 and V2 - they look abnormal.
The ST segment is down slopping and the T wave inverted. This reflects the fact that the depolarization
of the heart is not normal (due to the bundle branch block) and hence the repolarization process
(reflected in the ST and T wave) is abnormal. Take home point: if the QRS is wide - you can forget about
trying to identify myocardial ischemia by looking at the ST segments - the ECG loses its value as a tool for
diagnosing AMI. More on this in the next section.
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What do you think (Question)?

Look at the following ECG. Follow the "P" and QRS steps. What is the correct diagnosis?

o Atrial fibrillation with bundle branch block

o Sinus rhythm with bundle branch block
o Hypokalemia
o Ventricular tachycardia
o Hyperkaliemia

answer: Hyperkaliemia
Well done. This is the answer
Rationale: The ECG demonstrates the characteristic sine wave pattern of severe hyperkaliemia.
Hyperkaliemia results in a characteristic pattern of ECG changes associated with increasing potassium
levels and increasing toxicity. Early ECG changes are manifested by peaking of the T waves. This is followed
by a gradual slowing and eventual paralysis of conduction and cardiac depolarization manifested by
prolongation of the PR interval, diminishing and eventual loss of P waves and finally widening of the QRS
interval. In severe (life threatening) hyperkalemia the QRS interval becomes so wide that it blends into
the T wave giving the classic sine wave pattern and urgent treatment is required to avoid sudden cardiac
arrest.
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Step 3:.... And finally the ST

In the "normal" ECG the ST - T wave represent the process of ventricular repolarization. Contraction of
the ventricle has occurred as consequence of the depolarization of the heart and this is followed by the
cells returning to their baseline (negative) electrical state (the stage of repolarization). Abnormalities in
repolarization are associated with changes in the ST segment and the T wave.

Before looking at the ST - T wave it is essential to assure yourself that depolarization of the heart has been
normal. This is because the process of repolarization is dependent on depolarization and any abnormality
in ventricular depolarization will alter repolarization. So if the QRS is wide - an indication of abnormal
depolarization due to bundle branch block (or more rarely ventricular tachycardia) there is no need to
look at the ST - T wave - it will be abnormal and it is not possible to interpret changes accurately.

So ....

 If the QRS width is normal: look at the ST - T wave

 If the QRS is wide: ignore the ST - T wave as the ECG as it is no longer a useful tool for the diagnosis
of ischemia*.

* This is not completely correct as there are rare exceptions to this rule however we will not explore these
complex cases in this basics.

Normal and Abnormal ST Segment

The ST segment extends from the end of the QRS complex to the beginning of the T wave. In 75% of
normal adults the ST - T segment is isoelectric (flat) slanting slightly upward from the end of the QRS to
the T wave. Elevation or depression of the ST segment is identified by using the PR or TP segment as the
baseline reference point.

Minor ST elevation of < 1 mm may be seen in up to 25% of normal individuals. It is most significant in the
precordial leads V2 - V4. ST depression is a less commonly seen in normal adults and is minor (usually <
0.5 mm).

Any ST elevation > 1 mm or depression > 0.5 mm should be considered abnormal and a search made to
determine the cause.
What do you think (Question)?

Causes of abnormalities to the ST segment include all of the following EXCEPT?

o Inflammation of cardiac muscle in pericarditis causing altered depolarization

o Conduction block in the HIS Purkinje fibers
o Atrial hypertrophy
o Altered depolarization of cardiac muscle in ischemia
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answer: Atrial hypertrophy

Rationale: Atrial hypertrophy will not affect the repolarization of the ventricle.

ECG Changes in Acute Myocardial Infarction

ST elevation or depression is by far the most important diagnostic feature on the ECG for acute myocardial
ischemia. In fact, myocardial infarction is classified on the basis of ST changes into ST elevated myocardial
infarction (STEMI) and Non ST elevated myocardial infarction (NSTEMI).

We are generally most interested in the early diagnosis of STEMI as the major interventions of
Thrombolysis and Angioplasty are used in the treatment of STEMI and are time dependent requiring
urgency in diagnosis. Fortunately, the characteristic ECG changes associated with acute STEMI are
relatively easily identified on the ECG.
Diagnostic criteria for STEMI include:
 More than 1 mm ST elevation in two more concurrent limb leads (e.g. II, III or aVF)
 More than 2 mm ST elevation in two or more concurrent precordial leads (e.g. V2, V3, V4)
Nb. The limb leads include the leads I, II, III, aVL and aVF. The precordial leads are the leads that are
placed across the chest i.e. leads V1 - V6.
Location of the Myocardial Infarction
Location of the ST elevation can be used to pinpoint the location of the myocardial infarction and the
coronary artery likely to be causing the AMI.
 For inferior myocardial infarction, ST changes are seen in leads II, III and aVF. Inferior AMI is associated
with disease of the right coronary artery.
 In anterior myocardial infarction ST changes are most obvious in leads V3 and V4 but are often also
found in the immediately adjacent leads (V2, V5). Anterior MI is associated with disease of the left
coronary artery.
Both inferior and anterior MI may extend to involve the lateral part of the heart and is indicated by ST
elevation of one or more of the lateral leads (V5, V6, aVL and I).
What do you think (Question)?
Which of the following best describes the ECG below?
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o Acute anterior STEMI

o Acute anterior NSTEMI
o Acute inferior STEMI
o Acute lateral STEMI
o Acute inferior NSTEMI

answer: Acute anterior STEMI

Rationale: There is marked (coved) ST elevation in V3 and V4 indicating acute anterior ST elevated
myocardial infarction (STEMI). The ST elevation in V2 indicates septal involvement.
Before looking at the ST - T wave it is essential to assure yourself that depolarization of the heart has been
normal. This is because the process of repolarization is dependent on depolarization and any abnormality
in ventricular depolarization will alter repolarization. So if the QRS is wide - an indication of abnormal
depolarization due to bundle branch block (or more rarely ventricular tachycardia) there is no need to
look at the ST - T wave - it will be abnormal and it is not possible to interpret changes accurately.
So ....
 If the QRS width is normal: look at the ST - T wave
 If the QRS is wide: ignore the ST - T wave as the ECG as it is no longer a useful tool for the diagnosis
of ischemia*.
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What do you think (Question)?

Which of the following best describe the ECG below?

o Acute anterior NSTEMI

o Acute inferior NSTEMI
o Acute inferior STEMI
o Acute anterior STEMI
o Acute lateral STEMI

answer: Acute inferior STEMI

Rationale: There is > 1 mm ST elevation in the inferior leads (II,III and aVF) consistent with an acute
inferior myocardial infarction.

What do you think (Question)?

The ECG below is from a 52-year-old male patient with chest pain that began one hour previously. The
patient is obese and has a past medical history of hypertension and hypercholesterolemia. The patient's
pain settled after a GTN (Nitroglycerin) infusion was commenced.

Which of the following best describes the ECG below?

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o Acute anterior STEMI

o Acute inferolateral NSTEMI
o Acute inferolateral STEMI
o Acute anterior NSTEMI

answer: Acute inferolateral NSTEMI

Rationale: There is 0.5 mm - 1 mm ST depression in the inferior leads (II,III, avF) and lateral leads (V5, V6).
The clinical history of chest pain is highly suspicious for myocardial ischemia. The ECG changes (although
subtle) are highly significant and indicate the possibility of NSTEMI.
NSTEMI: ECG Findings

The ECG diagnosis of NSTEMI is not as clear as in STEMI but should be considered in all patients with chest
pain lasting longer than 20 minutes. The ECG should be examined carefully for any evidence of (new) ST
depression or elevation and/or T wave flattening /inversion that may indicate myocardial ischaemia.
Careful clinical and biochemical assessment of the patient should be undertaken to avoid missing a
NSTEMI.
ECG changes seen in NSTEMI may take on a variety of patterns including
 ST depression (the most common)
 T wave flattening or inversion
 Minor ST elevation (ie ST elevation not meeting diagnostic criteria for STEMI)
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The same ECG changes may be caused by reversible ischemia (angina) and a diagnosis of NSTEMI requires
biochemical (Troponin) confirmation of myocardial cell injury. Patients with NSTEMI appear to constitute
a distinct clinical group and do not appear to derive benefit from the dramatic revascularization
interventions used in STEMI (ie thrombolysis, acute angioplasty and stenting). For this reason, they are
generally managed medically with nitrates, anti-platelet agents and anticoagulation.

Final Words:

Scan the ECG.......And look at theP

Move on to the QRS.......And finally the ST

Let’s Have Some Practice

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Some Important and Basic Rhythms:

Normal Sinus Rhythm

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - (60-99 bpm)
 QRS Duration - Normal
 P Wave - Visible before each QRS complex
 P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree block)

Sinus Bradycardia

A heart rate less than 60 beats per minute (BPM). This in a healthy athletic person may be 'normal', but
other causes may be due to increased vagal tone from drug abuse, hypoglycemia and brain injury with
increase intracranial pressure (ICP) as examples

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - less than 60 beats per minute
 QRS Duration - Normal
 P Wave - Visible before each QRS complex
 P-R Interval - Normal
 Usually benign and often caused by patients on beta blockers
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Sinus Tachycardia

An excessive heart rate above 100 beats per minute (BPM) which originates from the SA node. Causes
include stress, fright, illness and exercise. Not usually a surprise if it is triggered in response to regulatory
changes e.g. shock. But if there is no apparent trigger then medications may be required to suppress the
rhythm

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - More than 100 beats per minute
 QRS Duration - Normal
 P Wave - Visible before each QRS complex
 P-R Interval - Normal
 The impulse generating the heart beats are normal, but they are occurring at a faster pace than
normal. Seen during exercise

Supraventricular Tachycardia (SVT) Abnormal

A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not under direct
control from the SA node. SVT can occur in all age groups

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 140-220 beats per minute
 QRS Duration - Usually normal
 P Wave - Often buried in preceding T wave
 P-R Interval - Depends on site of supraventricular pacemaker
 Impulses stimulating the heart are not being generated by the sinus node, but instead are
coming from a collection of tissue around and involving the atrioventricular (AV) node
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Atrial Fibrillation

Many sites within the atria are generating their own electrical impulses, leading to irregular conduction
of impulses to the ventricles that generate the heartbeat. This irregular rhythm can be felt when palpating
a pulse

It may cause no symptoms, but it is often associated with palpitations, fainting, chest pain, or congestive
heart failure.

Looking at the ECG you'll see that:

 Rhythm - Irregularly irregular

 Rate - usually 100-160 beats per minute but slower if on medication
 QRS Duration - Usually normal
 P Wave - Not distinguishable as the atria are firing off all over
 P-R Interval - Not measurable
 The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm

Atrial Flutter

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Around 110 beats per minute
 QRS Duration - Usually normal
 P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but
sometimes 3:1
 P Wave rate - 300 beats per minute
 P-R Interval - Not measurable
 As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the
atrioventricular node is not involved in this case.
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1st Degree AV Block

1st Degree AV block is caused by a conduction delay through the AV node but all electrical signals reach
the ventricles. This rarely causes any problems by itself and often trained athletes can be seen to have
it. The normal P-R interval is between 0.12s to 0.20s in length, or 3-5 small squares on the ECG.

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal
 QRS Duration - Normal
 P Wave - Ratio 1:1
 P Wave rate - Normal
 P-R Interval - Prolonged (>5 small squares)

2nd Degree Block Type 1 (Wenckebach)

Another condition whereby a conduction block of some, but not all atrial beats getting through to the
ventricles. There is progressive lengthening of the PR interval and then failure of conduction of an atrial
beat, this is seen by a dropped QRS complex.

 Looking at the ECG you'll see that:

 Rhythm - Regularly irregular
 Rate - Normal or Slow
 QRS Duration - Normal
 P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.
 P Wave rate - Normal but faster than QRS rate
 P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped
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2nd Degree Block Type 2

When electrical excitation sometimes fails to pass through the A-V node or bundle of His, this
intermittent occurance is said to be called second degree heart block. Electrical conduction usually has a
constant P-R interval, in the case of type 2 block atrial contractions are not regularly followed by
ventricular contraction

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal or Slow
 QRS Duration - Prolonged
 P Wave - Ratio 2:1, 3:1
 P Wave rate - Normal but faster than QRS rate
 P-R Interval - Normal or prolonged but constant

3rd Degree Block

3rd degree block or complete heart block occurs when atrial contractions are 'normal' but no electrical
conduction is conveyed to the ventricles. The ventricles then generate their own signal through an 'escape
mechanism' from a focus somewhere within the ventricle. The ventricular escape beats are usually 'slow'

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Slow
 QRS Duration - Prolonged
 P Wave - Unrelated
 P Wave rate - Normal but faster than QRS rate
 P-R Interval - Variation
 Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles
generate their own rhythm
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Bundle Branch Block

Abnormal conduction through the bundle branches will cause a depolarization delay through the
ventricular muscle, this delay shows as a widening of the QRS complex. Right Bundle Branch Block (RBBB)
indicates problems in the right side of the heart. Whereas Left Bundle Branch Block (LBBB) is an indication
of heart disease. If LBBB is present, then further interpretation of the ECG cannot be carried out.

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal
 QRS Duration - Prolonged
 P Wave - Ratio 1:1
 P Wave rate - Normal and same as QRS rate
 P-R Interval - Normal

Premature Ventricular Complexes

Due to a part of the heart depolarizing earlier than it should

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - Normal
 QRS Duration - Normal
 P Wave - Ratio 1:1
 P Wave rate - Normal and same as QRS rate
 P-R Interval - Normal
 Also you'll see 2 odd waveforms, these are the ventricles depolarizing prematurely in response to
a signal within the ventricles. (Above - unifocal PVC's as they look alike if they differed in
appearance they would be called multifocal PVC's, as below)
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Junctional Rhythms

In junctional rhythm the sinoatrial node does not control the heart's rhythm - this can happen in the case
of a block in conduction somewhere along the pathway. When this happens, the heart's atrioventricular
node takes over as the pacemaker.

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 40-60 Beats per minute
 QRS Duration - Normal
 P Wave - Ratio 1:1 if visible. Inverted in lead II
 P Wave rate - Same as QRS rate
 P-R Interval - Variable
 Below - Accelerated Junctional Rhythm

Ventricular Tachycardia (VT) Abnormal

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Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 180-190 Beats per minute
 QRS Duration - Prolonged
 P Wave - Not seen
 Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm.
Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac
arrest. Shock this rhythm if the patient is unconscious and without a pulse

Ventricular Fibrillation (VF) Abnormal

Disorganized electrical signals cause the ventricles to quiver instead of contract in a rhythmic fashion. A
patient will be unconscious as blood is not pumped to the brain. Immediate treatment by defibrillation is
indicated. This condition may occur during or after a myocardial infarct.

Looking at the ECG you'll see that:

 Rhythm - Irregular
 Rate - 300+, disorganised
 QRS Duration - Not recognisable
 P Wave - Not seen
 This patient needs to be defibrillated!! QUICKLY

Asystole - Abnormal

A state of no cardiac electrical activity, as such no contractions of the myocardium and no cardiac output
or blood flow are present.

Looking at the ECG you'll see that:

 Rhythm - Flat
 Rate - 0 Beats per minute
 QRS Duration - None
 P Wave - None
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 Carry out CPR!!

Myocardial Infarct (MI)

Looking at the ECG you'll see that:

 Rhythm - Regular
 Rate - 80 Beats per minute
 QRS Duration - Normal
 P Wave - Normal
 S-T Element does not go isoelectric which could indicate infarction. However this is NOT diagnostic
unless associated with a 12 lead ECG

Some More to practice

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Thanks, and wish you All the best

Regards
Dr.Muhammad Raza (Raza Khan kochai)