Basics of Electrocardiogram

CHAMBER ENLARGEMENT

Chamber Enlargement
The ECG criteria for diagnosing right or left
ventricular hypertrophy are very insensitive (i.e.,
sensitivity ~50%, which means that ~50% of
patients with ventricular hypertrophy cannot be
recognized by ECG criteria). However, the
criteria are very specific (i.e., specificity >90%,
which means if the criteria are met, it is very
likely that ventricular hypertrophy is present).

LVH - 1
S in V1 + R in V5 or V6 > 35 mm
R in aVL >11 mm or, if left axis deviation,
R in aVL >13 mm plus S in III >15 mm
CORNELL Voltage Criteria for LVH
(sensitivity = 22%, specificity = 95%)
S in V3 + R in aVL > 24 mm (men)
S in V3 + R in aVL > 20 mm (women)

LVH - 2
ESTES Criteria for LVH
("diagnostic", >5 points;
"probable", 4 points)

ECG Criteria

Points

R or S in limb leads
> 20mm
S in V1 or V2 > 30mm
R in V5 or V6 > 30mm

Any criteria positive

3 points

ST T abnormalities
Without digoxin
With digoxin

3 points
1 point

Left Atrial Enlargement

inV1

3 points

Left Axis Deviation

2 points

QRS duration 0.09sec

1 point

Delayed intrinsicoid
deflection in V5 or V6
> 0.05SEC

1 point

RVH
V1 Lead:
- R/S ratio > 1 and negative T wave
- R > 6 mm, or S < 2mm,
- rSR' with R' >10 mm
R in V1 + S in V5 (or V6) > 10 mm
V5 or V6
- R/S ratio in V5 or V6 < 1
- R in V5 or V6 < 5 mm
- S in V5 or V6 > 7 mm

LAE
Sensitivity = 50%; Specificity = 90%

P wave duration > 0.12s in frontal plane (usually

lead II)
Terminal P negativity in lead V1 (i.e., "P-terminal
force") duration >0.04s, depth >1 mm.

RAE
P wave amplitude >2.5 mm in II and/or >1.5 mm
in V1 (Sensitivity = 50%; Specificity = 90%)

QRS voltage in V1 is <5 mm and V2/V1

voltage ratio is >6 (Sensitivity = 50%;
Specificity = 90%)
Criteria derived from the QRS complex are
due to both the high incidence of RVH
when RAE is present, and the RV
displacement by an enlarged right atrium.

BUNDLE BRANCH BLOCKS

Left Bundle Branch Block

Electrocardiographic Criteria
1.The QRS duration is >/- 120 ms
2.Leads V5,V6 and AVL show broad and notched
or slurred R waves
3.With the possible exception of lead AVL, the Q
wave is absent in left-sided leads
4.Reciprocal changes in V1 and V2
5.Left axis deviation may be present

Right Bundle Branch Block

The diagnostic criteria include
1.QRS duration is >/- 120 ms
2.An rsr,rsR or rSR pattern in lead V1 or
V2 and occasionally a wide and notched R
wave.
3.Reciprocal changes in V5,V6,I and AVL

12 Lead ECG Basics

Bundle Branch Block
Step 1. Determine that the rhythm is
supraventricular in origin and has a QRS
that is > 0.12 secs in lead V1 or MCL1 .
Step 2. Locate the J point in the ECG cycle
(end of the QRS and beginning of the ST).
Step 3. Draw a line backward into the
terminal component of the QRS.
Step 4. Shade in the triangle created by this
line and the terminal component of the
QRS.

12 Lead ECG Basics

Bundle Branch Block
Shade this area

Step 5. If the triangle

points up then it is
a Right BBB.

12 Lead ECG Basics

Bundle Branch Block
Shade this area

Step 6. If the
triangle points
down then it is a
Left BBB.

Left Anterior Fascicular Block

Left axis deviation , usually -45 to -90 degrees
QRS duration usually <0.12s unless coexisting RBBB
Poor R wave progression in leads V1-V3 and deeper S
waves in leads V5 and V6
There is RS pattern with R wave in lead II > lead III
S wave in lead III > lead II
QR pattern in lead I and AVL,with small Q wave
No other causes of left axis deviation

Left Posterior Fascicular Block

Diagnostic Criteria include
1.QRS duration 100- <120 ms
2.No ST segment or T wave changes
3.Right axis deviation (100 degree)
4.QR pattern in inferior leads (II,III,AVF) small q
wave
5.RS patter in lead lead I and AVL(small R with
deep S)
6.No other causes of right axis deviation

Bifascicular Bundle Branch

Block
RBBB with either left anterior or left posterior
fascicular block
Diagnostic criteria
1.Prolongation of the QRS duration to 0.12 second
or longer
2.RSR pattern in lead V1,with the R being broad
and slurred
3.Wide,slurred S wave in leads I,V5 and V6
4.Left axis or right axis deviation

Trifascicular Block
The combination of RBBB, LAFB and long
PR interval
Implies that conduction is delayed in the
third fascicle

ST Elevation and non-ST Elevation MIs

When myocardial blood supply is abruptly
reduced or cut off to a region of the heart, a
sequence of injurious events occur beginning
with ischemia (inadequate tissue perfusion),
followed by necrosis (infarction), and eventual
fibrosis (scarring) if the blood supply isn't
restored in an appropriate period of time.
The ECG changes over time with each of
these events

INFARCTION

INJURY

ISCHAEMIA

INFARCTED MYOCARDIUM
(STEMI)
myocardium electrically dead
The electrode lying over the area of
infarction has the effect of looking through
the infarcted area as a window. This
therefore will detect and record potentials
from the myocardium directly opposite.

INJURED MYOCARDIUM
myocardium is never completely polarized
The electrode lying over the area of injury
will record ST Segment elevation on the
ECG because of the myocardium retaining
its polarity.

ISCHAEMIC MYOCARDIUM
myocardium exhibits impaired
repolarisation
The electrode lying over the area of
ischaemia will record T wave changes on
the ECG

STAGE 1
ACUTE STAGE - HOURS OLD
Acute stage of injury The myocardium is
not yet dead and unless rapid intervention
is possible then death of the affected area
of muscle will certainly follow. In the case
of rapid intervention then the area of death
may be reduced although even with
treatment some necrosis will take place

The typical shape of the ECG leads which are

positioned directly over the injured area of
myocardium will show significant ST segment
elevation of greater than 2 mm, there may also
be a reduction in the size of the R wave.
There will be ST segment depression in the
areas of myocardium opposite the injured area
these are known as RECIPROCAL CHANGES

STAGE 2
LATER PATTERN - DAYS OLD
In stage 2 the injured myocardium is now
starting to necrose and this results in Q
waves beginning to appear on the ECG
which are representations of
depolarization on the opposite wall of the
heart, this is due to the window effect over
the area of dead myocardium

The electrode is looking through the

electrical window where no electrical activity
occurs
The ST segment elevation will lessen as the
area of injury either becomes Ischaemic or
dies
T waves now begin to appear representing
the area of ischaemia which is surrounding
the infarcted muscle

STAGE 3
LATE PATTERN - WEEKS OLD
In stage three, the zone of injury has now
evolved into infarcted myocardium
There is a pathological Q wave seen on the
ECG due to the electrical window being
present
The ST segment has now returned to
normal/Iso-electric line because the injured
area has now necrosed or become ischaemic
There is now a symmetrically inverted T wave
present on the ECG which represents
persistent ischaemia surrounding the area of
infarct

STAGE 4
OLD INFARCT -MONTHS TO YEARS
In stage 4 the zone of ischaemia has recovered
and the ECG returns to almost normal
However there are changes which allow us to
identify a previous infarct on the ECG
The pathological Q wave is considered the
finger print for life of a previous myocardial
infarction
The R wave height is reduced in the leads
positioned directly over the area of infarct

ST Elevation Infarction
Heres a diagram depicting an evolving infarction:
A. Normal ECG prior to MI
B. Ischemia from coronary artery occlusion
results in ST depression (not shown) and
peaked T-waves
C. Infarction from ongoing ischemia results in
marked ST elevation
D/E. Ongoing infarction with appearance of
pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Qwaves, but normal ST segment and Twaves

ST Elevation Infarction
Heres an ECG of an inferior MI:
Look at the
inferior leads
(II, III, aVF).
Question:
What ECG
changes do
you see?
ST elevation
and Q-waves

Extra credit:
What is the
rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!

ST Elevation Infarction
Heres an ECG of an inferior MI later in time:
Now what do
you see in the
inferior leads?

ST elevation,
Q-waves and
T-wave
inversion

Non-ST Elevation Infarction

The ECG changes seen with a non-ST elevation infarction are:

Before injury Normal ECG

Ischemia

ST depression & T-wave inversion

Infarction

ST depression & T-wave inversion

Fibrosis

ST returns to baseline, but T-wave

inversion persists

Non-ST Elevation Infarction

Heres an ECG of an evolving non-ST elevation MI:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.

Question:
What area of
the heart is
infarcting?

Anterolateral

ECG

ECG

ECG

ECG

ECG

ECG

ECG

ECG

Rhythm disorders

Normal Sinus Rhythm

Rate

60-100bpm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Bradycardia

Rate

Less than 60bpm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal, gradually lengthens with HR decrease

QRS Width

Normal

Sinus Tachycardia

Rate

Greater than 100bpm, Gradual onset

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal, gradually shortens with HR increase

QRS Width

Normal

Sinus Arrhythmia

Rate

60-100bpm

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Pause/Arrest

Rate

Varies

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present, except during pause

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Node Exit Block

Rate

Varies

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present, except during dropped beats

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Rhythm w/ PAC

(Premature Atrial Contraction)

Rate

Depends on underlying sinus rate

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present, may be different morphology during PAC

P:QRS Ratio

1:1, associated

PR Interval

Normal, varies during PAC

QRS Width

Normal

Atrial Tachycardia

Rate

100-180bpm, Sudden onset

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Morphology will differ from sinus p-wave

P:QRS Ratio

1:1, associated

PR Interval

Interval of ectopic focus will differ from sinus PR

QRS Width

Normal, but can develop aberrant (wide) complexes

Multifocal Atrial Tachycardia

Rate

Greater than 100bpm

P-P Regularity

Irregularly irregular

R-R Regularity

Irregularly irregular

P wave

At least 3 different p-wave morphologies

P:QRS Ratio

1:1, associated

PR Interval

Varies

QRS Width

Normal

Atrial Flutter

Atrial Rate
Ventricular Rate

Atrial Rate commonly 250-350bpm

Ventricular Rate will vary with conduction

P-P Regularity

Regular

R-R Regularity

Usually regular, but may be variable

P wave

Saw-tooth p-wave morphology

P:QRS Ratio

Varies, can be 1:1, 2:1, 3:1, 4:1, etc.

PR Interval

Varies

QRS Width

Normal

Atrial Fibrillation

Rate

Varies, ventricular response can be fast or slow

P-P Regularity

Chaotic atrial activity

R-R Regularity

Irregularly irregular

P wave

No discernable p-waves

P:QRS Ratio

None

PR Interval

None

QRS Width

Normal, but can develop aberrant (wide) complexes

Junctional Rhythm

Rate

40-60bpm

P-P Regularity

None, or Regular if antegrade or retrograde

R-R Regularity

Regular

P wave

Variable (none, antegrade, or retrograde)

P:QRS Ratio

None, or 1:1 if antegrade or retrograde

PR Interval

None, short, or retrograde

QRS Width

Normal

Accelerated Junctional Rhythm

Supraventricular Tachycardia
(SVT)

Rate

60-100bpm (Accelerated Junctional Rhythm)

Greater than 100bpm (Supraventricular
Tachycardia)

P-P Regularity

None, or Regular if antegrade or retrograde

R-R Regularity

Regular

P wave

Variable (none, antegrade, or retrograde)

P:QRS Ratio

None, or 1:1 if antegrade or retrograde

PR Interval

None, short, or retrograde

QRS Width

Normal

Sinus Rhythm w/ PVC

(Premature Ventricular Contraction)

Rate

Depends on underlying sinus rate

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

No P-waves with the PVC

P:QRS Ratio

No P-waves with the PVC

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Ventricular Rhythm

Rate

20-40bpm

P-P Regularity

None

R-R Regularity

Regular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Accelerated Ventricular Rhythm

Rate

40-100bpm

P-P Regularity

None

R-R Regularity

Regular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Ventricular Tachycardia

Rate

100-200bpm

P-P Regularity

Variable

R-R Regularity Regular

P wave

Dissociated atrial rate

P:QRS Ratio

Variable

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Fast VT (Ventricular Flutter)

Rate

200-300bpm

P-P Regularity

None

R-R Regularity

Regular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Polymorphic VT (Torsades)

Rate

200-250bpm

P-P Regularity

None

R-R Regularity

Irregular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Variable with wide complexes

Ventricular Fibrillation

Rate

Indeterminate

P-P Regularity

None

R-R Regularity

Chaotic Rhythm

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

None

Sinus Rhythm
w/ 1st Degree AV Block

Rate

Depends on underlying rhythm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present, Normal

P:QRS Ratio

1:1, associated

PR Interval

Prolonged, > 0.20sec

QRS Width

Normal

Sinus Rhythm

w/ 2nd Degree AV Block Type I (Wenckebach)

Rate

Depends on underlying rhythm

P-P Regularity

Regular

R-R Regularity

Regularly irregular

P wave

Present

P:QRS Ratio

Variable; 2:1, 3:2, 4:3, etc

PR Interval

Variable, gradually lengthens until dropped

QRS Width

Normal

Sinus Rhythm

w/ 2nd Degree AV Block Type II

Rate

Depends on underlying rhythm

P-P Regularity

Regular

R-R Regularity Regularly irregular

P wave

Present

P:QRS Ratio

Variable; 2:1, 3:2, 4:3, etc

PR Interval

Normal for conducted beats

QRS Width

Normal

Sinus Rhythm

w/ 3rd Degree AV Block (Complete Heart Block)

Atrial Rate
Ventricular Rate

Atrial rate is the underlying rhythm (i.e, Sinus, Atrial Fib, etc.)
Ventricular rate is from the dissociated escape rhythm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

Variable, dissociated

PR Interval

Variable, No pattern

QRS Width

Normal (Junctional escape rhythm)

Wide (Ventricular escape rhythm)

Sinus Rhythm w/ BBB

(Bundle Branch Block)

Rate

Depends on the underlying sinus rhythm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Wide (>0.12ms)

Atrial Fib w/ BBB

(Bundle Branch Block)

Rate

Depends on the underlying Atrial Fibrillation,

Ventricular rate can be fast or slow.

P-P Regularity

Chaotic atrial activity

R-R Regularity

Irregularly irregular

P wave

Present

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide (>0.12ms)

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.
Complete Heart Block
D.
Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete
Complete Heart Block
D.Atrial
Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation

PRACTICE RHYTHM STRIPS

Practice Rhythm
Strips
On the following rhythm strips in subsequent slides,
determine rhythm presented.
Consider the following:

What is the atrial and ventricular rate? Is it normal?

What is the regularity (P-P and R-R)
Are any AV and/or Bundle branch blocks present?
Does the rhythm have a clinical significance?

Answers can be found in the notes section of the slides.

Practice Rhythm Strips

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