ECG

Electrocardiograph

Yang HaiBo MD
• Department of cardiology,
• 1st affiliated hospital of ZZU
Ventricular Hypertrophy
Left ventricular hypertrophy (LVH)
Right ventricular hypertrophy (RVH)
LVH increases the
amplitude of electrical forces
directed to the left (and
posteriorly). In addition,
repolarization abnormalities
can cause ST segment
depression and T wave
inversion in leads with a
prominent R wave (formerly
referred to as a "strain"
pattern).
RVH can shift the QRS
vector to the right; this effect
is usually associated with an
R, RS, or qR complex in lead
V1 , especially when due to
severe pressure overload. T
wave inversions may be
present in the right
precordial leads
Left Ventricular Hypertrophy
• The left ventricular myocardium will thicken as a
reaction to hypertension, aortic stenosis and mitral
regurgitation.

• These conditions → ventricle has to perform more

work than usual. Results in an increase in muscle
mass.
 ECG Criteria
• V5, V6, → tall R waves greater than 25mm
• V1 & V2 → deep S waves greater than 30mm
• sum of S wave V1 + R wave V5 /V6 should be greater
than 35mm(Sv1 + R v5 > 35 mm )
• Left Axis Deviation
• Slight increase in QRS duration
 Strain Pattern

• Leads facing the LV (V5 & V6) may show

a strain pattern.
• This is a reflection of the abnormal state of
the myocardium.
 ECG for strain

• In leads facing the LV, usually in V5, V6, I &

AVL
• Depressed ST segment
• Inverted T waves
 左心室肥大

Rv5=3.7mV 、 SV1= 1.5mV ,

* 左心室肥大 1*
Right Ventricular Hypertrophy
• This usually occurs in cor pulmonale, and
in some congenital heart defects when the
RV becomes dominant.
• In RVH, the potential force of the RV is
greatly increased.
 ECG Criteria
R wave ↑ in leads over right ventricles V1, V2, V3.
•
V1 导联 Rs 或 qR 形， R/S ≥1
The S wave in V5,V6 becomes more conspicuous,
•
V5 导联 R/S ≤1
RV1+SV5 > >1.2mV
•
RV1> 1.0mV ； RaVR>0.5mV
Right Axis Deviation, ≥ +90 degree
•
Slight increase in QRS duration
•
 Strain Pattern

• Leads facing the RV (V1 & V2) may show

a strain pattern.
• This is a reflection of the abnormal state of
the myocardium.
 ECG for Strain
• Seen in leads facing the right ventricle
(V1, V2,V3)

• Depressed ST segment

• Inverted T wave
 右心室肥大

RV1 +SV5 =1.6mV 心电轴： +110o

* 右室肥厚 1*
Myocardial infarction (MI)
• When myocardial blood supply is abruptly
reduced or cut off to a region of the heart, a
sequence of injurious events occur beginning
with ischemia (inadequate tissue perfusion),
followed by necrosis (infarction), and eventual
fibrosis (scarring) if the blood supply isn't
restored in an appropriate period of time.

• The ECG changes over time with each of

these events…
• The classic World Health Organization
(WHO) criteria for the diagnosis of AMI
require that at least two of the following
three elements be present: (1) a history of
ischemic-type chest discomfort, (2)
evolutionary changes on serially obtained
ECG tracings, and (3) a rise and fall in
serum cardiac markers.
 ECG Changes
Ways the ECG can change include:
ST elevation &
depression

T-waves

peaked flattened
Appearance inverted
of pathologic
Q-waves
 ECG Changes & the Evolving MI
There are two Non-ST Elevation
distinct patterns
of ECG change
depending if the
infarction is:
ST Elevation

ST Elevation (Transmural or Q-wave),

Non-ST Elevation (Subendocardial or non-Q-wave)
ST Elevation Myocardial Infarction
• Cross sectional analysis of an area of
infarcted myocardium reveals the three
electrically differentiated zones.
 E

INFARCTION INJURY ISCHAEMIA

(necrosis )
 INFARCTED MYOCARDIUM
• myocardium electrically dead

• The electrode lying over the area of

infarction has the effect of looking through
the infarcted area as a window.
 INJURED MYOCARDIUM
• myocardium is never completely polarized

• The electrode lying over the area of injury

will record ST Segment elevation on the
ECG because of the myocardium retaining
its polarity.
 ISCHEMIC MYOCARDIUM
• myocardium exhibits impaired repolarisation

• The electrode lying over the area of ischemia

will record T wave changes on the ECG
 Characteristic changes in AMI
• Pathological Q waves--- infarction
• ST segment elevation-- injury
• Inverted T waves-- ischemia
 Deep Q wave

• Only diagnostic change

R of myocardial infarction
ST

P • At least 0.04 seconds

T
in duration
Q
• Depth of more than 1/4
of ensuing R wave
 ST elevation

R
• Occurs in the early stages
ST
• Occurs in the leads facing
P
the infarction
Q
• Slight ST elevation may
be normal in V1 or V2
 T wave changes

• Late change
• Occurs as ST
R

ST
elevation is returning
P
to normal
T • Apparent in many
Q
leads
ECG Diagnostic criteria for AMI
• Q wave duration of more than
0.04 seconds, Q wave depth
of more than 1/4 of ensuing R
wave
• ST elevation in leads facing
infarct (or depression in
opposite leads)
• Deep T wave inversion
overlying and adjacent to
infarct
Sequence of changes in AMI

.The Hyper-acute Phase

.The Fully Evolved Phase
.The Chronic Stabilised Phase
 1.The Hyper-acute Phase
Less than 12 hours

• Hyperacute T wave changes - increased T

wave amplitude and width;
• “ST segment elevation is the hallmark ECG
abnormality of acute myocardial infarction”
(Quinn, 1996), May vary in severity from 1mm
to ‘tombstone’ elevation
• Usually occurs within a few hours of infarction
• Dramatic ST segment elevations in leads V1
through V5 with associated hyperacute T-
wave changes are noted.
 2.The Fully Evolved Phase
24 - 48 hours from the onset of a myocardial infarction
• ST segment elevation is less (coming
back to baseline).
• T waves are inverting.
• Pathological Q waves are developing
急性前间壁心肌梗死
 3.The Chronic Stablised Phase
• Isoelectric ST segments
• T waves upright.
• Pathological Q waves.
• May take months or weeks.
 a diagram depicting an evolving infarction:
A. Normal ECG prior to MI
B. Ischemia from coronary artery
occlusion results in ST
depression (not shown) and
peaked T-waves
C. Injury from ongoing ischemia
results in marked ST elevation
D/E. Infarction with appearance of
pathologic Q-waves and T-wave
inversion
F. Fibrosis (months later) with
persistent Q- waves, but normal
ST segment and T- waves
 Reciprocal Changes
• Changes occurring on the opposite
side of the myocardium that is
infarcting
Reciprocal Changes
 Regions of the Myocardium

Lateral
I, AVL,
V5-V6

Anterior /
Inferior Septal
II, III, aVF V1-V4
PED 596
 Localization of MI
• Anterior Septal infarction:V1,V2
• Anterior infarction:V1,V2, V3,V4
• Anterior lateral infarction: V5-V6, I, avL
• Extensive anterior infarction: V1-V6, I, avL
• High lateral infarction: I , avL
• Inferior infarction ： II,III,AVF
• Posterior infarction ： V7-V9 ,
reciprocal change in leads V1,V2
Acute anterior septal infarction
LAD
occlusion
 Anterior infarction
Anterior infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left
coronary
artery
 Extensive anterior infarction
•
Left main occlusion
 Lateral infarction
Lateral infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left
circumflex
coronary
artery
 Inferior infarction
Inferior infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Right
coronary
artery
 The ECG in
Non ST Elevation MI
 Non ST Elevation MI
• Commonly ST depression and deep T
wave inversion
• History of chest pain typical of MI
• Biochemistry results required to diagnose
MI
• Q-waves may or may not form on the ECG
 Non-ST Elevation Infarction
Here’s an ECG of an evolving non-ST elevation MI:

Note the ST
depression
and T-wave
inversion in
leads V2-V6.
 Non-ST Elevation Infarction
The ECG changes seen with a non-ST elevation infarction are:

Before injury Normal ECG

Ischemia ST depression & T-wave inversion

Infarction ST depression & T-wave inversion

Fibrosis ST returns to baseline, but T-wave

inversion persists
非 ST 抬高心肌梗死
 ST Segment Depression
Can be characterised as:-

Downsloping
•

Upsloping
•

Horizontal
•
 Horizontal ST Segment Depression

Myocardial Ischaemia:
• Stable angina - occurs on exertion, resolves
with rest and/or GTN
• Unstable angina - can develop during rest.
• Non ST elevation MI - usually quite deep, can
be associated with deep T wave inversion.
• Reciprocal horizontal depression can occur
during AMI.
Horizontal ST depression
 ST Segment Depression

Downsloping ST segment depression:-

• Can be caused by digoxin, Myocardial
Ischemia

Upward sloping ST segment depression:-

• Normal during exercise.
The ECG in Angina
 The ECG in Angina
• Ischaemic changes will be detected on the
ECG during pain
• ST depression and/or T wave inversion
• Patients should be managed on a coronary
care unit
• May go on to develop ST elevation
ECG during pain
Thanks