ECG diagnosis

10 ECG rules
ECG signs of M.I.
Evolution of changes in M.I.
Classical Appearences
QRS waveform nomenclature
R r qR qRs Qrs QS
Qr Rs rS qs rSr rSR
The 10 rules for a normal ECG
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
.2
Rule 1
PR
interval
M
i
l
l
i
v
o
l
t
s

Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
P
R
T
Q
S
PR interval should be 120 to
200 milliseconds or 3 to 5 little
squares
Rule 2
M
i
l
l
i
v
o
l
t
s

Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
QRS
P
R
T
Q
S
The width of the QRS complex
should not exceed 110 ms, less
than 3 little squares
Rule 3
I II III aVR aVL aVF
The QRS complex should be
dominantly upright in leads I and II
Rule 4
I II III aVR aVL aVF
QRS and T waves tend to have the
same general direction in the limb
leads
Rule 5
P
Q
T
S
All waves are negative in lead aVR
Rule 6
V
1

V
2

V
3

V
4

V
5

V
6

The R wave in the precordial leads must grow from V1 to at least V4
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Rule 7
The ST segment should start isoelectric except in V1 and
V2 where it may be elevated
Rule 8
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The P waves should be upright in I, II, and V2 to V6
Rule 9
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
There should be no Q wave or only a small q less than
0.04 seconds in width in I, II, V2 to V6
Rule 10
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The T wave must be upright in I, II, V2 to V6
Characteristic changes in AMI
ST segment elevation over area of damage
ST depression in leads opposite infarction
Pathological Q waves
Reduced R waves
Inverted T waves
ST elevation
R
P
Q
ST
Occurs in the early
stages
Occurs in the leads
facing the infarction
Slight ST elevation may
be normal in V
1
or V
2

Deep Q wave
R
P
Q
T
ST
Only diagnostic change of
myocardial infarction
At least 0.04 seconds in duration
Depth of more than 25% of
ensuing R wave
T wave changes
R
P
Q
T
ST
Late change
Occurs as ST elevation is
returning to normal
Apparent in many leads
Bundle branch block
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Anterior wall MI
Left bundle branch block
Sequence of changes in evolving AMI
1 minute after onset 1 hour or so after onset A few hours after onset
A day or so after onset Later changes A few months after AMI



Q
R
P
Q
T
ST
R
P
Q
ST
P
Q
T
ST
R
P
S
T
P
Q
T
ST
R
P
Q
T
Anterior infarction
Anterior infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Left
coronary
artery
Inferior infarction
Inferior infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Right
coronary
artery

Lateral infarction
Lateral infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Left
circumflex
coronary
artery
Location of infarct combinations
aVR
V1 V4
I
II
III
LATERAL
INFERIOR
ANT
POST
ANT
SEPTAL
ANT
LAT
aVL
aVF
V2
V3
V5
V6
Diagnostic criteria for AMI
Q wave duration of more than 0.04
seconds
Q wave depth of more than 25% of
ensuing r wave
ST elevation in leads facing infarct (or
depression in opposite leads)
Deep T wave inversion overlying and
adjacent to infarct
Cardiac arrhythmias