THE NORMAL

ELECTROCARDIOG
RAM
AND ITS (NORMAL)
VARIANTS
Presented by: Moderator:
Dr. Shah Md. Nahid Aktarul Islam Dr. Lima Asrin Sayami
MD (Cardiology) FCPS (Cardiology)
Phase-B (Resident) Assistant Professor
NICVD NICVD
THE GOAL OF THIS ACADEMIC
SESSION
 Interpretation of normal variants of ECG
 Outline the variations of ECG in normal adults.
 Describe normal aspects of the clinical application of the ECG
 Elaborate the Knowledge of the normal variations of the
Electrocardiogram (ECG)
 INTRODUCTION
 The Electrocardiogram (ECG) is a representation of the electrical
events of the cardiac cycle.

 Each event has a distinctive wave form, the study of wave form can
lead to greater insight into a patient’s cardiac patho physiology.
CONTINUE
 For accurate interpretation of ECG knowledge about the normal
electrocardiogram (ECG) and its (normal) variants is enormously important.

 A normal variant is an atypical finding that is seen in a percentage of the

population, which generally has no clinical significance, and is considered
within the spectrum of normal findings.
NORMAL VARIANTS
The following common ECG findings are considered normal variants and are not cause for
deferment unless the patient is symptomatic or there are other concerns.
 Early repolarization
 Ectopic atrial rhythm
 First-degree AV (atrioventricular) block with PR interval less than 0.21 in age < 51
 Incomplete Right Bundle Branch Block (IRBBB)
 Indeterminate axis
 Intraventricular conduction delay (IVCD)
 Left atrial abnormality
 Left axis deviation, less than or equal to -30 degrees
 Left ventricular hypertrophy by voltage criteria only
NORMAL VARIANTS
 Low atrial rhythm
 Low voltage in limb leads (May be a sign of obesity or hypothyroidism.)
 Premature Atrial Contraction (PAC) – multiple, asymptomatic
 Premature Ventricular Contraction (PVC) - single only; 2 or more on ECG require evaluation
 Short QT – if no history of arrhythmia
 Sinus arrhythmia
 Sinus bradycardia.

Up to age 49 if heart rate is >44;

Age 50 and older if heart rate is >48
 Sinus tachycardia – heart rate < 110
 Wandering atrial pacemaker
HEART RATE
HEART RATE
 A normal resting heart rate is 60 to 100
beats per minute.
 But in children heart rate >100 can be
considered as normal.
SINUS TACHYCARDIA
 Sinus tachycardia is normal during exercise and under conditions of mental
stress.
 Sinus tachycardia is a normal variant if the patients heart rate is less than 110
beats per minute.
 Differential diagnosis: Includes febrile status, heart failure, hyperthyroidism,
tumoral diseases, and cachexia.
SINUS BRADYCARDIA

 Sinus bradycardia is often seen as a normal variant in individuals at rest, and

usually in athletes.
 Episodes of sinus bradycardia at a rate < 40/min were observed in young
healthy people, in 24% of men and 8% of women; with sinus pauses of up to
2.06 sec in men and 1.92 sec in women.
 Especially in sinus bradycardia the J point, and thus the ST segment, may be
elevated up to 2–3 mm, and rarely up to 4 mm
RHYTHM
RHYTHM
 Evaluate the rhythm strip at the bottom of the 12-lead for the
following-

o Is the rhythm regular or irregular?

o Is there a P wave before every QRS complex?

o Are there any abnormal beats?

ARRHYTHMIAS
 It is quite difficult to classify certain arrhythmias into those that are normal

variants, and those that are pathologic findings.

 We know, for example, that episodes of ventricular tachycardia (VT) or a slow

ventricular escape rhythm may be found in apparently healthy individuals,

especially in athletes.

 However, a VT or a ventricular rhythm of 30/min would not be classified as a

normal finding
SINUS ARRHYTHMIA
 Sinus arrhythmia is almost always normal.

 The rate variation depends on respiration, so that during inspiration the rate

increases and during expiration the rate decreases, always with some delay.

 The rate deviation may reach 50% in children and +/− 15% in middle-aged

people; in the elderly the deviation is small or absent.

SINUS ARRHYTHMIA
 In young healthy people the rate variability may exceed 50%.

 Differential diagnosis: Atrial premature beats originating near the sinus node.

 Note: sinus arrhythmia is generally not a component of the sick sinus

syndrome.
 SINGLE PREMATURE VENTRICULAR
CONTRACTION

 Single PVCs are common in healthy persons. It is a normal variant.

 41% of healthy volunteers below the age of 45 years have been found to have

PVCs on 24-hour Holter ECG recording.

 However, two or more PVCs on a 12-lead ECG would require a workup.

 Isolated PVCs with benign characteristics and no underlying heart disease require

no treatment, especially if there are limited symptoms.

FIRST-DEGREE AV BLOCK
 First-degree AV Block With PR Interval Between 0.21 and 0.29 Seconds

 Any first-degree AV block with a PR interval 0.21 to 0.29 seconds is a normal

variant.

 Any PR interval greater than 0.30 requires an evaluation.

LOW ATRIAL RHYTHM
 The low atrial rhythm is an ectopic rhythm that can be found in pediatric patients and
athletes. It's considered as a variation of normality.
 Low atrial rhythm is a normal variant when there are upright P waves in the AVR lead,
and inverted P's in other limb leads with a short PR interval.
 Low atrial rhythm manifests with inverted P waves in inferior leads. It may be seen in sinus
venosus atrial septal defect.
P WAVE
 Always positive in lead I and II
 Always negative in lead aVR
 < 3 small squares ie 0.12sec in duration
 < 2.5 small squares(2.5mm) in amplitude
 Commonly biphasic in lead V1
 Best seen in leads II
WANDERING ATRIAL
PACEMAKER
 WAP is an atrial arrhythmia that occurs when the natural cardiac pacemaker
site shifts between the SA node, the atria, and/or AV node.
 This shifting of the pacemaker from the SA node to adjacent tissues is
identifiable on ECG Lead II by morphological changes in the P-wave;
 Sinus beats have smooth upright P waves, while atrial beats have flattened,
notched, or diphasic P-waves.
 It is often seen in the very young, very old, and in athletes, and rarely causes
symptoms or requires treatment.
ECTOPIC ATRIAL RHYTHM

 Ectopic atrial rhythms occur when the impulses for the atria to beat are
generated in the wrong area.
 The S.A. node rhythm originates in multiple areas of the atria.

 This results in p waves on the electrocardiogram which differ from the normal

appearance of p waves.
 The rate usually remains at less than 100 beats per minute.
Q WAVE
 Non-pathological Q waves may present in I, III, aVL, V5, and V6
 Pathological Q wave > 2mm deep and > 1mm wide or > 25%
amplitude of the subsequent R wave
Q WAVES IN INFERIOR AND LEFT LATERAL LEADS IN
CHILDREN
 ISOLATED Q WAVE IN LEAD
III
QRS SEGMENT

 The amplitude of QRS complexes in limb leads are < 5mm (0.5mV).

 The amplitude of QRS complexes in precordial leads are < 10mm (1 mV).
QRS VOLTAGE
 Low voltage ECG may be present in obese and High Voltage may be present in
lean person.
 QRS LOW VOLTAGE
 A QRS voltage of less than 5 mm (0.5 mV) in up to three of the six frontal

leads is not a rare finding.

 True peripheral low voltage is present if the QRS complex is smaller than 5

mm in five out of six or all six limb leads, a rare finding in normal individuals.
LOW VOLTAGE
 True peripheral low voltage in pathologic conditions is found in lung
emphysema, obese people, and in patients with extensive pericardial effusion.

 Peripheral low voltage has little clinical importance.

 The same is valuable for the very rare horizontal low voltage defined as QRS
voltage smaller than 7 mm in all precordial leads
THE QRS AXIS
 Normal QRS axis from -30° to +90°.
 -30° to -90° is referred to as a left axis deviation (LAD)
 +90° to +180° is referred to as a right axis deviation
(RAD)
RIGHT AXIS DEVIATION IN CHILDREN AND ADOLESCENTS
INCOMPLETE RIGHT BUNDLE-
BRANCH BLOCK
 An incomplete right bundle branch block is an RSR pattern that is 0.10 to 0.11
seconds.
 It is a frequent finding in healthy people, especially in young people.
 This pattern may lead to a notching or rSr’ complex in lead III also.
 A notched S upstroke in V1 often corresponds to iRBBB.
 In this case, there is a terminal R wave in lead aVR, as in common patterns of
iRBBB.
 In addition, the QRS configuration with r < r’ represents a normal variant in
many cases.
 However, we have to exclude diseases of the right ventricle.
INCOMPLETE RIGHT BUNDLE-
BRANCH BLOCK
DIFFERENTIAL DIAGNOSIS
IRBBB
 Right ventricular systolic overload (as in pulmonary embolism and any disease
with pulmonary hypertension, and/or right ventricular hypertrophy)

 RV diastolic overload (as in atrial septal defect) or may represent a precursor

of complete RBBB. iRBBB with r > r’ is a rarer finding in these pathologic
conditions.

 A new onset iRBBB may be a sign of acute right ventricular overload, or it

can appear after different placing of lead V1 – in which case it may be
harmless
 NOTCHING

Notching or a ‘notch’ is defined as

a small (about 1–2 mm high)
additional deflection with inverse
polarity, within the Q, R , or S
wave of the QRS complex
NOTCHING VERSUS PSEUDO-NOTCHING

 Notching and slurring correspond either to a localized disturbance (delay) of

conduction and excitation, or merely may be due to projections (known as
pseudo-notching).

 In practice it is important to distinguish between true intraventricular

conduction disturbance (notching) and a harmless functional alteration, based
only on vectorial projection (pseudo-notching).

 Notching in the limb leads may also be seen in old myocardial infarction, with
or without pathologic Q waves.
 NOTCHING VERSUS PSEUDO-NOTCHING

 Differentiation between notching and pseudo-notching may be difficult.

 Slight pseudo-notching is frequently seen in the inferior leads III, aVF and II and

occasionally in lead aVL. A pseudo-notching in lead I is rare.

 A pseudo-notching may also be present in the transition zone of the precordial

leads, mostly in only one lead, and predominantly in V3

NOTCHING VERSUS PSEUDO-
NOTCHING
 In cases of notching in three or more precordial leads, an intraventricular
conduction disturbance is probable, often due to an infarction scar

 Left posterior fascicular block: Often ‘slurred R downstroke’ in leads III,aVF

and V6.

 Left anterior fascicular block (always with left-axis deviation): Often ‘slurred
R downstroke’ in leads I and aVL
INTRAVENTRICULAR
CONDUCTION DELAY
Importance:

 Intraventricular condution delay (IVCD) ECG patterns can be seen commonly

in general population and their prevalence increases with age.
 Bifascicular block (especially RBBB and LAF block) is the most common
IVCD.
 Intraventricular conduction delay usually has no prognostic significance in
patients without underlying heart disease.
 May progress to complete heart block or ventricular arrhythmia with worse
prognosis in underlying heart disease.
POOR R WAVE
PROGRESSION
 Electrocardiographic poor R wave
progression (PRWR) is found in
patients with anterior myocardial
infarction, left ventricular
hypertrophy and right ventricular
hypertrophy, and is also seen in
apparently normal individuals.
ST SEGMENT
 ST Segment is flat (isoelectric)
 Elevation or depression of ST segment by 1 mm or more is significant.
 “J” (Junction) point is the point between QRS and ST segment
EARLY REPOLARIZATION
 Early repolarization is most often seen in healthy young adults.
 Look for ST elevation, tall QRS voltage, "fishhook" deformity at the J point,
and prominent T waves.
 ST segment elevation is maximal in leads with tallest R waves.
 Note high take off of the ST segment in leads V4-6
 The ST elevation in V2-3 is generally seen in most normal ECG's; the ST
elevation in V2-6 is concave upwards, another characteristic of this normal
variant.
 CHARACTERISTICS’ OF EARLY
REPOLARIZATION
 Notching or slurring of the terminal portion of the QRS wave
 Symmetric concordant T waves of large amplitude
 Relative temporal stability
 Most commonly presents in the precordial leads but

often associated with it is

 Less pronounced ST segment elevation in the limb

leads
TO DIFFERENTIATE FROM
ANTERIOR MI
 The initial part of the ST segment is usually flat or convex upward
in AMI
 Reciprocal ST depression may be present in AMI but not in early
repolarization
 ST segments in early repolarization are usually <2 mm (but have
been reported up to 4 mm)
TO DIFFERENTIATE FROM
PERICARDITIS
 The ST changes are more widespread in pericarditis

 The T wave is normal in pericarditis

 The ratio of the degree of ST elevation (measured using the PR

segment as the baseline) to the height of the T wave is greater than

0.25 in V6 in pericarditis.
T WAVE
 Normal T wave is asymmetrical, first half having a gradual slope than the
second.
 T wave amplitude rarely exceeds 10 mm.
 Abnormal T waves are symmetrical, tall, peaked, biphasic or inverted.
 T wave follows the direction of the QRS deflection.
JUVENILE T-WAVE PATTERN
 The Juvenile T-wave pattern refers to a normal electrocardiographic variant in
which T wave inversions are present in the right precordial leads (V1, V2, and
V3) along with an early repolarization pattern.
 If this inverted T-wave pattern sustained to adulthood, it is called persistent
juvenile T-wave pattern.
 It is more commonly found in females than males
 Patients are typically African American women under age 30.
JUVENILE T-WAVE PATTERN
 It is rare in males over 19 years of age to have T-wave inversion beyond lead
V1, unless there is lead misplacement or also possibly deep inspiration during
recording
 It does often extend out to V4 and beyond, has some ST elevation, and
biphasic T-waves
 T-waves are slightly asymmetrically inverted in V1-V3.
 T-wave inversion that extends out to V4 and beyond should only be seen in
patients under age 12.
 There are no structural cardiac abnormalities.
JUVENILE T-WAVE PATTERN
TECHNICAL ERRORS AND
ARTIFACTS
 Artifacts that may interfere with interpretation can come from movement of
the patient or electrodes, electrical disturbances related to current leakage and
grounding failure, and external sources such as electrical stimulators or
cauteries.
 Misplacement of one or more electrodes is a common cause for errors.
 Significant misplacement of precordial electrodes.
DEXTROCARDIA
SUMMARY
 Reading of ECG is an art, that can be mastered by practice
 It should be read by strict systemic approach, involving describing
the obvious abnormalities.
 Every ‘unusual’ ECG pattern should be interpreted in the context of
the conditions of the person being investigated, including age,
clinical findings and quality of symptoms.
 Try to find any old tracing to compare any abnormalities
REMEMBER…
|
|
TREAT
The patient..
NOT
THE ECG !!