Summary of ECG Abnormalities

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This summary of ECG abnormalities is part of the almostadoctor ECG series. For a more in
depth explanation of ECG abnormalities, see ECG abnormalities. To learn about the basic
principle of an ECG, see Understanding ECGs

Abnormality ECG sign Seen in Pathology

Sinus rhythm regular p waves, and each p All leads None

wave is followed by a QRS. 60- (best to look
100bpm at the
rhythm strip)

Sinus Tachycardia Same as above, except All leads Does not represent cardiac
>100bpm (best to look patholoy. May be a sign of
at the anxiety, dehydration, recent
rhythm strip) exercise, or general illness
(e.g. sepsis, pneumonia,
respiratory pathology, other
illness)

Sinus bradycardia Same as above except <60bpm All leads This is normal in young fit
(best to look people
at the
rhythm strip)

Right ventricular hypertrophy
Negative QRS Lead I Because the cardiac axis has
shifted from 11-5 o’clock to 1-
7 o’clock, thus lead I which
measures laterally from right
to left now gets a negative
signal because the signal is
going from left to right. This
axis shift is called right axis
deviation.

Right ventricular hypertrophy
Taller QRS Lead III – Because lead III measures
becomes vertically but also slightly left
taller than to right, and this is pretty
lead II much the exact direction of
the new shifted axis. Lead II,
measuring from right arm to
left leg is no longer lined up
as well. This axis shift is
called right axis deviation.

Transition point moved to the Equally

left – equal sized R and S sized R and
(normally seen in V3/V4) S now seen
in V5/V6

Left Ventricular Hypertrophy
Small lead I QRS, negative
leads II and lead III QRS
Leads I-III Left axis deviation – this is
often the results of a
conduction defect, and not an
increased bulk of left
ventricular tissue.

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 Atrial fibrillation Absent P waves – just an
irregular baseline.
Irregularly Irregular, irregular
QRS (but QRS is normal
shape)
Might look messy! E.g.
Atrial Flutter Tachycardia
Can’t tell if T/P waves are
present – rhythm is too fast
(250bpm). Often associated
block; i.e. there are QRS
complexes at a lower rate than
the p waves
Atrial tachycardia >150bpm, p waves
superimposed over t waves of
preceding beat, normal QRS
Junctional tachycardia P waves very close to QRS, or
no QRS visible. QRS is
normal
1st degree heart block PR interval >0.2s (one big
square)
1st Degree Heart Block
some? As well as no p waves, the
rhythm will be irregularly
irregular. There will be a
Rhythm strip fibrillating baseline due to
uncoordinated activity.
The causes of atrial
fibrillation are:
Generally 1. Ischaemic heart
disease
2. Thyrotoxicosis
(hyperthyroidism)
3. Sepsis
4. Valvular heart
disease
5. Alcohol excess
6. PE
Note that AF can also co-
exist with complete heart
block, in which case the
QRS will be regular!
Rhythm strip There will be saw tooth p
waves that occur at 300bpm,
Lead where but the QRS complexes will
p waves are only be at 150, 100 or 75
most easily bpm due to various blocks.
visible – you The QRS can be regular or
should use irregular.
drugs to It can be very difficult to see t
slow down waves – what looks like a T
the heart wave will probably just be a p
rate to see wave. The p waves occur at
what is very regular intervals.
going on
Any where p Caused by a foci of the atria
waves are (outside of the SA node)
best seen depolarising quickly
Anywhere Due to a ‘re-entry’ loop; there
is an area of depolarisation
near the AV node; this not
only transmits a signal
throughout the rest of the
ventricles to depolarise them
Allover – This is an AV node block
best in I or Can be caused by CAD,
V1 acute rheumatic carditis,
digoxin toxicity, or
electrolyte disturbance
It is NOT an medical
emergency
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 2nd degree heart block Progressive lengthening of
Mobitz type 1 – the PR interval followed by
Wencebach absent QRS, then cycle
repeats. Cycles are variable in
length. R-R interval shortens
with lengthening of PR
interval
Mobitz type 2
Absent QRS every now and
again
2:1 and 3:1 conduction
This is the ratio of P:QRS
Complete (third degree) 90 P waves/min, only about 38
heart block QRS/min, and not relationship
between the P waves and the
QRS complexes. QRS will
often have an abnormal
shape, and be broad
(>120ms). However, the P-P
intervals will be regular, as will
the R-R intervals – they are
just not in time with each
other. The rhythm of the
ventricles is the escape
rhythm.
Anywhere This can be an AV node
block (nearly always), or an
SA node block. usually
benign and generally doesn’t
require specific treatment.
can be caused by CHD or
acute MI.
It is usually symptomless, but
can present with:
–Dizziness / light-
headedness / syncope
Anywhere This can be an SA node
block, or far more commonly
infra-Hisian block (distal
block). It can progress to
complete heart block, from
which there is often no
escape rhythm; and thus
this needs treatment! the
definitive treatment is an
implanted pacemaker.
Can be caused by CHD or
MI
Anywhere May require a pacemaker,
particularly if the rate is slow
Best in II This is an AV node block.
and V1 Atrial activity will be
completely normal, but this
conductivity does not pass
into the ventricles.
This always indicates
underlying disease – the
disease is often fibrosis
rather than ischaemia, but it
can occur in MI.
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RBBB – right bundle branch ECG may appear normal. In
block some people there may be 2 R
waves. This creates a
distinctive pattern:
V1 – there is an M shaped
QRS – this is sometimes called
an RSR pattern
V6 – there is a W shaped QRS
Wide QRS (120ms)
LBBB – left bundle branch V1 – there is an W shaped
block QRS
V6 – there is a M shaped QRS
Wide QRS (>120ms)
The axis can be deviated either
way in BBB’s, but it is most
commonly normal
Sinus bradycardia Normal rhythm <60bpm
Sinus Tachycardia Normal rhythm >100bpm
Supraventricular rhythms This is any rhythm that
originates outside the
ventricle
These are infra-Hisian
blocks. In bundle branch
blockages, the wave of
depolarisation can still
reach the IV septum, then
the PR interval will be
normal – and it is. However,
the time taken for the
depolarisation to spread
throughout the ventricles is
longer – thus QRS complex
duration is lengthened.
In the acute setting it may be
caused by MI
RBBB – may indicate right
sided disease. The two R
waves indicate the
depolarisation of the right and
left sides of the heart at
different times (the right
depolarises after the left).
You can remember the
pattern with the word
MarroW – there is M in V1,
and W in v6, and the ‘rr’ tells
you it is on the right!
There is NOT specific
treatment, and it is often
caused by an atrial septal
defect.
In the acute setting it may be
caused by MI
LBBB – often indicates left
sided heart disease.
Remember the pattern with
WillaM.
Causes:
Aortic stenosis, dilated
cardiomyopathy, acute MI,
CAD
Symptoms:
Syncope, and in more severe
cases; heart failure. Those
with syncope and / or heart
failure will usually be
treated with a pacemaker.
Anywhere Associated with; athletic
training, fainting,
hypothermia, myxedema
(hypothyroidism), seen
immediately after MI
Anywhere Associated with; exercise,
fear, pain, haemorrhage,
thyrotoxicosis
Examples include:
–Sinus rhythms
–LBBB
–RBBB
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 Ventricular rhythms Wide QRS complexes Anywhere
(aka escape rhythms)
Atrial escape Abnormal p wave (e.g. Anywhere This occurs when the SA
Junctional escape inverted) node fails to depolarise.
Ventricular escape Normal QRS Instead, some other part of
Accelerated idioventricular Some normal beats after the the atrium depolarises and
rhythm abnormal one sends the signal to the
ventricles.

No p waves The escape occurs

Normal QRS somewhere at the AV
Slightly slow rate (max 75bpm) junction. It occurs when the
rate of depolarisation of the
SA node falls below the rate
of the AV node, thus the AV
node starts the beat instead.
The resulting bradycardia
reduces cardiac output and
can cause symptoms
similar to other
bradycardias such as:
–Dizziness
–Light-headedness
–Syncope
–Hypotension
Usually the bradycardia can
be tolerated as long as it is
above 50bpm

Two types: Somewhere along the line

–Many p waves per QRS the p waves isn’t getting
(complete heart block) conducted to the ventricles,
–Occasional missing p wave, and thus the ventricles
followed by long gap, and then a depolarise at their normal
ventricular QRS, then normal escape rate.
rhythm

Wide QRS Don’t confuse this with

Rhythm of about 75bpm ventricular tachycardia –
No p waves which requires a HR of
Abnormal T waves >125pbm. Otherwise it looks
very similar.
Usually benign and does
not need to be treated. Also
associated with MI

Extrasystoles These are easy – they are the same as ventricular escapes, except that where
(aka ectopics) in escapes the escape beat comes after a pause in the rhythm, in
extrasystole, there is an abnormal beat earlier than expected.
The QRS complexes are the same as those of sinus rhythm, but there are
usually abnormal p waves that tend to come immediately before or immediately
after the QRS.

Inferior MI ST elevation II, III, aVF The ST elevation in these

(probably the right coronary (the inferior leads is often accompanied
artery) leads) by ST depression in the
antero-lateral leads – V1-
V6, and possibly in lead I
and aVL

Anterior MI ST elevation V2-5 – the This will also cause deep q

(probably the left anterior anterior waves. The presence of Q
descending) leads waves implies a full
thickness infarction.

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 Posterior MI ST depression, tall R waves
ST elevation MI ST elevation >2mm in 2+
(STEMI) chest leads OR >1mm in 2+
limb leads,
T-wave inversion (after several
hours)
Pathological Q waves (24 hours
+)
NSTEMI Pathological Q waves only
Ventricular tachycardia Wide QRS, no p waves, T
waves difficult to identify, rate
>200bpm
Supraventricular Narrow QRS
tachycardia
Ventricular fibrillation No discernable pattern, no
QRS, no P, no T
Wolff-Parkinson-White Delta waves present, right axis
SYndrome deviation, short PR interval,
short QRS
The digoxin effect Depression of ST, inverted T
waves
V1-V3 Posterior MI is unusual!
The changes that occur are
opposite to the changes of
other type of MI. thus the tall
R waves are the opposite of
Q waves (remember Q waves
are negative), and ST
depression occurs in place of
ST elevation
T wave Both factors, if they occur,
inversion are usually permanent. In a
occurs full thickness infarction
within a few then there are pathological
hours of MI, Q waves, and T wave
pathological inversion, but in a non-full
Q waves thickness MI then there is
occur only T wave inversion. The
several days differentiation between full
after initial /thickness and non full
MI thickness is pretty much the
same as ST elevation / non-
ST elevation
? Can be difficult to differentiate
from BBB. BBB has p waves,
and a QRS generally 120-
160ms. VT is more likely
scenario after MI, and has
QRS >160ms
Patient is very likely to lose
consciousness – thus the
diagnosis is easy!
Accessory pathway, usually
from the left atria to the left
ventricle allows direct
transition of the signal,
bypassing the AV node,
hence the shortened PR
interval. It has a risk of
mortality as it can cause re-
entry tachycardia; however,
most patients are
symptomless and live with no
problems.
widespread This causes a sloping ST
segment that has a ‘reversed
tick’ look. This occurs
because digoxin blocks the
na/K pump, which increases
intracellular Ca2+
concentrations. (similarly,
ischaemia causes reduced
production of ATP, and thus
reduced pump activity)
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 Pericarditis T wave inversion (rare: also ST Widespread If ST elevation does occur,
elevation) then the ST waves will
appear ‘saddle shaped’ thus
helping you to differentiate it
from MI. also, the elevation in
MI tends to be confined to a
certain area, but in
pericarditis, it is widespread

P pulmonale Tall ,peaked T waves, p wave Lead II Seen in cor pulmonale, or

height >2mm in lead II pretty much anything that
causes right atrial
enlargement (or
hypertrophy) – such as
tricuspid stenosis or
pulmonary hypertension

Bifid P waves (‘P-Mitrale’) P waves with two peaks, broad ? Left ventricular
– looks like an ‘M’; hence the hypertrophy
name ‘Mitrale’

Bi-phasic T waves T waves with t peaks Can occur as a result of MI

Prolonged QT interval Prolonged QT The corrected QT, is the QT

interval as it would be at
60bpm. if this is long, then
there is a risk of sudden
cardiac death. It can be
congenital, but also caused
by drugs

Hyperkalaemia Wide, tall, ‘tented’ T waves, ? Can lead to VF and AF

shortened/absent ST segment,
small or absent p waves, wide
QRS

Left ventricular S wave in V1 or V2 >35mm AND R wave in V5 or V6

hypertrophy >35mm R in aVF >20mm
R in aVL
>11mm
Any chest lead >45mm
R in lead I >12mm

Pacemaker Occasional P waves, not related ? The large spike is pacemaker

to QRS, QRS precede by large stimulus. The QRS’s are wide
spike, QRS complexes broad because the stimulus
originates in the ventricles

Axis deviation

Lead I Lead II Axis

+ + Normal

+ – LAD

– Either RAD

aVR should always be negative!

If it is positive, it is called north-west axis. it could be due to incorrect limb lead placement,
dextrocardia, or artificial pacing, due to the pacemaker wire – this enters the heart at the
apex.
Carotid sinus pressure

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By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via
vagal stimulation. This will reduce the frequency of discharge of the SA node, and
increase the time of conduction across the AV node.
Thus, by applying pressure to the carotid sinus you can:
Reduce the rate of some arrhythmias
Completely stop some arrhythmias
It will have NO EFFECT ON VENTRICULAR TACHYCARDIAS – thus is can help you
differentiate these from supraventricular tachycardias (SVT)

Applying the pressure reduces the frequency of QRS complexes, and allows the
underlying atrial arrhythmia to become more visible.

Related Articles
ECG Abnormalities
Understanding ECGs
Angiotensin II Receptor Blockers (ARBs)
Amiodarone
Cardiac Tamponade

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