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KURSK STATE MEDICAL UNIVERSITY

Department of the Propaedeutics of the Internal


Diseases

Electocardiogram
Analysis
A Systemic Guide to ECG Diagnosis

Prepared for Foreign Students


of the Medical Faculty
Kursk – 2005

2
UDK 612.172.4-07(072)
BBK 54.10:53.4я7

Electocardiogram Analysis. A Systemic Guide to ECG Diagnosis. Prepared for


foreign students of the Medical Faculty – Kursk: KSMU, 2005. – 44 p.

Authors:
E.N. Konoplya, M.D., Ph.D., Professor, Head of the Department
T.A. Dronova, M.D., Ph.D., Professor of the Department
P.S. Dronov, Translator Editor

Reviewed by I.A. Saraev, M.D., Ph.D., Professor.

This guide is devised for foreign students of the Medical Faculty in the
Propaedeutics Department of the Internal Diseases and contains a detailed plan of
ECG analysis. The systematic guide will help the students to learn theoretical
knowledge and work out practical skills in the main topic of internal medicine course
“Examination of patients with cardiovascular pathology” and elective course
“Functional diagnostics of cardiovascular pathology”. The guide will help the
students to prepare for exams remarkably, and to develop diagnostic skills for using
in future physician’s practice.

© Group of authors, KSMU, 2005

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Государственное образовательное учреждение
высшего профессионального образования
«Курский государственный медицинский университет
Министерства здравоохранения РФ»

Анализ
электрокардиограмм

руководство по ЭКГ диагностике

для студентов высших медицинских учреждений,


занимающихся на английском языке,
по специальности 040100 «Доктор медицины»

Курск – 2005

4
УДК 612.172.4-07(072) Печатается по решению
ББК 54.10:53.4я7 редакционно-издательского
совета КГМУ

Конопля Е.Н., Дронова Т.А., Дронов П.С. Анализ электрокардиограмм.


Руководство по ЭКГ диагностике для студентов высших медицинских
учреждений, занимающихся на английском языке, по специальности 040100
«Доктор медицины». – Курск: КГМУ, 2005. – 44 с.

Руководство по ЭКГ диагностике предназначено для студентов


иностранного факультета, обучающихся на кафедре пропедевтики внутренних
болезней, и содержит детально разработанный план анализа
электрокардиограмм. Данное издание будет способствовать не только
овладению базисом теоретических знаний, но и выработке практических
навыков при подготовке студентов по одной из основных тем курса внутренней
медицины «Обследование больных с заболеваниями сердечно-сосудистой
системы», а также при использовании этого руководства на занятиях по
элективному курсу «Функциональная диагностика патологии сердечно-
сосудистой системы». Руководство поможет студентам полноценно
подготовиться к экзаменам, будет способствовать формированию
диагностических навыков, необходимых для дальнейшей практической
деятельности врача.

Рецензент:
профессор кафедры внутренних болезней № 2, д.м.н. И.А. Сараев

ISBN 5-7487-0905-8 ББК 54.10:53.4я7

© Коллектив авторов, КГМУ, 2005

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ELECTROCARDIOGRAM
(ECG)

In every ECG 10 features must be examined systematically:

1) Rhythm
2) Rate
3) P-wave
4) P-R (or P-Q) interval
5) QRS interval
6) QRS complex:
a) duration,
b) voltage,
c) Q wave,
d) electrical axis,
e) transitional zone,
f) intrinsicoid deflection
7) ST segment
8) T wave
9) U wave
10) Q-T duration

SCHEME of ECG ANALYSIS and ECG NORMS

Analysis of cardiac rhythm and conductivity:

REGULARITY

Cardiac rhythm is classified as “regular” or “irregular”

a) Regular rhythm: R-R1 = R1-R2


Equality of R-R interval + 10% of average R-R duration

b) Irregular rhythm R-R1 / R1-R2


Inequality of R-R (difference is greater than 10% of average R-R duration)

REGULAR RHYTHM
RATE:
Rate (per minute) = 60: R-R
60 – 1 min (in sec.)
R-R – duration (in sec.)

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NORMAL RATE = 60 – 100 heart beats per minute
TACHYCARDIA > 100 heart beats per minute
BRADYCARDIA < 60 heart beats per minute

ECG pattern of NORMAL RATE:


– Normal sinus rhythm (usual rate in rest 60 – 100 heart beats per minute)
– Second degree AV block – irregular rhythm (usual rest rate 60 – 100 heart
beats per minute)
– Atrial flutter with a regular ventricular response (75 – 100 heart beats per
minute)
ECG pattern of TACHYCARDIA:
– Sinus tachycardia (usual rest rate 100 – 180 heart beats per minute)
– Supraventricular (atrial or nodal) tachycardia (150 – 250 heart beats per
minute)
– Atrial flutter with a regular ventricular response (100 – 175 heart beats per
minute)
– Ventricular tachycardia (110 – 250 heart beats per minute)

ECG pattern of BRADYCARDIA:


– Sinus bradycardia (< 60 heart beats per minute)
– Second degree AV block – irregular rhythm (30 – 60 heart beats per minute)
– Third degree AV block = complete heart block (< 40 heart beats per minute)

CARDIAC PACEMAKER
SINUS RHYTHM
Sinus rhythm – pacemaker in sinus node
(usual rest rate 60 – 100 heart beats per minute) [Fig.1].

Fig. 1. Sinus rhythm


Sinus rhythm features:
Positive P before each QRS complex
in I, II, and III standard leads, AVF, V4 – V6.
P waves are the same in one lead.

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SINUS RATE DISTURBANCES

SINUS BRADYCARDIA:
 Regular rhythm
 Rate:40 – 60 heart beats per minute
 P wave before each QRS complex
 P-Q (P-R) interval normal
 QRS complex usually normal

SINUS TACHYCARDIA:
 Regular rhythm
 Rate:100 –150 heart beats per minute
 P wave before each QRS complex (may be buried in preceding T wave)
 P-Q (P-R) interval normal
 QRS complex usually normal

ATRIAL RHYTHM

Atrial rhythm – pacemaker in low parts of atria


(usual rest rate 75 / min.) [Fig. 2].

Fig. 2. Atrial rhythm

Atrial rhythm features:


Negative P before QRS complex in the II and III standard leads.

Paroxysmal atrial tachycardia


(abrupt onset and cessation):
 Regular rhythm
 Rate:150–250 heart beats per minute
 P wave distorted before each QRS complex (may be found in preceding T wave)
 P-Q (P-R) interval <0,12 seconds
 QRS complex usually normal

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Atrial flutter with a regular ventricular response
(100 – 175 heart beats per minute)
 Regular rhythm
 Rate:100 –175 heart beats per minute (depending on kind of block (2:1, 3:1)
 Atrial rate: 250 – 400 beats per minute
 P wave absent, replaced by saw tooth F waves
 QRS complex < 0,10 seconds
 T waves may be obscured by flutter waves

ATRIO-VENTRICULAR-NODAL RHYTHM

Pacemaker is AV-node – AV-nodal rhythm


(usual rest rate 40 – 60 / min) [Fig. 3, 4].

Fig. 3. AV-nodal rhythm

Fig. 4. AV-nodal rhythm

AV-nodal rhythm features:


Absent P or negative P after every QRS complex,
QRS is not deformed.

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Paroxysmal AV-nodal tachycardia
(abrupt onset and cessation):
 Regular rhythm
 Rate:150 –250 heart beats per minute
 P waves invisible
 QRS complex < 0,10 seconds

IDIOVENTRICULAR RHYTHM
Ventricular (idioventricular) rhythm – pacemaker is in the ventricles
(bundle of His or Purkinje system) – usual rest rate 30–40 / min.[Fig. 5].

Fig. 5.
Ventricular
(idioventricular)
rhythm
Idioventricular
rhythm
features:
Absent P wave,
Deformed QRS
(QRS > 0,12 sec).

Ventricular rhythm is characteristic of complete heart block


(independence of P waves and QRS complex).

Ventricular tachycardia
 Regular rhythm (usually)
 Rate:150 –200 beats per minute
 P waves invisible (usually buried in QRS complex)
 QRS complex deformed (QRS > 0,12 sec)
 T wave in opposite direction with QRS complex

IRREGULAR RHYTHM

TOTALLY AND SPORADICALLY

TOTALLY IRREGULAR RHYTHM

ECG patterns of totally irregular rhythm:


- Atrial fibrillation

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- Atrial flutter with varying block

The ventricular rhythm is totally irregular, although short runs of the irregular
ventricular rhythm sometimes can seem regular.

ATRIAL FIBRILLATION

Atrial fibrillation – irregular irregularity


(delirium cordi) [Fig. 6].

Characteristics of atrial fibrillation:


Irregular ventricular rate:
R-R1 / R1-R2,
Absence of P waves,
Quick f waves of atrial fibrillation (f-waves 350 – 700 / min),
QRS  0,10 sec.

Fig. 6. Atrial fibrillation

ATRIAL FLUTTER
Atrial flutter with varying block [Fig. 7].
Characteristics of atrial flutter with varying block:
Irregular ventricular rate:
R-R1 / R1-R2,
Absence of P waves,
“Saw tooth” F atrial waves (atrial rate 250 – 350 /min),
QRS  0, 10 sec.

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Fig. 7. Atrial flutter with varying block

RHYTHMICALLY or SPORADICALLY IRREGULAR RHYTHM

SINUS ARRHYTHMIA

 Sinus arrhythmia – variation of R-R > 0,15 sec


Normal P waves present before every QRS complex.

 Respiratory sinus arrhythmia [Fig. 8] is a variant of norm in young. The


heartbeats are varied cyclically, usually speeding up with inspiration and
slowing down with expiration.

Fig. 8. Respiratory sinus arrhythmia

EXTRASYSTOLES

 Early heart beats = extrasystoles


Premature contraction of the heart.
Extrasystoles are supraventricular and ventricular
Supraventricular extrasystoles:
atrial or nodal – a beat of atrial or AV nodal origin came earlier than the next
normal heart beat (a pause follows)

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ATRIAL EXTRASYSTOLES

Atrial extrasystoles [Fig. 9]:


- Early appearance of P and QRS
- QRS complex  0,10 sec.
- Premature P may be “+” or “–“ (in II standard lead – low atrial extrasystole)
- Compensatory pause (cp) is incomplete (slightly longer than the sinus cycle)

Fig. 9. Atrial extrasystole

3 main features of atrial extrasystole:


- Premature, ectopic P wave (abnormal, often inverted) before QRS.
- QRS unchanged from that of the conducted sinus beats (QRS  0,10 sec).
- Post-extrasystolic cycle is less than fully compensatory.

ATRIOVENTRICULAR JUNCTIONAL EXTRASYSTOLES

AV- junctional extrasystole (nodal) [Fig. 10, 11]:


Ectopic rhythm arising in AV node may retrogradely activate the atria before,
during or after ventricular activation: retrograde P wave may be seen preceding or
following QRS complex, or lost within it.

Fig. 10. AV-nodal extrasystole

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Fig. 11. AV-nodal extrasystole

AV- nodal extrasystole:


- QRS complex unchanged from that of conducted sinus beats (QRS  0,10 sec)
- P wave absent or negative (-P)
- Incomplete compensatory pause (cp / 2R-R)

Premature heart contractions (extrasystoles) – pulse deficit may be existed.


Pulse deficit = difference between apical and radial pulse rate

VENTRICULAR EXTRASYSTOLES

Ventricular extrasystole [Fig. 12]:


Wide and deformed QRS 0,12 sec (QRS sticks out like a sore thumb)
Discordant RS-T and T
Absence of P wave
Fully compensatory pause (complete compensatory pause)
cp=2R-R

Fig. 12. Ventricular extrasystole

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ALLORHYTHMIA

Bigeminy: - alteration of normal and abnormal heart beats


(sinus QRS – extrasystolic QRS, sinus QRS – extrasystolic QRS, and so on)

Trigeminy: - alteration of 2 normal and 1 abnormal premature heart beats


(sinus QRS – sinus QRS – extrasystolic QRS,
sinus QRS – sinus QRS – extrasystolic QRS, and so on)

The ventricle of origin of ectopic beat can best be recognized in V1 lead:


 if extrasystolic complex in V1 is predominantly positive – left ventricular
extrasystole [Fig. 13, 14],
 if extrasystolic complex in V1 is predominantly negative – right ventricular
extrasystole [Fig. 15, 16].
V1

Fig. 13. Left ventricular extrasystole (in V1)

V6

Fig. 14. Left ventricular extrasystole (in V6)

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LEFT VENTRICULAR EXTRASYSTOLE:

ectopic QRS complex is predominantly positive in V 1 – the impulse is traveling


toward the right and coming from the left ventricle.

V1

Fig. 15. Right ventricular extrasystole (in V1)

V6

Fig. 16. Right ventricular extrasystole (in V6)

RIGHT VENTRICULAR EXTRASYSTOLE:

ectopic QRS complex is predominantly negative in V1 – the impulse must be


traveling toward the left and therefore originating on the right.

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ELECTRICAL AXIS

 HEXAXIAL REFERENCE SYSTEM (by Bailey)


Constitution of hexaxial reference system [Fig. 17–20]

Fig. 17. Einthoven’s triangle (three standard leads)

Fig. 18. Traxial reference system

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Fig. 19. Unipolar limb leads (aVR, aVL, aVF)

Fig. 20. Hexaxial reference system (by Bailey)

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Electrical axis determination [Fig. 21]:
 In general, axis between 0 degree and + 90 degree corresponds with normal axis
 Axis between 0 degree and –90 degree corresponds with left axis deviation
 Axis between +90 degree and +180 degree respects left axis deviation

Fig. 21. Electrical axis determination (alpha – angle)

Alpha – angle:
Variants of norms:
Normal axis: (+30 degree)–(+69degree)
Vertical axis: (+70degree)-(+90degree)
Horizontal axis: (0 degree)-(+29degree)
Axis deviation:
Left axis deviation: (0 degree)-(-90 degree)
Right axis deviation: (+91degree)-(+ 180 degree)

1. Graphic method of alpha-angle determination [Fig. 22-24]:


Calculate the algebrique sum of all waves of QRS complex in I and III standard
leads, and project its duration (in mm) to the I and III axis of hexaxial system, then

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make perpendicular lines. From the cross of those lines make the line to central point
(this line is electrical axis).

I lead

+15 mm

Sum= +15 mm.

Fig. 22. Algebrique sum of all waves of QRS complex in I standard lead

III lead
Sum = -15mm + 3mm= -12 mm

Fig. 23. Algebrique sum of all waves of QRS complex in III standard lead

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+ 15

Fig. 24. Left axis deviation

2. Visual method of electrical axis determination:


Normal axis:
 RII  RI  RIII
 R=S in III and AVL
Horizontal axis or left axis deviation:
 high R in I and AVL
 RI, RI, RIII, deep S in III
Vertical axis or right axis deviation:
 high R in III and AVF
 RIII  RII > RI
 deep S in I and AVL

3. Quadrant system:

2 leads divided the clock face into four quadrants; there are AVF and I leads. The
positive part of I lead is shade vertically [Fig. 25]. The positive part of AVF lead is
shade horizontally [Fig. 26]. The quadrant of normal axis is where the positive parts
of both leads overlap [Fig.27].

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Fig. 25. Vertical shade of positive part of I lead

Fig. 26. Horizontal shade of positive part of AVF lead

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Fig. 27. Normal axis (both leads overlap)

And so, if QRS is upright in both leads, the axis is normal.


If QRS is positive in AVF but negative in I lead, it is in the right axis quadrant.
If QRS is positive in I lead but negative in AVF, it is in the left axis quadrant.

4. 1/AVF method:
The smallest deflection shown in any of 6 leads indicates that the axis is roughly at
right angle to that lead in the hexaxial clock-face.

“CLOCKWISE and COUNTERCLOCKWISE ROTATION”


(rotation about longitudinal axis)
The transitional zone is the area in which QRS is equiphasic (R = S; RS complex).
Transitional zone usually is in V3 or V4 (or between them) [Fig. 28, 29].
If the transitional zone is between V1 and V2 (Rs) - counterclockwise rotation (shift
the transitional zone toward the right) [Fig. 32, 33].
If the transitional zone is between V5 and V6 (rS) - clockwise rotation [Fig.30, 31].
In description of rotation about longitudinal axis look up at the heart from under the
diaphragm.

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V3

R=S

Fig. 28. Transitional zone in V3 (norm)

V6

Fig. 29. Normal transition (qRs in V6)

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V4, V5
R=S

Fig. 30. Clockwise rotation: V4, V5 transitional zone

V6

Fig. 31. Clockwise rotation: RS - complex in V6 and I lead (absence of P)

25
V2

Fig. 32. Counterclockwise rotation: V2 transitional zone (R = S)

V6

Fig. 33. Counterclockwise rotation: qR in V6 and I lead

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ANALYSIS OF ECG WAVES AND INTERVALS

Analysis of P wave:

Normal P wave [Fig. 34]:


- Duration: P  0,10 sec.,
- Amplitude: P  2,5 mm,
- Upright (+ P) in II and I leads, AVF, V2-V6,
- Inverted (– P) in AVR,
- Variable (+P, +P, -P) in lead III, AVL, (+P, +P) in V1.

P wave is formed by atria contraction


 first half of P wave is due to contraction of right atrium
 second half of P wave is due to contraction of left atrium

Fig. 34. Normal P

P-mitrale [Fig. 35]:


 increased width and notching of P wave (width > 0,10 sec.),
taller in I than III lead.
Hypertrophy of left atrium

Fig. 35. P-mitrale

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P–pulmonale [Fig. 36]:
 increased amplitude, pointed, planking P-wave,
 taller in III than in I (amplitude > 2.5mm).
Activation of right atrium

Fig. 36. P–pulmonale

Atrial hypertrophy

Left atrial hypertrophy:


 P > 0.10 sec.,
 M – shaped P in I, II, or AVL (p-mitrale),
 (+ -) P in V1 with increased second (-) phase.

Right atrial hypertrophy:


 P  0.10 sec.,
 Pointed P > 2.5 mm in II, III, AVF (sometimes in V1).

Inverted P wave:
 Variant of norm in III, AVF, V1, V2,
 Nodal rhythm,
 Dextrocardia.

P–Q INTERVAL
Analysis of P-Q (P-R) interval:

P-Q interval from the beginning of P wave to the beginning of QRS complex
normal P-Q (P-R) interval = 0.12-0.20 sec.

PREEXCITATION:
P-Q (P-R) < 0,12 sec.
Two main variants of preexcitation are:
1) WPW-syndrome (Wolf-Parkinson-White),
2) LGL-syndrome (Lown-Ganong-Levine).

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WPW – syndrome [Fig. 37]
(Wolf-Parkinson-White syndrome):
 P-R interval < 0.12 sec.
 QRS complex contains an initial slur-delta wave that broadens the complex
 QRS > 0,11 sec.

Delta wave

Fig. 37. WPW–syndrome

LGL-syndrome
(Lown-Ganong-Levine syndrome):
 Short P-Q (P-R)< 0,12 sec.
 Normal QRS-complex = 0,10 sec.

ATRIOVENTRICULAR BLOCK

IST DEGREE ATRIOVENTRICULAR BLOCK [Fig. 38]:


 P-Q (P-R) > 0,20 sec.
 (P-Q)1 = (P-Q)2, constant P-Q

Fig. 38. I degree AV block

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 Equal P-Q > 0,20 sec.
 QRS complex presents always after every P
 QRS usually  0,10 sec.

IIND DEGREE ATRIOVENTRICULAR BLOCK :

 Mobitz I type of II degree AV block


 Mobitz II type of II degree AV block

Mobitz I type of II degree AV block (with Wenckebach phenomenon) [Fig. 39]:


 Gradually increasing of P-Q (P-R) duration until QRS-complex is dropped
(prolonged impulse finally fails to reach the ventricles). It is Wenckebach
phenomenon.
 P-Q (P-R) gradually > 0,20 sec.
 (R-Q)1  (P-Q)2, inconstant P-Q
 Periodically absent QRS complex

Fig. 39. Mobitz I type of II degree AV block

The beats tend to cluster in small groups and usually in pairs (3:2 Wenchebach
phenomenon is more common than 4:3; which in turn is more common than 5:4).
As the P-Q (P-R) lengthens, the ventricular cycle shortens (QRS  0,10 sec.).

Mobitz II type of II degree AV block [Fig. 40]:

 P-Q (P-R) > 0,20 sec.


 (P-Q)1 = (P-Q)2; constant P-Q.
 Periodical absence of QRS complex.

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Fig. 40. Mobitz II type of II degree AV block

Variant of II degree AV block with P-Q (P-R) < 0,20


 Rate: 30 - 55 heart beats per minute
 Atrial rate may be 2-, 3- or 4-times faster than ventricular rate
 P waves: 2, 3 or 4 P waves for each QRS complex
 P-Q (P-R) interval of the conducted beat is usually normal in duration
 Usually slow and regular rhythm (irregular rhythm may be present due to varying
block – 2:1 to 3:1 or other variations)

IIIRD DEGREE ATRIOVENTRICULAR BLOCK


(complete heart block)
The impulses couldn’t pass the AV-barrier – completely blocked. Impulses
originate in sinus node, but are not conducted to Purkinje fibers.

 Independent P-waves and QRS-complexes


 Regular P wave, atrial rate 60 – 100 beats per minute
 Regular QRS with low ventricular rate (60 - 40 or less per minute)
 Rhythm regular from AV node (40 – 60 beats per minute) or ventricles (20 – 40
beats per minute)
Proximal form of complete heart block [Fig. 41]
 regular rare QRS < 0,10 sec.
 Independent P-waves and QRS-complexes

Fig. 41. Proximal form of complete heart block

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Distal form of complete heart block [Fig. 42]
 Regular rare QRS > 0,12 sec.
 Independent P-waves and QRS-complexes

Fig. 42. Distal form of complete heart block

ANALYSIS OF QRS COMPLEX


Norm:
 QRS = 0,08-0,10 sec.
 Q wave < 0,03 sec.
 Q wave < ¼ R wave
 Maximal R in V4
 Transition zone in V3
 Intrinsicoid deflection in V1 < 0.03 sec.
 Intrinsicoid deflection in V6 < 0.05

Intrinsicoid deflection is measured horizontally from the beginning of QRS


complex to the peak of R wave [Fig. 43]

Fig. 43. Intrinsicoid deflection measurement

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BUNDLE-BRANCH BLOCK
(intraventricular block)
The important leads to study in Bundle-Branch Block are I standard, V 1 and V6.
BBB is characterized by prolongation of QRS interval and opposite direction of ST-
segment to the main QRS deflection.

Left Bundle-Branch Block


 QRS > 0,12 sec (may be as long as 0,20 sec.)
 QRS is deformed and splintered in I, aVL and V5, V6
 Monophasic R in I standard [Fig. 44]
 Q waves absent in I standard
 Late intrinsicoid in V6 (intrinsicoid deflection > 0,05 sec. in V6)
 Q waves absent in V6
 Monophasic R in V6 [Fig. 46] and V5 – RR or M-shaped complexes
 QS or rS in V1 [Fig. 45], V2 and in III, aVF
 RsR complex or wide unnotched complex in aVL
 Secondary S-T segment and T changes opposite in direction to terminal QRS
deflection

Monophasic R

Ist Standard Lead

Fig. 44. Left Bundle-Branch Block


(monophasic R in I standard lead)

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Fig. 45. Left Bundle-Branch Block
(QS in V1)

Fig. 46. Left Bundle-Branch Block


(monophasic R in V6)

Incomplete Left Bundle-Branch Block:


 Initial ‘q’ in V5 and V6 disappears and results single tall R wave
 Small initial ‘r’ of rS complex in V1 disappears and results in QS complex

Clinical significance of left bundle-branch block (LBBB):


LBBB is the indication of the organic heart disease

34
(common in ischemic heart disease or hypertension).
Right Bundle-Branch Block

 QRS > 0,12 sec.


 Late intrinsicoid deflection in V1 (>0.03 sec.)
 M-shaped QRS in V1 (RSR’-variant) [Fig. 47]
 Wide S in I standard lead, aVL, V5, V6
 Secondary S-T segment and T changes

Fig. 47. Right Bundle-Branch Block


(M-shaped QRS in V1)

Incomplete Right Bundle-Branch Block:


 Diminution of S in V2
 QRS < 0,12 sec.

Clinical significance of right bundle-branch block (RBBB):


RBBB may be physiological and pathological:
may be in coronary artery disease, atrial septal defect,
cardiomyopathy, massive pulmonary embolism.

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VENTRICULAR HYPERTROPHY

Left Ventricular Hypertrophy (LVH):

1. Sokolow and Lyon criterion of LVH:


 S wave in V1 + R wave in V5 or V6 > 35mm (whichever is taller R)
 S V1 + R V5 or V6 > 35mm

2. Cornell Voltage of LVH:


 R in aVL + S in V3 > 28mm in men and > 20mm in women

3. Left axis deviation.


 Increased R in V5 or V6 > 25mm
 Increased R in I Standard lead > 15mm
 Increased R in aVL > 12mm
 Possible ST depression (RS-T shift without digitalis)
and (–) or (– +) T (TV1 > TV6)
 Increased S in V1 or V2
 RV5 (V6) + SV1 (V2) > 35mm (if patient is elder 40 years)
 RV5 (V6) + SV1 (V2) >45mm (if patient is younger 40 years)
 Intrinsicoid deflection in V5 (V6) > 0,05 sec.

Right Ventricular Hypertrophy:

 rSR’ or qR’ in V1
 Increased R in V1 > 7mm
 Increased S in V5 (V6)
 RV1 + SV5 (V6) > 10mm
 Intrinsicoid deflection in V1 > 0,03sec.
 Possible ST depression and (–) T in V1-V3, III standard lead, aVF
 Clockwise heart deviation (transition zone in V4 -V5)
 Right axis deviation (  angle > 100º)
 R/S ratio in V1 > 1,0
 S/R ratio in V6 > 1,0

Biventricular Hypertrophy:
 ECG evidence of LVH + right axis deviation
 ECG evidence of LVH + clockwise electrical rotation
 ECG evidence of LVH + R/S ratio > 1,0 in V1
 Large equiphasic QRS in midprecordial leads (Katz-Wachtel phenomenon)

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 Left atrial enlargement + R/S ratio in V5 and V6 > 1,0
or S wave in V5 and V6 > 7 mm or right axis deviation
PAROXYSMAL TACHYCARDIA

Paroxysmal supraventricular tachycardia.

 Rapid, regular rate = 150 - 250 beats/min.


 Normal QRS complexes ( < 0,10sec.)
 Abnormal P waves are constantly related to QRS, or P waves may not be
discernible at all.

Paroxysmal ventricular tachycardia.

 Rapid, regular rate = 110 - 250 beats/min.


 Deformed QRS complexes (QRS > 0,14 sec.) with discordant RS-T segment
and T wave

VENTRICULAR FLUTTER AND FIBRILLATION

Ventricular Flutter [Fig. 48]

 Almost regular heart rate, very rapid = 200 – 300 beats/min.


 Sinusoidal curves (almost uniformed waves)

Fig. 48. Ventricular flutter

Ventricular Fibrillation [Fig. 49]

Ventricular fibrillation is a terminal or at least a catastrophic event.


 Irregular chaotic different waves with very rapid rate = 200 - 300 beats/min.

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Fig. 49. Ventricular fibrillation
ST SEGMENT

S-T segment is isoelectric in norm.

Variants of norm:
 Elevation < 1 mm in standard leads.
 Elevation < 2 mm in chest leads.
 Depression < 0,5 mm.

T WAVE

Normal T wave direction:


 Upright in I, II leads, V3 – V6.
 Inverted in aVR.
 Variable in III, aVL, aVF, V1 – V2.
Normal T wave shape:
 Slightly rounded and asymmetrical.

Normal T wave height:


 T < 5 mm in standard leads.
 T < 10 mm in precordial leads.

U WAVE

U wave – small wave of low voltage (better visible in V 3). U wave direction in
norm is the same as T wave direction, but reversed in ischemia of myocardium of left
ventricular overload (in hypertension, mitral or aortic regurgitation). U wave is more
prominent in potassium deficiency.

Q-T DURATION

Q-T interval (QRST) – electrical systole of ventricles.


Normal Q-T duration = 0,35-0,44 sec.
Bazett’s formula = Q-T / √ R-R

Q-T = C•√ R-R,

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C – coefficient:
C = 0,37 in male,
C = 0,40 in female.

Q-T duration depends on rate.

ISCHEMIC HEART DISEASE


ECG findings

Basic reason of Ischemic Heart Disease (IHD) is disturbance of relationship


between myocardial oxygen supply and demand (usually obstructive injury of main
coronary arteries and their branches: atherosclerotic plaque, thrombus or spasm).

Prognosis in IHD depends on


 Number of stenosed coronary arteries
 Functional conduction of myocardium

Information about IHD according to ECG:


 Ischemia of myocardium
 Myocardial infarction (MI)
 Postinfarctive cardiosclerosis

Information about MI according to ECG:


 MI location
 Depth of MI
 Size of MI

Left ventricular segments:


 Septal segment (Septum)
 Apical segment (Apex)
 Lateral segment
 Posterior segment
 Inferior segment
The first 3 segments are included to anterior wall, the last 3 segments are
included to posterior wall. Lateral segment may be consisted in MI of anterior and
posterior walls.

Myocardial infarction classification:


 Q-wave MI
 Non-Q-wave MI

Q wave MI:
 Abnormal Q wave development within 1 – 3 days
 Q wave > 0,04 second

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 Q wave depth > 25% of R wave or QS complex
 RS-T elevation (J-point elevation) [Fig. 50] – “cat’s back”.

J-point is located between the end of QRS complex and the beginning of S-T
segment – junction point.

J (junction) point

Fig.50. Myocardial infarction (S-T elevation – J-point elevation)

Coronary ischemia:
 T wave slightly flat, depressed or deeply inverted (coronary T - typically
ischemic T – Pardee T - symmetrically inverted and larger T wave – inverted
symmetrical T like “arrow head”)
 ST segment changes (+ 1 mm):
- epicardial myocardial injury – ST segment elevation
- endocardial myocardial injury - ST segment depression

Transmural MI
(all walls of the heart are involved) –
“indicative changes”:
 Pathological Q-wave (Q > 0,04 sec.; Q/R > ¼ ) = tissue necrosis
 ST segment elevation = tissue injury
 T wave inversion = ischemia

Myocardial Infarction Stages:


1. Acute (hyperacute) stage
2. Subacute (fully evolved) stage
3. Restorative (resolution) stage
4. Cicatrization (chronic) stage

Myocardial Infarction Phases (Stages):


1. Hyperacute phase – several hours: during the first few hours – ST segment
elevation

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2. Fully evolved phase – several days – formation of Q wave as well as deep and
symmetrical inversion of T wave (“arrow head” T wave)
3. Resolution phase – several weeks: few days or few weeks – depressed ST-
segment to isoelectric line with negative T wave
4. Chronic phase – several months – with deep and wide Q, upright T wave (other
term sometimes used – “old MI”
The changes of ischemia or myocardial infarction are in the leads closest to the
involved heart surface.
Features of acute myocardial infarction and it’s stages, location and duration are
in tables 1, 2 and 3.

Table 1
Features of Acute Myocardial Infarction

Leads
ECG changes Anterior MI Inferior MI

Indicative changes: I, aVL, anterior II, III, aVF,


pathological Q, ST segment chest leads posterior chest
elevation, T wave inversion leads
Reciprocal (opposite) II, III, aVF, I, aVL, anterior
changes posterior chest leads chest leads

Progressive changes from day to day

Table 2
Stages of Acute Myocardial Infarction

Stage Duration Features


Acute The first few hours Monophasic curve (“cat’s back”),
from MI onset within ST segment elevation (pathological
24 hours / or some Q is ivisible, T wave inversion is
days absent)
Subacute 1-3 weeks from MI Pathological Q-wave (Q > 0,04
onset sec.; Q/R > ¼ ), Low R or QS,
Appearance of negative inverted T
wave (“arrow head” T wave).
Restorative 2 – 6 weeks Pathological Q wave, ST segment
isoelectric, T wave inversion

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Cicatrization May remain Pathological Q (becomes less
permanently prominent). T wave upright or
isoelectric / or slightly negative

Table 3
Myocardial Infarction Location

Myocardial Infarction Leads


Location
Anterior–septal V1 – V3

Anterior–apical V3 – V4

Anterior–lateral I, aVL, V5, V6

Widely-spread anterior I, aVL, V1 – V6

Inferior III, aVF, II


(posterior–diaphragmatic)
Posterior V7 – V9,
(posterior–basal) reciprocal (mirror picture) in V1 – V3
Posterior–lateral V5, V6, III, aVF

Widely-spread posterior III, aVF, II, V5, V6, V7 – V9, reciprocal


(mirror picture) in V1 – V3

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