Electrocardiogramm: Basics

and Major ECG

Abnormalities
Khatuna Diasamidze
Batumi
2023
• Electrocardiogram (ECG or EKG) – graphic
representation of electrical activity generated by the
heart.
• ECG – noninvasive, inexpensive and highly versatile
test.
The five -tropies of the Heart
1897 Engelmann described
1. Inotropy – contractility
2. Chronotropy – rate (Sinoatrial node)
3. Dromotropy – conduction (AV node)
4. Bathmotropy – excitability
1982 described
5. Lusitropy – relaxation (active)
ECG records:
1. Depolarization ( “stimulation”)
2. Repolarization (“recovery”)

The cardiac conduction system is a collection of nodes and specialized conduction

cells that initiate and co-ordinate contraction of the heart muscle. It consists of:
• Sinoatrial node
• Atrioventricular node
• Atrioventricular bundle (bundle of His)
• Purkinje fibers
The electric currents are produced by:
*Cardiac pacemaker cells
*Specialized conduction tissue
*Heart muscle itself

Sinoatrial node – 60-80/min

Atruioventricular node – 40-60/min
Bundle of His – 15-40/min
Purkinje fibers – 15-30/min
Schematic of the cardiac conduction system
ECG waveforms and intervals
• P wave – atrial depolarization
• QRS complex – ventricular depolarization
• ST-T-U complex – ventricular repolarization
ST segment
T wave
U wave
J point
 ECG Leads
12 conventional ECG leads:
- 6 limp (extremity) leads [frontal plane]
- 6 chest (precordial) leads [horizontal plane]
- Additional leads:
right precordial leads V₃R to V₆R ( acute right ventricular ischemia)
Bedside monitors and ambulatory ECG – 1 or 2 modified leads
ECG leads placement
Frontal Plane ECG leads
ECG Axis Interpretation
Characteristics of the normal P wave
*Morphology:
- Smooth contour
- Monophasic in lead II
- Biphasic in lead V₁
- Negative in lead aVR
*Duration:
- <0.12 s(<120 ms or 3 small squares)
*Atrial abnormalities – easily seen in
the leads II,III, aVF and V₁
Characteristics of the normal QRS complex
• The normal QRS complex is
narrow and sharply pointed
• Duration – 0.08-0.12 sec
• Amplitude – varies from less
than 5 mm to more than 15 mm
 Normal QRS complex
*Q wave – first negative deflection
from the baseline following P
wave (septum depolarization) :
- Duration <0.03sec
- Amplitude <25% of R wave
*R wave – first positive deflection
following Q wave
*S wave – negative deflection
following R wave
Characteristics of the normal T wave
• Represents ventricular
repolarization
• Upright in all leads except aVR
and V₁
• Amplitude - < 5 mm in limb
leads, <15 mm in precordial
leads
• Duration – 0.10-0.25 sec
Normal ranges of ECG parameters
ECG parameters Normal range

Heart rate 60-90/min

PQ interval 120-200 msec

QRS complex <120 msec

QT interval Less than half of the R-R interval;

<440 msec
 Major ECG Abnormalities
*Cardiac enlargement and hypertrophy
*Bundle branch blocks and related patterns
*Myocardial ischemia and infarction
*Tachycardias
*Bradycardias
*Mortal rhythms
*Metabolic factors
 Right atrial enlargement
• Duration – mostly normal
• Shape – Tall/peaked in II, III and
aVF, biphasic in V₁-V₂
• Direction – positive
• Amplitude ≥ 2.5 mm
• Cause – right atrial overload
(acute or chronic)
P-pulmonale
 Left atrial enlargement
• Increased amplitude in the
terminal portion of the P wave in
V₁ ;
• Increased duration or width of
the P wave - >0.12sec
• Cause – left atrial overload
(mitral stenosis or regurgitation)
P-mitrale
 Right ventricular hypertrophy
• Right axis deviation of +110
degrees or more
• Dominant R wave in lead V₁
(R≥S)
• R wave in lead V₁ ≥7 mm
• ST depression and T inversion in
leads V₁ -V₄ - right ventricular
“strain”
• Deep S wave V₅-V₆ , I and aVL
Left ventricular hypertrophy
• Tall left precordial R waves
• Deep right precordial S waves
• SV₁+[RV₅ or RV₆] > 35 mm –
Sokolov-lyon criteria
• ST depression with T wave
inversion in leads with
prominent R waves – left
ventricular “strain”
Bundle brunch blocks
Intraventricular conduction disturbances:
* Wide QRS complex ≥120 ms (complete blocks)
110-120 ms (incomplete blocks)
*Discordance of the QRS – T waves
*Left anterior fascicular block – QRS axis more negative then -45⁰
*Left posterior fascicular block – QRS axis more rightward than +110-
120⁰
Left bundle branch block
 Myocardial Ischemia and Infarction
• The ECG is central to diagnosis of acute and chronic ischemic heart
disease
• Ischemic changes cause a voltage gradient between normal and
damaged zones → current flows between those regions.
• These currents of injury are represented on the surface ECG by
deviation of the ST segment
• Necrosis of sufficient myocardial tissue - ↓ R-wave amplitude and
abnormal Q waves.
• Reciprocal changes
• ECG leads – in localizing regions of ischemia
Acute ischemia causes a current of injury
(A) Subendocardial ischemia – the
ST vector is directed towards
the inner layer of the affected
ventricle – ST depression
(B) Transmural or epicardial injury
– the ST vector is directed
outwards – ST elevation
ECG - STEMI
ECG – non-STEMI
 Bradyarrhythmias (ECG)
(1) Disorder in impulse generation – Sinus node disfunction
Sinus bradycardia (<beats/min)
Sinus pauses, sinus arrest
Sick sinus syndrome
(2) Disorder in impulse conduction – AV blocks
I degree AV block
II degree AV block
Mobitz type I
Mobitz type II
III degree AV block
First degree AV block
2nd degree AV block
3rd degree AV block
 Tachyarrhythmias
• Heart rate >100/min
(1)Supraventricular : - narrow QRS complex tachycardia
- wide QRS complex tachycardia
- physiologic sinus tachycardia
- pathologic supraventricular tachycardia
*regular rhythm ( AVNRT, atrial flutter,
orthodromic AVRT)
*irregular ( atrial fibrillation)
(2)Ventricular
Usual Relation of P-wave to QRS in
Paroxysmal Supraventricular Tachycardias
• – AVNRT either has no discernible p-waves because they are
synchronous with the QRS, or p-waves that are negative in II, III, aVF
immediately following the QRS (referred to as short R-P tachycardia).
Atypical forms may have a longer R-P interval.
• – ORT has p-waves following the QRS, although they may be difficult
to define when simultaneous with the T-wave.
• – AT typically has p-waves preceding the QRS (R-P) interval > P-R
interval. P wave morphology depends on the focus location and is
different compared to sinus rhythm unless the focus is near the sinus
node
Sinus tachycardia
AVNRT Orthodromic AVRT
WPW syndrome and antidromic AVRT
Atrial Flutter
• No “P” – waves
• Rapid, undulating waves – flutter
waves
• Report F wave to QRS ratio (3:1)
• QRS – normal
• Rhythm mostly regular
Atrial Fibrillation

• No “P” waves
• “f” waves
• Irregular rhythm
• QRS normal
 Mortal Rythms
*Ventricular Tachycardia
- Monomorphyc
- Polymorphic
*Ventricular Fibrillation
Monomorphic VT
• Rate: usually between 120-
250/min.
• Rates >250/min – ventricular
flutter
• No P-waves preceding QRSs – AV
dissociation
• Wide QRS
Polymorphic VT
 Metabolic Factors

Hyperkalemia/Hypokalemia Hypercalcemia/Hypocalcemia
Hypothermia ECG changing
• Hypothermia (below 32⁰C)
• Most prominent in precordial
leads
• Size of wave correlates with
degree of hypothermia
• Usually resolves with warming
• No prognostic value
Acute Pericarditis ECG findings
Brugada Syndrome Early repolarization syndrome
CLINICAL INTEPRERATION OF THE
ECG
• The following 14 points should be analyzed carefully in every ECG:
(1) standardization (calibration) and technical features (including lead
placement and artifacts),
(2) rhythm,
(3) heart rate
(4) PR interval/AV conduction,
(5) QRS interval
(6) QT/QTc intervals
(7) mean QRS electrical axis
 (8) P waves
(9) QRS voltages
(10) precordial R-wave progression
(11) abnormal Q waves
(12) ST segments
(13) T waves, and
(14) U waves.
Comparison with any previous ECGs is invaluable.