Electrocardiogram (ECG) Indications for Ordering an electrocardiogram: 1. To determine cardiac rate 2. To accurately define cardiac rhythm 3.

To diagnose old or new myocardial infarction 4. To identify intracardiac conduction disturbances 5. To aid in the diagnosis of ischemic heart dise4ase, pericarditis, myocarditis, electrolyte abnormalities and pacemaker malfunction Position of Limb Leads RA Red Right arm RL Black Right leg LA Yellow Left arm LL Green Left leg Position of Chest Leads Leads Color Position on the chest V1 Red 4th intercostals space (ICS) at the right sternal border V2 Yellow 4th ICS at the left sternal border V3 Green Halfway between V2 and V4 V4 Brown 5th ICS at the left midclavicular line V5 Black 5th ICS at the left anterior axillary line V6 Violet 5th ICS at the left mid-axillary line V3R Halfway between V1 & V4R V4R 5th ICS at the right midclavicular line ECG Lead sequence: Lead I, Lead II, Lead III, AVR, AVL, AVF, V1, V2, V3, V4, V5, V6 Six components of ECG Interpretation: Mnemonic: RRAHIM I. Rate II. Rhythm III. Axis IV. Hypertrophy V. Ischemia and Infarction VI. Miscellaneous findings (including normal variants) I. KNOW THE RATE A. Rate Interpretation has three possibilities 1. Bradycardia (<60 beats per minute) 2. Normal rate (60-100 beats per minute) 3. Tachycardia (> 100 beats per minute) B. Rate Analysis Memorize the following: 300, 150, 100...75, 60, 50 Heart Rate No. of big squares between R-R interval Interpretation

300 Tachycardia 150 Tachycardia 100 Rate 75 Rate 60 Rate 50

1 2 3 4 5 6 Normal Normal Normal Bradycardia

Short cut: If R to R interval > 5 big squares: Bradycardia If R to R interval between 3-5 big squares: Normal Rate If R to R interval < 3 big squares: Tachycardia Specific Formula: Heart Rate = ___1500____ or # of small boxes

___ 300____ # of big boxes

II. KNOW THE RHYTHM A. Common Rhythm Interpretations: 1. Sinus Rhythm 2. Common Supraventricular Arrhytyhmias: a. Atrial Fibrillation (rate variable, irregularly irregular rhythm, p waves absent, qrs narrow) b. Atrial Flutter (rate between 250 350, usually regular rhythm, p waves saw tooth pattern, qrs usually narrow) c. Supraventricular Tachycardia 3. Hear Blocks a. First degree AV block b. Second degree AV block Mobitz type 1 (Wenckebach) c. Second degree AV block Mobitz type II d. Third degree AV block e. Left or Right Bundle Branch Block (complete and incomplete) 4. Ventricular Arrhythmias a. Premature ventricular Contractions b. Ventricular tachycardia (sustained and unsustained), (rate 100-220, rhythm usually regular, p waves absent, qrs > 0.12 s wide) c. Ventricular Fibrillation (rate 350-450, no Ps or QRS, completely chaotic and disorganized rhythm, absent p waves, absent QRS) B. Rhythm Analysis: 1. Identify the P wave 2. Check the relation of P wave to QRS a. P wave is before QRS (normal) b. P wave is buried or after QRS (e.g. found in SVT, complete heart block) 3. Check PR interval (Normal PR interval: 0.12 0.20 sec) a. Short PR (WPW syndrome)

b. Normal PR c. Prolonged PR (1st or 2nd degree AV block) 4. Check QRS duration (Normal QRS duration <0.10 sec) a. Normal QRS b. Wide QRS (Bundle branch blocks) 5. Check the relation of R-R and p-P interval a. Equal R-R and P-P interval (normal) b. P-P interval shorter than R-R interval (Complete Heart Block) c. P-P interval longer than R-R interval (AV dissociation) III. DETERMINE THE AXIS A. Axis interpretation has four possibilities: 1. Normal axis 2. Left axis deviation (LAD) 3. Right Axis deviation (RAD) 4. Indeterminate Axis B. Axis Analysis: -90 I Extreme Right I Left Axis Deviation Axis Deviation I I 180 --------------------------------------------------------- 0 I Lead 1 Right Axis Deviation I Normal Axis I (between -30 to +90 I 90 Lead AVF Lead I AVF + + + Getting the Axis Deviation: Lead I Normal Axis + Left Axis Deviation + Right Axis Deviation Indeterminate Axis (+) QRS deflection: average QRS vector is above the baseline (-) QRS deflection: average QRS vector is below the baseline

Lead AVF + + -

Differential Diagnosis for Left Axis Deviation and Right Axis Deviation Left Axis Deviation Right Axis Deviation Normal variant (short, fat individuals) Normal variant(thin, tall individuals) Left ventricular Hypertrophy (e.g. due Right ventricular hypertrophy (e.g. due to hypertension) to COPD, cor pulmonale) Inferior Wall Infarction Lateral Wall Infarction

Left Bundle branch Block Pulmonary Embolism Left Anterior Fascicular Block Left Posterior Fascicular block WPW syndrome WPW Syndrome IV.CHECK FOR HYPERTROPHY A. Hypertrophy Interpretation has six possibilities: 1. No hypertrophy 2. Left ventricular hypertrophy (LVH) 3. Right Ventricular Hyperthrophy (RVH) 4. Left Atrial Enlargement (LAE) 5. Right Atrial Enlargement (RAE) 6. Combination of the above B. Hypertrophy Analysis: Three Left Ventricular Hypertrophy (LVH) ECG Criteria: These criteria are not applicable in the presence of complete LBBB. 1. S wave in V1 + R wave in V5 or V6 > 35 mm (commonly used) (sensitivity 43%, specificity 97%) 2. R in AVL > 11 mm (sensitivity = 11%, specificity 100%) 3. Romhilt and Estes Criteria (Best Criteria) (sensitivity 50%, specificity 95%) a. Amplitude (any of the following) 3 points Largest R or S wave in the limb leads 20 mm S wave in V1 or V2 30 mm R wave in V5 or V6 30 mm b. ST-T segment changes typical of LV strain pattern without digitalis 3 points with digitalis 1 point

c. LAE: terminal negativity of the P wave in V1 is 1 mm or more in depth with a

duration of 0.04 seconds or more 3 points d. LAD: 30 degrees or more points 2

e. QRS duration 0.09 seconds (but < 0.12 sec)

point f. Intrinsicoid deflection in V5 and V6 0.05 sec point

Total = ________ Interpretation of total score : Possible LVH = 3 points Probable LVH = 4 points Definite LVH 5 points

Right Ventricular Hypertrophy (RVH) ECG Criteria: Right axis deviation of + 110 degrees or more, with any of the following: Lead V1 : R wave > S wave Deep S wave in leads V5 and V6 ST depression and T wave inversion in V1-V3 Differential Diagnosis of RVH ECG Pattern 1. Tall R wave in lead V1 (R wave > S wave) Normal variant (counter-clockwise rotation) Normal in young adults and children Right ventricular hypertrophy including displacement of the heart due to pulmonary disease, COPD Right bundle branch block True posterior infarction WPW syndrome, type A 2. Deep S wave in leads V5 and V6 (R/S ratio less than 1 in leads V5 and V6) Right ventricular hypertrophy especially due to Chronic Obstructive Pulmonary Disease (COPD) Left Atrial Enlargement (LAE) ECG Criteria: Any of the following: 1. In lead V1: wide terminal component of P wave which is 1mm wide (0.04 sec) and 1 mm deep (p mitrale). 2. In any lead: P wave wider than 0.12 sec (> 3 small squares0 or with a 1 mm notched in the middle. Right Atrial Enlargement (RAE) ECG Criteria: Any of the following: 1. In lead V1: tall initial component of p wave which is 2mm wide (0.08 sec) and 2 mm tall (p pulmonale). 2. In any lead: p wave 2.5 mm tall. Biventricular hypertrophy ECG Criteria: Any of the following: (Sensitivity 17%) 1. The ECG meets one or more of the diagnostic criteria for isolated left and right ventricular hypertrophy. 2. The precordial leads show signs of left ventricular hypertrophy but the QRS axis is greater than +90 degrees (RAD). Biatrial enlargement ECG Criteria: Any one of the following: 1. In lead V1, the presence of a large diphasic P wave with the initial positive component 2mm tall (RAE) and the terminal negative component 1mm deep and 0.04 second in duration (LAE). 2. In any lead, an increase in both the amplitude which is 2.5 mm or greater (RAE) and duration of 0.12 second or more of the P wave (LAE). CHECK FOR ISCHEMIA AND INFARCTION A. Ischemia and infarction Has Four Possibilities: 1. Within Normal Limits (WNL): No ischemia or infarction present by ECG

V.

Note: 50% of patients with CAD and chronic stable angina have a normal ECG. 2. Non-specific ST-T wave changes (NSSTWC) 3. Myocardial Ischemia changes: a. Identify which myocardial area is ischemic 4. Myocardial Infarction changes: a. Identify which myocardial area is infracted b. Determine the timing of infarction B. Ischemia and Infarction Analysis: Correspondence of Specific ECG Leads and Left Ventricular Myocardial Area Leads Involved Corresponding LV Areas II, III & AVF Inferior wall I & AVL High lateral wall V1, V2 Septal wall V3, V4 Anterior wall V5, V6 Lateral wall V1 V3 Anteroseptal wall V3- V6, I, AVL Anterolateral wall V5, V6, II, III & AVF Inferolateral wall Almost all leads Diffuse/ global/ massive Mirror image of V1, V2 Posterior LV wall V3R & V4R RV wall ECG Findings in Myocardial Ischemia: Diagnostic Criteria: 1. At least 1 mm ST- segment depression 2. Symmetrically or deeply inverted T waves 3. Abnormally tall T waves 4. Normalization of abnormal T waves 5. Prolongation of the QT interval in addition to the above 6. Others: Arrhythmias, bundle branch blocks, AV blocks, or electrical alternans, Inverted T waves is symmetrical (left half and right half are mirror images Differential Diagnosis of ST Depression (Aside from Myocardial Ischemia) Digitalis effect Hypokalemia Left ventricular hypertrophy (in V5-V6) Right ventricular hypertrophy (In V1-V2) Left bundle branch block Right bundle branch block Subendocardial myocardial infarction ECG Criteria for Myocardial Infarction: Diagnostic criteria: (any of the following) 1. ST elevation 2 mm in 2 or more chest leads or 1 mm in 2 or more limb leads 2. Q waves 0.04 sec(1 small square) 3. Others : Q waves, Inverted T waves, ST segment elevation or depression Seven Useful Rules Concerning Q waves:

1. Q waves in lead AVR are never significant. 2. Q waves in lead V1 are not significant unless with abnormalities in other precordial 3.
4. 5. 6. 7. leads. Q waves in lead III are not significant unless with abnormalities in leads II and aVF. Q waves associated with ST changes are more reliable than without ST changes. Q waves in the presence of LBBB are not significant if located in leads V1 to v3. Q waves in the presence of RBBB are significant. The most significant criteria for pathologic Q waves are: a. 0.04 seconds duration b. 25% of the R wave amplitude

Differential Diagnosis of Peaked T waves Myocardial ischemia Hyperacute myocardial infarction Hyperkalemia Normal variant in young athletes Differential Diagnosis of ST Elevation (Aside from Acute Myocardial Infarction) Acute pericarditis Ventricular aneurysm Severe LV wall hypokinesia Early repolarization changes Variant (prinzmetal) angina VI. CHECK FOR MISCELLANEOUS ECG FINDINGS A. List of 17 Miscellaneous ECG findings 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypercalcemia 5. Digitalis effect 6. Digitalis toxicity 7. Electrical alterans of QRS complexes 8. Poor RT wave progression 9. Persistent S wave at V5-V6 10. Early repolarization changes 11. Juvenile T wave inversion 12. Low voltage QRS complexes 13. High voltage QRS complexes 14. Cerebral T waves of intracranial hemorrhage 15. Wrong lead placement 16. Wrong speed 17. Artifacts or noise B. Short Diagnostic Criteria to the Miscellaneous ECG Findings: 1. Hypokalemia U wave as tall or taller than the T wave at leads V2 and V3. Normal serum potassium: 3.6-5.5 mEq/L. Moderate: flat T wave, U wave

 Extereme: prominent U wave 2. Hyperkalemia In the chest leads, height of T waves > 10 mm in most leads. In limb leads, height of T waves > 5 mm in most leads. Moderate: wide flat P wave, wide QRS, peaked T wave Extreme: no P wave, QRS widens 3. Hypocalcemia Prolonged QT interval 4. Hypercalcemia Shortened QT interval Reference: Cardiology Blue Book 4th edition by Willie Ong and Gregorio Patacsil Rapid Interpretation of EKGS 4th Edition by Dale Dubin