ECGPedia Sinus Rhythm Criteria

A P wave morphology P wave (atrial contraction) precedes every QRS complex The rhythm is regular, but varies slightly during respirations The rate ranges between 60 and 100 beats per minute The P waves maximum height at 2.5 mm in II and/or III The P wave is positive in I and II, and biphasic in V1

Rate

The square counting method is ideal for regular heart rates. Use the sequence 300-150100-75-60-50-43-37. Count from the first QRS complex, the first thick line is 300, the next thick line 150 etc. Stop the sequence at the next QRS complex. When the second QRS complex is between two lines, take the mean of the two numbers from the sequence or use the fine-tuning method listed below. 300 250 214 187 167 150 136 125 115 107 100 94 88 83 79 75 71 68 65 62 60

Conduction

The PQ interval

The PQ duration depends on the conduction velocity in the atria, AV node, His bundle, bundle branches and Purkinje fibers

The PQ interval starts at the beginning of the atrial contraction and ends at the beginning of the ventricular contraction. The PQ interval (sometimes referred to as the PR interval as a Q wave is not always present) indicates how fast the action potential is transmitted through the AV node (atrioventricular) from the atria to the ventricles. Measurement should start at the beginning of the P wave and end at the beginning of the QRS segment. The normal PQ interval is between 0.12 and 0.20 seconds. A prolonged PQ interval is a sign of a degradation of the conduction system or increased vagal tone (Bezold-Jarisch reflex), or it can be pharmacologically induced. This is called 1st, 2nd or 3rd degree AV block. A short PQ interval can be seen in the WPW syndrome in which faster-than-normal conduction exists between the atria and the ventricle

The QRS duration

The QRS duration indicates how fast the ventricles depolarize. The normal QRS is < 0.10 seconds The ventricles depolarize normally within 0.10 seconds. When this is longer than 110 [1] miliseconds , this is a conduction delay. Possible causes of a QRS duration > 110 miliseconds include:

Left bundle branch block Right bundle branch block Electrolyte Disorders Idioventricular rhythm and paced rhythm

For the diagnosis of LBBB or RBBB QRS duration must be >120 ms.

QT interval The normal QTc (corrected) interval The QT interval indicates how fast the ventricles are repolarized, becoming ready for a new cycle. The normal value for QTc is: below 450ms for men and below 460ms for women as [2] agreed upon by the ACC / HRS. In a recent ACC consensus document an expert writing group suggest that in a hospital setting the upper limit be raised to the 99th percentile of normal: 470ms in males and 480 ms in females, as approximately 10% to 20% of the general population have a QTc > 440m s. [3] For both men and women QTc > 500ms is considered highly abnormal. If QTc is < 340ms short QT syndrome can be considered. The QT interval comprises the QRS-complex, the ST-segment, and the T-wave. One difficultly of QT interpretation is that the QT interval gets shorter as the heart rate increases. This problem can be solved by correcting the QT time for heart rate using the Bazett

formula:

Heart Axis With these basics in mind, one can easily estimate the heart axis by looking at leads I and AVF: Positive (the average of the QRS surface above the baseline) QRS deflection in lead I: the electrical activity is directed to the left (of the patient) Positive QRS deflection in lead AVF: the electrical activity is directed down.

This indicates a normal heart axis. Usually, these two leads are enough to diagnose a normal heart axis! A normal heart axis is between -30 and +90 degrees.

A left heart axis is present when the QRS in lead I is positive and negative in II and AVF. (between -30 and -90 degrees) A right heart axis is present when lead I is negative and AVF positive. (between +90 and +180) An extreme heart axis is present when both I and AVF are negative. (axis between +180 and -90 degrees). This is a rare finding.

Morphology P The P wave morphology can reveal right or left atrial hypertrophy or atrial arrhythmias and is best determined in leads II and V1 during sinus rhythm. Characteristics of a normal p wave:
[1]

The maximal height of the P wave is 2.5 mm in leads II and / or III The p wave is positive in II and AVF, and biphasic in V1 The p wave duration is shorter than 0.12 seconds

Elevation or depression of the PTa segment (the part between the p wave and the beginning of the QRS complex) can result from atrial infarction orpericarditis. If the p-wave is enlarged, the atria are enlarged. If the P wave is inverted, it is most likely an ectopic atrial rhythm not originating from the sinus node.

QRS Morphology The basic questions in judging QRS morphology are:

Are there any pathological Q waves as a sign of previous myocardial infarction?

Are there signs of left or right ventricular hypertrophy?

[1]

LVH The Sokolow-Lyon criterium ), this is most often used:

R in V5 or V6 + S in V1 >35 mm.

RVH
R wave in V1 + S wave in V5 or V6 > 10.5 mm

The ECG shows a negative QRS complex in I (and thus a right heart axis) and a positive QRS complex in V1.

Right ventricular hypertrophy, the R wave is greater than the S wave in V1

ATRIAL ENLARGEMENT Criteria for left atrial voor left atrial enlargement. Either P wave with a broad (>0.04 sec or 1 small square) and deeply negative (>1 mm) terminal part in V1 P wave duration >0.12 sec in leads I and / or II

Right atrial enlargement is defined as either P >2.5 mm in II / III and / or aVF P >1.5 mm in V1

Does the QRS complex show microvoltage (roughly QRS < 5mm)? Is the conduction normal or prolonged (QRS-interval > 0,12s)?

If the QRS complex is wider than 0.12 seconds this is mostly caused by a delay in the conduction tissue of one of the bundle branches:

Left Bundle Branch Block (LBBB)) Right Bundle Branch Block(RBBB) Intraventricular conduction delay

A right or left axis rotation can be caused by a:

Left anterior fascicular block (LAFB) Left posterior fascicular block (LPFB)

Sometimes this conduction delay is rate-dependent : the bundle branch block occurs only at higher heart rates and disappears at slower heart rates.

Is the R wave propagation normal? Normally R waves become larger from V1-V5. At V5 it should be maximal. If the R wave in V2 is larger than in V3, this could be a sign of a (previous) posterior myocardial infarction. Other causes are noted in the chapterClockwise and Counterclockwise rotation.

ST Morphology The ST segment represents ventricular repolarization

ST Elevation The most important cause of ST segment elevation is acute Ischemia. Other cause :

High potassium (hyperkalemia): V1-V2 (V3) Pulmonary embolism: ST elevation in V1 and aVR Acute pericarditis: ST elevation in all leads except aVR

ST Depression The most important cause of ST segment depression is Ischemia Other cause:

Digoxin effect Low potassium / low magnesium