15.12.

2014

SummaryofECGAbnormalities

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Home>Systems>TheCardiovascularSystem>ECGs>SummaryofECGAbnormalities

SummaryofECGAbnormalities

Abnormality
Sinusrhythm
SinusTachycardia

ECGsign
regularpwaves,and
eachpwaveisfollowed
byaQRS.60100bpm
Sameasabove,except
>100bpm

Sinusbradycardia

Sameasaboveexcept
<60bpm

Rightventricular
hypertrophy

NegativeQRS

Rightventricular
hypertrophy

TallerQRS

LeftVentricular
Hypertrophy
Atrialfibrillation

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Transitionpoint
movedtotheleft
equalsizedRandS
(normallyseenin
V3/V4)
SmallleadIQRS,
negativeleadsIIand
leadIIIQRS
AbsentPwavesjust
anirregularbaseline.

Seenin
Allleads(bestto
lookatthe
rhythmstrip)
Allleads(bestto
lookatthe
rhythmstrip)

Pathology
None

Doesnotrepresentcardiac
patholoy.Maybeasignofanxiety,
dehydration,recentexercise,or
generalillness(e.g.sepsis,
pneumonia,respiratorypathology,
otherillness)
Allleads(bestto Thisisnormalinyoungfitpeople
lookatthe
rhythmstrip)
LeadI
Becausethecardiacaxishas
shiftedfrom115oclockto17
oclock,thusleadIwhich
measureslaterallyfromrighttoleft
nowgetsanegativesignal
becausethesignalisgoingfrom
lefttoright.Thisaxisshiftiscalled
rightaxisdeviation.
LeadIII
BecauseleadIIImeasures
becomestaller verticallybutalsoslightlyleftto
thanleadII
right,andthisisprettymuchthe
exactdirectionofthenewshifted
axis.LeadII,measuringfromright
armtoleftlegisnolongerlinedup
aswell.Thisaxisshiftiscalled
rightaxisdeviation.
EquallysizedR

andSnowseen
inV5/V6
LeadsIIII

some?

Leftaxisdeviationthisisoften
theresultsofaconductiondefect,
andnotanincreasedbulkofleft
ventriculartissue.
Aswellasnopwaves,therhythm
willbeirregularlyirregular.There
willbeafibrillatingbaselinedue
touncoordinatedactivity.
Thecausesofatrialfibrillation
are:
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SummaryofECGAbnormalities

IrregularlyIrregular,
irregularQRS(butQRS
isnormalshape)

Rhythmstrip

Mightlookmessy!E.g.

Generally

AtrialFlutter

Tachycardia
CanttellifT/Pwaves
arepresentrhythmis
toofast(250bpm).
Oftenassociated
blocki.e.thereare
QRScomplexesata
lowerratethanthep
waves

Rhythmstrip
Leadwherep
wavesaremost
easilyvisible
youshoulduse
drugstoslow
downtheheart
ratetosee
whatisgoing
on

Atrialtachycardia

>150bpm,pwaves
superimposedovert
wavesofpreceding
beat,normalQRS
Pwavesverycloseto
QRS,ornoQRS
visible.QRSisnormal

Anywherep
wavesarebest
seen

1stdegreeheartblock

PRinterval>0.2s(one
bigsquare)

Alloverbestin
IorV1

2nddegreeheartblock
Mobitztype1
Wencebach

Progressive
lengtheningofthePR
intervalfollowedby
absentQRS,then
cyclerepeats.Cycles
arevariableinlength.
RRintervalshortens
withlengtheningof
PRinterval

Anywhere

AbsentQRSeverynow
andagain

Anywhere

Thisistheratioof
P:QRS

Anywhere

Junctional
tachycardia

Mobitztype2

2:1and3:1
conduction

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Anywhere

1. Ischaemicheartdisease
2. Thyrotoxicosis
(hyperthyroidism)
3. Sepsis
4. Valvularheartdisease
5. Alcoholexcess
6. PE

NotethatAFcanalsocoexist
withcompleteheartblock,in
whichcasetheQRSwillbe
regular!
Therewillbesawtoothpwaves
thatoccurat300bpm,buttheQRS
complexeswillonlybeat150,100
or75bpmduetovariousblocks.
TheQRScanberegularor
irregular.
Itcanbeverydifficulttoseet
waveswhatlookslikeaTwave
willprobablyjustbeapwave.The
pwavesoccuratveryregular
intervals.
Causedbyafocioftheatria
(outsideoftheSAnode)
depolarisingquickly
Duetoareentryloopthereisan
areaofdepolarisationneartheAV
nodethisnotonlytransmitsa
signalthroughouttherestofthe
ventriclestodepolarisethem
ThisisanAVnodeblock
CanbecausedbyCAD,acute
rheumaticcarditis,digoxin
toxicity,orelectrolytedisturbance
ItisNOTanmedicalemergency
ThiscanbeanAVnodeblock
(nearlyalways),oranSAnode
block.usuallybenignand
generallydoesntrequirespecific
treatment.canbecausedbyCHD
oracuteMI.
Itisusuallysymptomless,butcan
presentwith:
Dizziness/light
headedness/syncope
ThiscanbeanSAnodeblock,or
farmorecommonlyinfraHisian
block(distalblock).Itcan
progresstocompleteheart
block,fromwhichthereisoften
noescaperhythmandthusthis
needstreatment!thedefinitive
treatmentisanimplanted
pacemaker.
CanbecausedbyCHDorMI
Mayrequireapacemaker,
particularlyiftherateisslow
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Complete(thirddegree)
heartblock

RBBBrightbundle
branchblock

SummaryofECGAbnormalities

90Pwaves/min,only
about38QRS/min,and
notrelationship
betweenthePwaves
andtheQRS
complexes.QRSwill
oftenhavean
abnormalshape,and
bebroad(>120ms).
However,thePP
intervalswillberegular,
aswilltheRRintervals
theyarejustnotin
timewitheachother.
Therhythmofthe
ventriclesistheescape
rhythm.
ECGmayappear
normal.Insomepeople
theremaybe2R
waves.Thiscreatesa
distinctivepattern:
V1thereisanM
shapedQRSthisis
sometimescalledan
RSRpattern
V6thereisaW
shapedQRS
WideQRS(120ms)

LBBBleftbundle
branchblock

V1thereisanW
shapedQRS
V6thereisaM
shapedQRS
WideQRS(>120ms)

Theaxiscanbe
deviatedeitherwayin
BBBs,butitismost
commonlynormal

Sinusbradycardia

Normalrhythm<60bpm

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BestinIIandV1

ThisisanAVnodeblock.Atrial
activitywillbecompletelynormal,
butthisconductivitydoesnotpass
intotheventricles.
Thisalwaysindicatesunderlying
diseasethediseaseisoften
fibrosisratherthanischaemia,but
itcanoccurinMI.

TheseareinfraHisianblocks.In
bundlebranchblockages,the
waveofdepolarisationcanstill
reachtheIVseptum,thenthe
PRintervalwillbenormaland
itis.However,thetimetakenfor
thedepolarisationtospread
throughouttheventriclesis
longerthusQRScomplex
durationislengthened.
Intheacutesettingitmaybe
causedbyMI

RBBBmayindicaterightsided
disease.ThetwoRwavesindicate
thedepolarisationoftherightand
leftsidesoftheheartatdifferent
times(therightdepolarisesafter
theleft).
Youcanrememberthepattern
withthewordMarroWthereisM
inV1,andWinv6,andtherrtells
youitisontheright!
ThereisNOTspecifictreatment,
anditisoftencausedbyanatrial
septaldefect.
Intheacutesettingitmaybe
causedbyMI

LBBBoftenindicatesleftsided
heartdisease.Rememberthe
patternwithWillaM.
Causes:
Aorticstenosis,dilated
cardiomyopathy,acuteMI,CAD
Symptoms:
Syncope,andinmoresevere
casesheartfailure.Thosewith
syncopeand/orheartfailure
willusuallybetreatedwitha
pacemaker.

Anywhere

Associatedwithathletictraining,
fainting,hypothermia,myxedema
(hypothyroidism),seen
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SummaryofECGAbnormalities

immediatelyafterMI
Associatedwithexercise,fear,
pain,haemorrhage,
thyrotoxicosis
Examplesinclude:
Sinusrhythms
LBBB
RBBB

SinusTachycardia

Normalrhythm
>100bpm

Anywhere

Supraventricular
rhythms

Thisisanyrhythm
thatoriginatesoutside
theventricle

Ventricularrhythms
(akaescaperhythms)
Atrialescape

Junctionalescape

Ventricularescape

WideQRScomplexes

Anywhere

Abnormalpwave(e.g.
inverted)
NormalQRS
Somenormalbeats
aftertheabnormalone
Nopwaves
NormalQRS
Slightlyslowrate(max
75bpm)

Anywhere

ThisoccurswhentheSAnode
failstodepolarise.Instead,
someotherpartoftheatrium
depolarisesandsendsthe
signaltotheventricles.
Theescapeoccurssomewhereat
theAVjunction.Itoccurswhen
therateofdepolarisationoftheSA
nodefallsbelowtherateoftheAV
node,thustheAVnodestartsthe
beatinstead.Theresulting
bradycardiareducescardiac
outputandcancause
symptomssimilartoother
bradycardiassuchas:
Dizziness
Lightheadedness
Syncope
Hypotension
Usuallythebradycardiacanbe
toleratedaslongasitisabove
50bpm
Somewherealongthelinethep
wavesisntgettingconductedto
theventricles,andthusthe
ventriclesdepolariseattheir
normalescaperate.

Accelerated
idioventricularrhythm

Twotypes:
Manypwaves
perQRS
(completeheart
block)
Occasional
missingpwave,
followedbylong
gap,andthena
ventricularQRS,
thennormal
rhythm
WideQRS
Rhythmofabout
75bpm
Nopwaves
AbnormalTwaves

Extrasystoles
(akaectopics)

InferiorMI
(probablytheright
coronaryartery)
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Dontconfusethiswith
ventriculartachycardiawhich
requiresaHRof>125pbm.
Otherwiseitlooksverysimilar.
Usuallybenignanddoesnot
needtobetreated.Also
associatedwithMI
Theseareeasytheyarethesameasventricularescapes,exceptthatwhere
inescapestheescapebeatcomesafterapauseintherhythm,in
extrasystole,thereisanabnormalbeatearlierthanexpected.
TheQRScomplexesarethesameasthoseofsinusrhythm,butthereare
usuallyabnormalpwavesthattendtocomeimmediatelybeforeorimmediately
aftertheQRS.
STelevation
II,III,aVF(the
TheSTelevationintheseleadsis
inferiorleads)
oftenaccompaniedbyST
depressionintheanterolateral
leadsV1V6,andpossiblyin
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SummaryofECGAbnormalities

AnteriorMI
(probablytheleft
anteriordescending)

STelevation

V25the
anteriorleads

PosteriorMI

STdepression,tallR
waves

V1V3

STelevationMI
(STEMI)

STelevation>2mmin
2+chestleadsOR
>1mmin2+limb
leads,
Twaveinversion(after
severalhours)
PathologicalQwaves
(24hours+)

Twave
inversionoccurs
withinafew
hoursofMI,
pathologicalQ
wavesoccur
severaldays
afterinitialMI

NSTEMI

PathologicalQwaves
only
WideQRS,nop
waves,Twavesdifficult
toidentify,rate
>200bpm

Ventricular
tachycardia

Supraventricular
tachycardia
Ventricularfibrillation

NarrowQRS

Nodiscernable
pattern,noQRS,noP,
noT
Deltawavespresent,
rightaxisdeviation,
shortPRinterval,short
QRS

Thedigoxineffect

DepressionofST,
invertedTwaves

widespread

Pericarditis

Twaveinversion(rare:
alsoSTelevation)

Widespread

Ppulmonale

Tall,peakedTwaves,p

LeadII

WolffParkinson
WhiteSYndrome

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leadIandaVL
Thiswillalsocausedeepq
waves.ThepresenceofQwaves
impliesafullthickness
infarction.
PosteriorMIisunusual!The
changesthatoccurareopposite
tothechangesofothertypeof
MI.thusthetallRwavesarethe
oppositeofQwaves(rememberQ
wavesarenegative),andST
depressionoccursinplaceofST
elevation
Bothfactors,iftheyoccur,are
usuallypermanent.Inafull
thicknessinfarctionthenthere
arepathologicalQwaves,andT
waveinversion,butinanonfull
thicknessMIthenthereisonlyT
waveinversion.The
differentiationbetweenfull
/thicknessandnonfullthicknessis
prettymuchthesameasST
elevation/nonSTelevation
Canbedifficulttodifferentiate
fromBBB.BBBhaspwaves,and
aQRSgenerally120160ms.VTis
morelikelyscenarioafterMI,and
hasQRS>160ms

Patientisverylikelytolose
consciousnessthusthe
diagnosisiseasy!
Accessorypathway,usuallyfrom
theleftatriatotheleftventricle
allowsdirecttransitionofthe
signal,bypassingtheAVnode,
hencetheshortenedPRinterval.It
hasariskofmortalityasitcan
causereentrytachycardia
however,mostpatientsare
symptomlessandlivewithno
problems.
ThiscausesaslopingSTsegment
thathasareversedticklook.This
occursbecausedigoxinblocksthe
na/Kpump,whichincreases
intracellularCa2+
concentrations.(similarly,
ischaemiacausesreduced
productionofATP,andthus
reducedpumpactivity)
IfSTelevationdoesoccur,then
theSTwaveswillappearsaddle
shapedthushelpingyouto
differentiateitfromMI.also,the
elevationinMItendstobe
confinedtoacertainarea,butin
pericarditis,itiswidespread
Seenincorpulmonale,orpretty
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SummaryofECGAbnormalities

waveheight>2mmin
leadII

BifidPwaves(P
Mitrale)
BiphasicTwaves
ProlongedQTinterval

Hyperkalaemia

Leftventricular
hypertrophy

Pacemaker

Pwaveswithtwo
peaks,broadlooks
likeanMhencethe
nameMitrale
Twaveswithtpeaks
ProlongedQT

Wide,tall,tentedT
waves,
shortened/absentST
segment,smallor
absentpwaves,wide
QRS

muchanythingthatcausesright
atrialenlargement(or
hypertrophy)suchastricuspid
stenosisorpulmonary
hypertension
Leftventricularhypertrophy

CanoccurasaresultofMI
ThecorrectedQT,istheQT
intervalasitwouldbeat60bpm.if
thisislong,thenthereisariskof
suddencardiacdeath.Itcanbe
congenital,butalsocausedby
drugs
CanleadtoVFandAF

SwaveinV1orV2>35mmANDRwaveinV5orV6
>35mmRinaVF>20mm
RinaVL
>11mm
Anychestlead>45mm
RinleadI
>12mm
OccasionalPwaves,
?
Thelargespikeispacemaker
notrelatedtoQRS,
stimulus.TheQRSsarewide
QRSprecedebylarge
becausethestimulusoriginatesin
spike,QRScomplexes
theventricles
broad

Axisdeviation
LeadI
LeadII
Axis
+
+
Normal
+

LAD

Either
RAD
aVRshouldalwaysbenegative!
Ifitispositive,itiscallednorthwestaxis.itcouldbeduetoincorrectlimbleadplacement,
dextrocardia,orartificialpacing,duetothepacemakerwirethisenterstheheartattheapex.

Carotidsinuspressure
ByapplyingpressuretothecarotidsinusyoucanstimulatetheAVandSAnodesviavagal
stimulation.ThiswillreducethefrequencyofdischargeoftheSAnode,andincreasethetimeof
conductionacrosstheAVnode.
Thus,byapplyingpressuretothecarotidsinusyoucan:
Reducetherateofsomearrhythmias
Completelystopsomearrhythmias
ItwillhaveNOEFFECTONVENTRICULARTACHYCARDIASthusiscanhelpyou
differentiate.
ApplyingthepressurebasicallyreducesthefrequencyofQRScomplexes,andallowsthe
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underlyingatrialarrhythmiatobecomemorevisible.
Copyright20092013DrTomLeach
SourceURL(modifiedon10/09/201404:06):http://almostadoctor.co.uk/content/systems/cardiovascular
system/ecgs/summaryecgabnormalities

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