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ECG Interpretation

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Presentation on ECG Interpretation in NIDCH, Dhaka,Bangladesh.

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ECG Interpretation

  1. 1. ECG INTERPRETATION Dr Saleh Ahmed MD Phase A, Cardiology NICVD, Dhaka
  2. 2. CONDUCTIVE SYSTEM There are 5 specialized tissues called conductive system of the heart. These are: • SA node. • AV node. • Bundle of His. • Right bundle branch (RBB) and left bundle branch (LBB). • Purkinje fibers.
  3. 3. Bundle of his Purkinje fibers
  4. 4. ELECTROCARDIOGRAM • It is the graphical representation of electrical potentials produced when the electric current passes through the heart. • Electrical activity is the basic characteristic of heart and is the stimulus for cardiac contraction
  5. 5. P wave Atrial depolarization. PR interval The time taken for the cardiac impulse to spread over the atrium and through AV node and His- Purkinje system QRS Complex Ventricular depolarization. T wave Ventricular repolarization.
  6. 6. Waves of ECG P wave Height ≤2.5mm Width ≤2.5mm Q wave Depth <2mm Width <1mm R wave aVL <13mm aVF <20mm V5,V6 <25mm QRS complex Width <3mm T wave Standard lead ≤5mm Chest lead ≤10mm
  7. 7. Intervals of ECG PR interval 0.12 to 0.20 sec (3- 5mm) QT interval 0.35 to 0.43 seconds
  8. 8. In a normal ECG recording, there are 12 leads: • 3 bipolar standard leads (LI, LII, LIII ) • 3 unipolar limb leads (aVR, aVL, aVF) • 6 chest leads (V1, V2, V3, V4, V5, V6)
  9. 9. VIEW OF THE HEART IN ALL LEADS V1 and V2 Right ventricle V3 and V4 Interventricular septum V5 and V6 Left ventricle V1 to V6 Anterior aspect of heart LI, aVL, V1 to V6 Extensive anterior aspect of heart or anterolateral LI, aVL, V5 and V6 Lateral LI and aVL High lateral LII, LIII and aVF Inferior aspect of heart
  10. 10. ECG Paper Paper Speed – 25mm/s
  11. 11. SYSTEMATIC APPROACH IN ECG INTERPRETATION •Rate—what is the rate ? • Rhythm—regular or irregular, regularly followed by occasional irregular. • Characters of individual waves (P, PR, Q, R, QRS, ST, T, U). • Specific pathological changes.
  12. 12. Heart Rate  When the cardiac rhythm is regular: • If large square is calculated • If small square is calculated:
  13. 13.  When the rhythm is irregular: 1. Count the number of R in 30 large squares 2. Then simply multiply this by 10
  14. 14. RHYTHM OF HEART • If the RR interval is equal, it is called regular rhythm. • If the RR interval is irregular, then it is called irregular rhythm
  15. 15. Causes of Irregular Rhythm 1. Physiological: Sinus arrhythmia. 2. Pathological: • Atrial fibrillation. • Atrial flutter. • Ectopic beat. • SA block or sinus arrest. • Atrial tachycardia with block. • Second degree heart block. • Ventricular fibrillation.
  16. 16. CARDIAC AXIS • Normal axis is between –30° to +90° Tall R in both LI andLII Axis is normal Tall R in LI and deep S in LII Left axis deviation Tall R in LII and deep S in LI Right axis deviation
  17. 17. LOW VOLTAGE ECG Normal standardization 10 mm in height CRITERIA OF LOW VOLTAGE TRACING • In standard limb leads—QRS < 5 mm (mainly R wave). • In chest leads—QRS < 10 mm (mainly R wave)
  18. 18. CAUSES OF LOW VOLTAGE ECG TRACING • Incorrect standardization (i.e. if < 10 mm). • Obesity. • Emphysema • Pericardial effusion. • Chronic constrictive pericarditis. • Myxedema. • Hypothermia.
  19. 19. ECG Changes in Different Diseases
  20. 20. LEFT VENTRICULAR HYPERTROPHY • S in V1 + R in V6 or V5 > 35 mm • R in V5 or V6 > 26 mm • R in aVL > 11 mm • R in aVF > 20 mm • Left axis deviation S in V2 + R in V5 > 35 mm
  21. 21. RV5 SV1 RV5+SV1>35mm RV6>26mm T inversion
  22. 22. RIGHT VENTRICULAR HYPERTROPHY • Tall R wave in V1 > 7 mm • Right axis deviation
  23. 23. RV1>7mm
  24. 24. LEFT ATRIAL HYPERTROPHY • P > 2.5 small squares • P may be notched or bifid (like M), called P mitrale • P in V1-Biphasic
  25. 25. P Mitrale Biphasic P
  26. 26. RIGHT ATRIAL HYPERTROPHY • P > 2.5 mm (P pulmonale) • P in V1 Biphasic
  27. 27. P Pulmonale
  28. 28. ATRIAL FIBRILLATION • P wave Absent • P may be replaced by fibrillary f wave • Rhythm: Irregularly irregular
  29. 29. Rhythm irregularly irregular Fibrillatory wave
  30. 30. ATRIAL FLUTTER • P is saw toothed appearance (flutter or F wave) • RR regular or irregular when there is variable block
  31. 31. P saw toothed appearance R-R regular
  32. 32. • A Saw tooth appearance 7:1 4:1 Atrial Flutter with variable block
  33. 33. SUPRAVENTRICULAR TACHYCARDIA • P—absent. • QRS—narrow. • Rhythm—regular. • Trachycardia
  34. 34. P absent Rhythm regular Trachycardia
  35. 35. VENTRICULAR ECTOPIC • P—absent. • QRS—wide > 0.12 second (3 small squares). • T—opposite to major deflection. P absent Wide QRS T opposite to major deflation
  36. 36. • Bigeminy — every other beat is a ventricular ectopic • Trigeminy — every third beat is a ventricular ectopic
  37. 37. VENTRICULAR TACHYCARDIA • P wave—absent • QRS—broad , abnormal or bizarre pattern • Rate > 100 beats /minute
  38. 38. Broad bizzare QRS complex Absent P wave Heart rate >100b/min
  39. 39. VENTRICULAR FIBRILLATION • Chaotic irregular deflections of varying amplitude • No identifiable P waves, QRS complexes, or T waves Irregular deflaction
  40. 40. FIRST DEGREE AV BLOCK • PR interval—prolonged > 0.22 second
  41. 41. SECOND DEGREE AV BLOCK • Second degree AV block may be of 2 types: • Mobitz type I (Wenckebach’s phenomenon). • Mobitz type II.
  42. 42. MOBITZ TYPE I • Progressive lengthening of PR interval followed by absent QRS complex Drop Beat PR interval lengthening
  43. 43. MOBITZ TYPE II • Some P waves are not followed by QRS complexes • PR interval is constant Drop beat PR constant
  44. 44. COMPLETE HEART BLOCK • PP interval—constant • RR interval- constant • No relationship between P wave and QRS complex P P P P P PR R R
  45. 45. RIGHT BUNDLE BRANCH BLOCK • RSR’—in V1 and V2 (M pattern). • QRS complex— wide (3 small squre) RSR’ QRS wide
  46. 46. LEFT BUNDLE BRANCH BLOCK • RSR’—in V5 and V6, also in LI and aVL (M pattern). • QRS—wide (3 small squares) RSR’ QRS wide
  47. 47. MYOCARDIAL INFARCTION Criteria for acute myocardial infarction: Rise of Troponin I with at least one of the following: 1. Symptoms of myocardial ischaemia 2. New ischaemic ECG changes 3. Development of pathological Q waves 4. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality 5. Identification of a coronary thrombus by angiography or autopsy (Fourth universal definition of myocardial infarction (2018),ESC)
  48. 48. ECG Criteria of Acute MI • ST elevation (with upward convexity). • Pathological Q wave. • T inversion
  49. 49. Masurement of ST elevation All lead accept V2-V3 ≥1mm V2-V3 Men ≥40 years ≥2mm <40 years ≥2.5mm Women ≥1.5mm Fourth universal definition of myocardial infarction (2018),ESC
  50. 50. Sites of Myocardial Infarction is Detected in Different Leads Anteroseptal MI V1 to V3 or V4 Anterior MI V1 to V6. Extensive anterior MI L1, aVL, V1 to V6. Lateral MI L1, aVL, V5, V6 High lateral L1 and aVL Inferior MI L2, L3 and aVF Right ventricular infarction V3R to V6R Posterior (true) MI V1 and V2
  51. 51. Artery involve in MI Inferior MI Anterior MI Lateral MI RCA LCX LAD
  52. 52. ST elevation Anterioseptal MI
  53. 53. ST elevation Extensive Anterior MI
  54. 54. ST elevation High lateral MI
  55. 55. • I ST elevation Inferior MI
  56. 56. Right Ventricular Infarction When suspect • ST elevation in V1 • ST elevation in lead III > lead II ST elevation L3>L2
  57. 57. ST elevation Right Ventricular Infarct
  58. 58. Posterior Myocardial Infarction • Posterior MI is suggested by the following changes in V1-3: • Tall, broad R waves (>30ms) • Horizontal ST depression • Upright T waves
  59. 59. Horizontal ST depressionTall R Upright T
  60. 60. Posterior Lead
  61. 61. • ST elevation in V7-V9 >0.5 mm diagnostic for Posterior MI
  62. 62. Old Myocardial Infarction • Pathological Q wave. • ST—in baseline. • T—normal or inverted
  63. 63. Pathological Q wave
  64. 64. Acute Pericarditis • Widespread ST elevation with upward concavity (chair shaped or saddle shaped) • PR depression ST PR
  65. 65. ST Elevation PR depression
  66. 66. PERICARDIAL EFFUSION • Low voltage ECG • Tachycardia • Electrical alternans • T inversion
  67. 67. Electrical altrnans Low voltage ECG
  68. 68. HYPOKALEMIA • Prolonged PR interval • U—prominent in chest leads . • ST depression • T is small or inverted U T
  69. 69. U wave ST depression
  70. 70. HYPERKALEMIA • T—tall, peaked and tented (in chest leads). • P—wide, small, ultimately absent. • PR interval—prolonged. • QRS—wide, slurred and bizarre.
  71. 71. Tall peaked T Broad bizzare QRS
  72. 72. DEXTROCARDIA • Right axis deviation • Positive QRS complexes in aVR • Absent R-wave progression in the chest leads ,dominant S waves throughout
  73. 73. aVR-Positive QRS complex Absent of R wave progression
  74. 74. PULMONARY EMBOLISM • Sinus tachycardia • RBBB • Right axis deviation • S in LI, Q and T inversion in LIII (SI, QIII, TIII pattern) • ST depression and T wave inversion in right precordial leads (V1 and V2)
  75. 75. S wave Q wave T inversion RBBB
  76. 76. Pulmonary Hypertension • P pulmonale • RV1>7mm • Right axis deviation • RBBB
  77. 77. P pulmonale RV1>7mm
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Presentation on ECG Interpretation in NIDCH, Dhaka,Bangladesh.

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