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Terminology
Aims
To provide an introduction to the
terminology of the electrocardiogram.
Learning Objectives
By the end of the session the students
will be able to:
What is an ECG?
A recording of the changing potentials of the
electrical field imparted by the heart.
P Wave/PR Interval
P Wave
P Wave
SA Node
P Wave II
Wave of
depolarisation
Negative P wave in
lead I
Incorrect lead
placement
Dextrocardia
Ectopic atrial foci
PR Interval
PR interval is the time between the
onset of atrial depolarisation and the
onset of ventricular depolarisation.
From BEGINNING of P wave to first
deflection of QRS.
Normal duration 0.12-0.2 seconds.
PR Interval is constant.
PR Interval
Shortened PR interval
Pre-Excitation
Wolff-Parkinson-White syndrome
Abnormal (accessory) pathway connecting atria
Lown-Ganong-Levine syndrome
Normal QRS Complex duration.
Lengthened PR Interval
AV Block
1st degree
2nd degree
Mobitz II
Wenkebach
3rd degree
nd
2
degree AV BlockWenkebach
PR prolonged beat by beat until dropped
QRS.
QRS
QRS Complex
Electrical forces generated by
ventricular depolarisation.
QRS complex duration is measured in
lead with widest complex.
QRS<0.11s (3 small squares).
Delay in ventricular depolarisation gives
broad QRS.
Nomenclature-QRS Complex
Q Wave: Any INITIAL negative
deflection after P wave.
R Wave: Any positive deflection.
S Wave: Any negative deflection after
an R wave.
QRS
Non-pathological Q waves
QRS
Depolarisation of right and left
ventricles produces opposing electrical
vectors.
Left ventricle large muscle mass.
Left ventricle predominates.
QRS
Lead V1 small initial R wave followed by
large negative deflection S wave.
Lead V6 small initial Q wave followed by
large positive deflection.
Height of R wave progresses across the
precordial leads.
QRS Progression
RBBB (MaRRoW)
Delayed RV activation
RBBB
No conduction down right
bundle.
Septal depolarisation
normal.
Excitation of LV S wave in
V1.
RV depolarises after left
therefore secondary R
wave (RSR pattern).
RBBB
Causes RBBB
NORMAL in young people
IHD
Atrial septal defect (ostium secundum)
Dominant R wave V1
Right ventricular hypertrophy
Posterior MI
Dextrocardia
WPW
RBBB
LBBB (WiLLiaM)
Delay in activation of LV
LBBB
Causes LBBB
Always Abnormal
IHD
LVH
Aortic valve disease
Cardiomyopathy
Right ventricular pacemaker
ST Segment/T Wave/QT
Interval
ST Segment
The interval between the termination of
the QRS and the start of the T wave.
End of ventricular depolarisation and
the beginning of repolarisation.
ST segment should be level (isoelectric)
with the subsequent TP segment.
ST Segment
Changes in AMI
Early
Late
T wave
Ventricular
repolarisation produces
T Wave.
Normal T wave is
asymmetrical.
T wave orientation
usually corresponds to
QRS complex.
T wave inversion in
leads V1-V2 is normal.
T waves
Tall T Waves
Hyper acute
E.g. AMI
Peaked
Metabolic disorders
QT Interval
Measured from beginning QRS to end of
T wave.
Total time for depolarisation and
repolarisation of ventricles.
As heart slows QT interval widens.
QT Interval
QT interval measured relevant to the
heart rate QTc.
QT should not be more than R-R
distance.
Usually <0.44s (11 small squares).
Prolonged QT interval predisposes to
ventricular arrhythmias.
QT Interval
Causes prolonged QT
Congenital
Acquired
Metabolic
Hypo-calcaemia, -thyroidism, -thermia,
kalaemia
IHD
Drugs
Amiodarone, Sotalol, erythromycin, tricyclic
antidepressants
BREAK
Quiz
True/False
The following are correctly paired,
P wave
Q wave
R wave
S wave
T wave
Atrial depolarisation
First positive deflection
Increases in size V1 V6
Negative deflection after R
Ventricular repolarisation
(T, F, T, T, T)
True/False
The following are normal findings on
ECG,
PR interval 0.22s
Mean frontal QRS axis 40
R wave in aVL of 12mm
RBBB
Q wave in lead III
(F, F, T, T, T)
True/False
The ECG ST/T wave,
(T, T, T, T)
True/False
The following are associated with LBBB,
PE
LVH
Pacemaker
IHD
ASD
(F, T, T, T, F)
True/False
A short PR interval is associated with,
(F, T, F, T, F)
Summary
P Wave
SA node initiates atrial depolarisation.
Little muscle mass therefore small
deflection.
P waves upright in leads I, II.
Negative P wave in Lead I abnormal
(check lead positions).
QRS Complex
Ventricular depolarisation.
QRS<0.11s.
Delay in ventricular depolarisation gives
broad QRS complex.
Pacemakers produce LBBB pattern.
Intervals
PR interval measured from beginning of
P wave to first deflection of QRS.
Normal PR interval 0.12-0.2s.
QRS<0.11s.
QT interval varies with rate.
Prolonged QT interval predisposes to
ventricular arrhythmias.
Nomenclature
Q Wave: Any INITIAL negative
deflection.
R Wave: Any positive deflection.
S Wave: Any negative deflection after
an R wave.
T Wave: Ventricular repolarisation.
HyperK
Miscellaneous diagnoses
Hypothermia
Hypocalcaemia
Prolongs QT
Hypercalcaemia
Ventricular Hypertrophy
Sokolow and Lyon
Precordial Leads (one or more)
RI 14 mm
RaVL 12 mm
RaVR 15 mm
> 24 mm in males
> 20 mm in females
Recommended Reading
The ECG made easy
J Hampton
ABC of electrocardiography
BMJ 2002
Any Questions?