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Summary of ECG Abnormalities



This summary of ECG abnormalities is part of the almostadoctor ECG series. For a more in
depth explanation of ECG abnormalities, see ECG abnormalities. To learn about the basic
principle of an ECG, see Understanding ECGs

Abnormality ECG sign Seen in Pathology

Sinus rhythm regular p waves, and each p All leads None

wave is followed by a QRS. 60- (best to look
100bpm at the
rhythm strip)

Sinus Tachycardia Same as above, except All leads Does not represent cardiac
>100bpm (best to look patholoy. May be a sign of
at the anxiety, dehydration, recent
rhythm strip) exercise, or general illness
(e.g. sepsis, pneumonia,
respiratory pathology, other

Sinus bradycardia Same as above except <60bpm All leads This is normal in young fit
(best to look people
at the
rhythm strip)

Right ventricular hypertrophy Negative QRS Lead I Because the cardiac axis has
shifted from 11-5 o’clock to 1-
7 o’clock, thus lead I which
measures laterally from right
to left now gets a negative
signal because the signal is
going from left to right. This
axis shift is called right axis

Right ventricular hypertrophy Taller QRS Lead III – Because lead III measures
becomes vertically but also slightly left
taller than to right, and this is pretty
lead II much the exact direction of
the new shifted axis. Lead II,
measuring from right arm to
left leg is no longer lined up
as well. This axis shift is
called right axis deviation.

Transition point moved to the Equally

left – equal sized R and S sized R and
(normally seen in V3/V4) S now seen
in V5/V6

Left Ventricular Hypertrophy Small lead I QRS, negative Leads I-III Left axis deviation – this is
leads II and lead III QRS often the results of a
conduction defect, and not an
increased bulk of left
ventricular tissue.

Atrial fibrillation Absent P waves – just an some? As well as no p waves, the
irregular baseline. rhythm will be irregularly
irregular. There will be a
Irregularly Irregular, irregular Rhythm strip fibrillating baseline due to
QRS (but QRS is normal uncoordinated activity.
shape) The causes of atrial
fibrillation are:
Might look messy! E.g. Generally 1. Ischaemic heart
2. Thyrotoxicosis
3. Sepsis
4. Valvular heart
5. Alcohol excess
6. PE

Note that AF can also co-

exist with complete heart
block, in which case the
QRS will be regular!

Atrial Flutter Tachycardia Rhythm strip There will be saw tooth p

waves that occur at 300bpm,
Can’t tell if T/P waves are Lead where but the QRS complexes will
present – rhythm is too fast p waves are only be at 150, 100 or 75
(250bpm). Often associated most easily bpm due to various blocks.
block; i.e. there are QRS visible – you The QRS can be regular or
complexes at a lower rate than should use irregular.
the p waves drugs to It can be very difficult to see t
slow down waves – what looks like a T
the heart wave will probably just be a p
rate to see wave. The p waves occur at
what is very regular intervals.
going on

Atrial tachycardia >150bpm, p waves Any where p Caused by a foci of the atria
superimposed over t waves of waves are (outside of the SA node)
preceding beat, normal QRS best seen depolarising quickly

Junctional tachycardia P waves very close to QRS, or Anywhere Due to a ‘re-entry’ loop; there
no QRS visible. QRS is is an area of depolarisation
normal near the AV node; this not
only transmits a signal
throughout the rest of the
ventricles to depolarise them

1st degree heart block PR interval >0.2s (one big Allover – This is an AV node block
square) best in I or Can be caused by CAD,
V1 acute rheumatic carditis,
digoxin toxicity, or
electrolyte disturbance
1st Degree Heart Block It is NOT an medical

2nd degree heart block Progressive lengthening of Anywhere This can be an AV node
Mobitz type 1 – the PR interval followed by block (nearly always), or an
Wencebach absent QRS, then cycle SA node block. usually
repeats. Cycles are variable in benign and generally doesn’t
length. R-R interval shortens require specific treatment.
with lengthening of PR can be caused by CHD or
interval acute MI.
It is usually symptomless, but
can present with:
–Dizziness / light-
Mobitz type 2 headedness / syncope

Absent QRS every now and Anywhere This can be an SA node

again block, or far more commonly
infra-Hisian block (distal
block). It can progress to
complete heart block, from
which there is often no
2:1 and 3:1 conduction escape rhythm; and thus
this needs treatment! the
definitive treatment is an
implanted pacemaker.
Can be caused by CHD or

This is the ratio of P:QRS Anywhere May require a pacemaker,

particularly if the rate is slow

Complete (third degree) 90 P waves/min, only about 38 Best in II This is an AV node block.
heart block QRS/min, and not relationship and V1 Atrial activity will be
between the P waves and the completely normal, but this
QRS complexes. QRS will conductivity does not pass
often have an abnormal into the ventricles.
shape, and be broad This always indicates
(>120ms). However, the P-P underlying disease – the
intervals will be regular, as will disease is often fibrosis
the R-R intervals – they are rather than ischaemia, but it
just not in time with each can occur in MI.
other. The rhythm of the
ventricles is the escape

RBBB – right bundle branch ECG may appear normal. In These are infra-Hisian
block some people there may be 2 R blocks. In bundle branch
waves. This creates a blockages, the wave of
distinctive pattern: depolarisation can still
V1 – there is an M shaped reach the IV septum, then
QRS – this is sometimes called the PR interval will be
an RSR pattern normal – and it is. However,
V6 – there is a W shaped QRS the time taken for the
Wide QRS (120ms) depolarisation to spread
throughout the ventricles is
LBBB – left bundle branch V1 – there is an W shaped longer – thus QRS complex
block QRS duration is lengthened.
V6 – there is a M shaped QRS In the acute setting it may be
Wide QRS (>120ms) caused by MI
The axis can be deviated either RBBB – may indicate right
way in BBB’s, but it is most sided disease. The two R
commonly normal waves indicate the
depolarisation of the right and
left sides of the heart at
different times (the right
depolarises after the left).
You can remember the
pattern with the word
MarroW – there is M in V1,
and W in v6, and the ‘rr’ tells
you it is on the right!
There is NOT specific
treatment, and it is often
caused by an atrial septal
In the acute setting it may be
caused by MI
LBBB – often indicates left
sided heart disease.
Remember the pattern with
Aortic stenosis, dilated
cardiomyopathy, acute MI,
Syncope, and in more severe
cases; heart failure. Those
with syncope and / or heart
failure will usually be
treated with a pacemaker.

Sinus bradycardia Normal rhythm <60bpm Anywhere Associated with; athletic

training, fainting,
hypothermia, myxedema
(hypothyroidism), seen
immediately after MI

Sinus Tachycardia Normal rhythm >100bpm Anywhere Associated with; exercise,

fear, pain, haemorrhage,

Supraventricular rhythms This is any rhythm that Examples include:

originates outside the –Sinus rhythms
ventricle –LBBB

Ventricular rhythms Wide QRS complexes Anywhere
(aka escape rhythms)
Atrial escape Abnormal p wave (e.g. Anywhere This occurs when the SA
Junctional escape inverted) node fails to depolarise.
Ventricular escape Normal QRS Instead, some other part of
Accelerated idioventricular Some normal beats after the the atrium depolarises and
rhythm abnormal one sends the signal to the

No p waves The escape occurs

Normal QRS somewhere at the AV
Slightly slow rate (max 75bpm) junction. It occurs when the
rate of depolarisation of the
SA node falls below the rate
of the AV node, thus the AV
node starts the beat instead.
The resulting bradycardia
reduces cardiac output and
can cause symptoms
similar to other
bradycardias such as:
Usually the bradycardia can
be tolerated as long as it is
above 50bpm

Two types: Somewhere along the line

–Many p waves per QRS the p waves isn’t getting
(complete heart block) conducted to the ventricles,
–Occasional missing p wave, and thus the ventricles
followed by long gap, and then a depolarise at their normal
ventricular QRS, then normal escape rate.

Wide QRS Don’t confuse this with

Rhythm of about 75bpm ventricular tachycardia –
No p waves which requires a HR of
Abnormal T waves >125pbm. Otherwise it looks
very similar.
Usually benign and does
not need to be treated. Also
associated with MI

Extrasystoles These are easy – they are the same as ventricular escapes, except that where
(aka ectopics) in escapes the escape beat comes after a pause in the rhythm, in
extrasystole, there is an abnormal beat earlier than expected.
The QRS complexes are the same as those of sinus rhythm, but there are
usually abnormal p waves that tend to come immediately before or immediately
after the QRS.

Inferior MI ST elevation II, III, aVF The ST elevation in these

(probably the right coronary (the inferior leads is often accompanied
artery) leads) by ST depression in the
antero-lateral leads – V1-
V6, and possibly in lead I
and aVL

Anterior MI ST elevation V2-5 – the This will also cause deep q

(probably the left anterior anterior waves. The presence of Q
descending) leads waves implies a full
thickness infarction.

Posterior MI ST depression, tall R waves V1-V3 Posterior MI is unusual!
The changes that occur are
opposite to the changes of
other type of MI. thus the tall
R waves are the opposite of
Q waves (remember Q waves
are negative), and ST
depression occurs in place of
ST elevation

ST elevation MI ST elevation >2mm in 2+ T wave Both factors, if they occur,

(STEMI) chest leads OR >1mm in 2+ inversion are usually permanent. In a
limb leads, occurs full thickness infarction
T-wave inversion (after several within a few then there are pathological
hours) hours of MI, Q waves, and T wave
Pathological Q waves (24 hours pathological inversion, but in a non-full
+) Q waves thickness MI then there is
occur only T wave inversion. The
several days differentiation between full
after initial /thickness and non full
MI thickness is pretty much the
same as ST elevation / non-
NSTEMI Pathological Q waves only ST elevation

Ventricular tachycardia Wide QRS, no p waves, T ? Can be difficult to differentiate

waves difficult to identify, rate from BBB. BBB has p waves,
>200bpm and a QRS generally 120-
160ms. VT is more likely
scenario after MI, and has
QRS >160ms

Supraventricular Narrow QRS


Ventricular fibrillation No discernable pattern, no Patient is very likely to lose

QRS, no P, no T consciousness – thus the
diagnosis is easy!

Wolff-Parkinson-White Delta waves present, right axis Accessory pathway, usually

SYndrome deviation, short PR interval, from the left atria to the left
short QRS ventricle allows direct
transition of the signal,
bypassing the AV node,
hence the shortened PR
interval. It has a risk of
mortality as it can cause re-
entry tachycardia; however,
most patients are
symptomless and live with no

The digoxin effect Depression of ST, inverted T widespread This causes a sloping ST
waves segment that has a ‘reversed
tick’ look. This occurs
because digoxin blocks the
na/K pump, which increases
intracellular Ca2+
concentrations. (similarly,
ischaemia causes reduced
production of ATP, and thus
reduced pump activity)

Pericarditis T wave inversion (rare: also ST Widespread If ST elevation does occur,
elevation) then the ST waves will
appear ‘saddle shaped’ thus
helping you to differentiate it
from MI. also, the elevation in
MI tends to be confined to a
certain area, but in
pericarditis, it is widespread

P pulmonale Tall ,peaked T waves, p wave Lead II Seen in cor pulmonale, or

height >2mm in lead II pretty much anything that
causes right atrial
enlargement (or
hypertrophy) – such as
tricuspid stenosis or
pulmonary hypertension

Bifid P waves (‘P-Mitrale’) P waves with two peaks, broad ? Left ventricular
– looks like an ‘M’; hence the hypertrophy
name ‘Mitrale’

Bi-phasic T waves T waves with t peaks Can occur as a result of MI

Prolonged QT interval Prolonged QT The corrected QT, is the QT

interval as it would be at
60bpm. if this is long, then
there is a risk of sudden
cardiac death. It can be
congenital, but also caused
by drugs

Hyperkalaemia Wide, tall, ‘tented’ T waves, ? Can lead to VF and AF

shortened/absent ST segment,
small or absent p waves, wide

Left ventricular S wave in V1 or V2 >35mm AND R wave in V5 or V6

hypertrophy >35mm R in aVF >20mm
R in aVL
Any chest lead >45mm
R in lead I >12mm

Pacemaker Occasional P waves, not related ? The large spike is pacemaker

to QRS, QRS precede by large stimulus. The QRS’s are wide
spike, QRS complexes broad because the stimulus
originates in the ventricles

Axis deviation

Lead I Lead II Axis

+ + Normal

+ – LAD

– Either RAD

aVR should always be negative!

If it is positive, it is called north-west axis. it could be due to incorrect limb lead placement,
dextrocardia, or artificial pacing, due to the pacemaker wire – this enters the heart at the
Carotid sinus pressure

By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via
vagal stimulation. This will reduce the frequency of discharge of the SA node, and
increase the time of conduction across the AV node.
Thus, by applying pressure to the carotid sinus you can:
Reduce the rate of some arrhythmias
Completely stop some arrhythmias
It will have NO EFFECT ON VENTRICULAR TACHYCARDIAS – thus is can help you
differentiate these from supraventricular tachycardias (SVT)

Applying the pressure reduces the frequency of QRS complexes, and allows the
underlying atrial arrhythmia to become more visible.

Related Articles
ECG Abnormalities
Understanding ECGs
Angiotensin II Receptor Blockers (ARBs)
Cardiac Tamponade