ECG TUTORIAL

PRESENTER: DR. OKAFOR SN

19TH SEPTEMBER, 2025
OUTLINE
• BASIC PHYSIOLOGY CONCEPTS
• AV BLOCK
• BUNDLE BRANCH BLOCK (RBBB AND LBBB)
• SMITH MODIFIED SGARBOSA CRITERIA
• QRS AXIS
• P WAVE
• ACS
• PERICARDITIS
NORMAL HEART ELECTRICAL
CONDUCTION SYSTEM
 BASIC PHYSIOLOGY
CONCEPTS
• PR IN PR INTERVAL
• NORMAL PR INTERVAL: 0.12 TO 0.20 seconds (3-5 small squares)

• QRS COMPLEX: 0.08 TO 0.10 seconds ( less than 3 small squares)

LEADS DEFLECTION
NORMAL ECG
 FIRST DEGREE AV
BLOCK
• THIS OCCURS WHEN THERE IS A LONGER THAN NORMAL DELAY IN
CONDUCTION AT THE AV NODE.
• THERE IS A CONSTANT LONG PR INTERVAL MORE THAN 0,20 seconds
• WHEREAS THE CONDUCTION IS DELAYED BUT THERE ARE NO MISSED
BEATS
• ALL P WAVES ARE FOLLOWED BY QRS COMPLEX
• EVERY ATRIAL IMPULSE IS TRANSMITTED TO THE VENTRICLES
RESULTING IN REGULAR VENTRICULAR RATE
1ST DEGREE AV BLOCK
1ST DEGREE AV BLOCK
 MOBITZ 1
• THE PR INTERVAL APPEARS TO BE WIDENING EVERY BEAT AND THEN
A QRS COMPLEX MISSES.
• THE LENGHTENING OF THE PR INTERVAL IN SUBSEQUENT BEAT IS
CALLED WENCKEBACH PHENOMENON
MOBITZ 1
 MOBITZ 11
• THE PR INTERVAL IS CONSTANT BUT THERE IS A MISEED QRS
COMPLEX
 THIRD DEGREE AV
BLOCK
• THERE IS NO DISCERNABLE RELATIONSHIP BETWEEN P-WAVE AND
QRS COMPLEX.
• THERE IS ALWAYS BRADYCARDIA
3RD DEGREE AV BLOCK
 SHORT PR INTERVAL
• IF THE PR INTERVAL IS SHORT (< 3 small squares), IT MAY SIGNIFY THAT THERE IS
AN ACCESSORY ELECTRICAL PATHWAY BETWEEN THE ATRIA AND THE
VENTRICLES , HENCE THE VENTRICLES DEPOLARISE EARLY GIVING A SHORT PR
INTERVAL.
• THE NORMAL WAVE OF DEPOLARISATION FROM SA NODE IS USUALLY DELAYED
AT THE AV NODE BUT THE ACCESSORY PATHWAY HAS NO SUCH DELAY AND
DEPOLARISATION BEGINS EARLY IN THE PART OF THE VENTRICLE SERVED BY THE
PATHWAY

• THIS IS CALLED PRE-EXCITATION SYNDROME

• ONE EXAMPLE OF THIS IS WOLFF-PARKINSON -WHITE SYNDROME (WPW)
WHERE THE ACCESSORY PATHWAY IS CALLED THE BUNDLE OF KENT.
 DELTA WAVE IN WPW
• AS THE DEPOLARISATION IN THIS PART OF THE VENTRICLE DOES NOT
TRAVEL IN THE HIGH SPEED CONDUCTION PATHWAY, THE SPEED OF
DEPOLARISATION ACROSS THE VENTRICLE IS SLOW, CAUSING A SLOW
RISING DETA WAVE UNTIL RAPID DEPOLARISATION RESUMES VIA THE
NORMAL PATHWAY AND A NORMAL COMPLEX FOLLOWS
WPW ECG
 BUNDLE BRANCH BLOCK
• THE WIDTH OF QRS COMPLEX SHOULD BE LESS THAN 0.12 sec ( 3
small squares).
• IF THE QRS COMPLEX IS WIDER THAN THIS, IT SUGGESTS?
• A VENTRICULAR CONDUCTION PROBLEM – USUALLY RIGHT OR LEFT
BUNDLE BRANCH BLOCK (RBBB OR LBBB)
• IN BUNDLE BRANCH BLOCK, YOU WILL SEE TWO CHANGES
- QRS COMPLEX WIDENS (> 0.12 sec)
- QRS MORPHOLOGY CHANGES ( RBBB OR LBBB) IN V1 AND V6
NORMAL ECG
 RBBB
• THE INTERVENTRICULAR SEPTUM DEPOLARISES NORMALLY FROM
LEFT TO RIGHT CAUSING A TINY R WAVE IN LEAD V1 AND A SMALL
SEPTAL Q-WAVE IN LEAD V6.
• THE LEFT VENTRICLE IS NORMALLY DEPOLARISED VIA THE LEFT
BUNDLE BRANCH CAUSING AN S-WAVE IN LEAD V1 AND R WAVE IN
LEAD V6
• THE RIGHT VENTRICLE IS DEPOLARISED BY THE LEFT CAUSING
ANOTHER R-WAVE IN LEAD V1 AND S-WAVE IN LEAD V6
• IT IS CALLED rSR PATTERN IN V1 AND qRs PATTERN IN V6
• THE QRS COMPLEX MAY LOOK LIKE M IN V1 AND W IN V6
RBBB
RBBB
 LBBB
• THE INTERVENTRICULAR SEPTUM HAS TO DEPOLARISE FROM RIGHT
TO LEFT- A REVERSAL OF THE NORMAL PATTERN. THIS CAUSES A
SMALL Q-WAVE IN LEAD V1 AND A SMALL R WAVE IN V6 (NOT
REFLECTED ON ECG)
• THE RIGHT VENTRICLE IS NORMALLY DEPOLARISED VIA THE RIGHT
BUNDLE BRANCH CAUSING AN R-WAVE IN V1 AND S-WAVE IN V6
(MAY NOT ALWAYS BE SEEN ON ECG)
• THE LEFT VENTRICLE IS DEPOLARISED BY THE RIGHT CAUSING AN S-
WAVE IN LEAD V1 AND ANOTHER R- WAVE IN V6
• THE QRS COMPLEX MAY LOOK LIKE W IN V1 AND M IN V6
LBBB
LBBB
 RBBB AND LBBB SUMMARY
• IT IS USEFUL TO LOOK AT LEADS V1 AND V6.

• RBBB AND LBBB CAN BE REMEMBERED BT THE MNEMONIC: WiLLiaM

MaRRoW.

• BUNDLE BRANCH BLOCK IS CAUSED BY EITHER INFARCTION OR FIBROSIS

( RELATED TO AGEING PROCESS)

• NEW ONSET LBBB WITH CHEST PAIN SUGGESTS MYOCARDIAL

INFARCTION
 CAUSES OF BUNDLE BRANCH
BLOCK
 MODIFIED SGARBOSA
CRITERIA
• IN PATIENTS WITH LBBB, INFARCT (STEMI) DIAGNOSIS BASED ON ECG
CAN BE DIFFICULT.
• ABNORMAL DEPOLARISATION SHOULD BE FOLLOWED BY ABNORMAL
REPOLARISATION MANIFESTING AS ST-SEGMENT AND T-WAVE
DEVIATION THAT DO NOT NECESSARILY INDICATE ACUTE ISCHAEMIA
(APPROPRIATE DISCORDANCE).
• MODIFIED SGARBOSA CRITERIA ASSIST CLINICIANS TO DIAGNOSE
STEMI IN THE PRESENCE OF LBBB
NORMAL ECG
LBBB
 SMITH MODIFIED SGARBOSA
CRITERIA
• CTITERIA 1 : CONCORDANT ST ELEVATION MORE THAN OR EQUAL TO
1mm IN AT LEAST ONE LEAD

• CRITERIA 2 : CONCORDANT ST DEPRESSION MORE THAN OR EQUAL

TO 1mm IN ONE OR MORE THAN ONE LEAD OF V1 – V3

• CRITERIA 3 : PROPORTIONALLY EXCESSIVE DISCORDANCE ST

ELEVATION IN AT LEAST ONE LEAD ANYWHERE WITH MORE THAN OR
EQUAL TO 1mm STE AS DEFINED BY MORE THAN OR EQUAL TO 25%
OF THE DEPTH OF THE PRECEDING S-WAVE
 QRS ELECTRICAL AXIS
• THIS IS DEFINED AS THE AVERAGE DIRECTION OF ELECTRICAL IMPULSE AS THE
HEART VENTRICLES DEPOLARIZE. IT CAN BE

• NORMAL AXIS
• LEFT AXIS DEVIATION (LAD)
• RIGHT AXIS DEVIATION (RAD)
• EXTREME AXIS DEVIATION (NORTH WEST AXIS)

• QRS AXIS IS DETERMINED BY LOOKING AT LEADS 1, 11, 111, aVR, aVL AND aVF.
THESE LEADS ARE DERIVED USING THREE ELECTRODES. THEY DETECT ELECTRICAL
ACTIVITY OF THE HEART IN A FRONTAL PLANE
EINTHONVEN TRIANGLE
 HEXAXIAL REFERENCE
SYSTEM
 METHODS OF AXIS
DETERMINATION
• QUADRANT METHOD: USE LEAD 1 AND aVF

• THREE LEAD ANALYSIS: USE LEAD 1, 11 AND aVF

• ISOELECTRIC (EQUIPHASIC) LEAD ANALYSIS

QUADRANT METHOD
 THREE LEAD ANALYSIS: 1, 11
,aVF
 ISOELECTRIC (EQUIPHASIC) LEAD
ANALYSIS
• ISOELECTRIC (EQUIPHASIC) LEAD IS THE LEAD WITH A NET
AMPLITUDE OF ZERO
• THE QRS AXIS IS APPROXIMATELY PERPENDICULAR (90 degrees) FROM
THE POSITIVE POLE OF THAT LEAD
 CAUSES OF QRS AXIS
DEVIATION
 P WAVE

• P WAVE REPRESENTS THE DEPOLARISATION OF BOTH LEFT AND RIGHT

ATRIA
• ALWAYS POSITIVE IN LEAD I AND II
• ALWAYS NEGATIVE IN LEAD aVR
 HEIGHT
• P WAVE > 2.5mm SHOULD AROUSE SUSPICION
• A TALL P WAVE( > 2.5mm) IS CALLED P- PULMONALE.
• OCCURS DUE TO RIGHT ATRIAL HYPERTROPHY.
• CAUSES INCLUDE: PULMONARY HYPERTENSION, PULMONARY
STENOSIS AND TRICUSPID STENOSIS
P-PULMONALE
 LENGHT

• P WAVE LONGER THAN 0.08sec (2 small squares) SHOULD AROUSE

SUSPICION
 P WAVE > 0.08sec WITH A BIFID SHAPE IS CALLED P- MITRALE IT IS
CAUSED BY LEFT ATRIAL HYPERTROPHY AND DELAYED LEFT ATRIAL
DEPOLARISATION.
 CAUSES INCLUDE MITRAL VALVE DISEASE, LVH
 MYOCARDIAL
ISCHAEMIA/INFARCTION
• UNSTABLE ANGINA
• NSTEMI
• STEMI
ANATOMY OF CORONARY
ARTERY BRIEF OVERVIEW
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY
• UNSTABLE ANGINA IS DUE TO MYOCARDIAL ISCHAEMIA WITHOUT
INFARCTION (TISSUE DAMAGE)

• NSTEMI IS DUE TO MYOCARDIAL ISCHAEMIA AND INFARCTION BUT

THE INFARCTION IS LIMITED TO THE SUBENDOCARDIUM OR JUST
PART OF THE MYOCARDIUM

• STEMI IS DUE TO MYOCARDIAL ISCHAEMIA AND INFARCTION. THE

INFARCTION IS TRANSMURAL (WHOLE THICKNESS OF THE AREA OF
THE MYOCARDIUM)
ECG CHANGES IN
NSTEMI/UNSTABLE ANGINA
• THE TWO CONDITIONS HAVE SIMILAR CLINICAL PRESENTATIONS. THE
DIFFERENTIATION BETWEEN THEM IS ACTUALLY RETROSPECTIVE,
BASED ON THE PRESENCE OR ABSENCE OF RAISED CARDIAC ENZYMES
AT 8-12HRS AFTER ONSET OF CHEST PAIN. BOTH PRODUCE THE SAME
SPECTRUM OF ECG CHANGES AND THEIR MANAGEMENT IS
ESSENTIALLY SAME IN EMERGENCY DEPARTMENT.
THE CLASSICAL ECG CHANGES ARE:
• ST SEGMENT DEPRESSION AND
• T WAVE FLATTENING OR INVERSION
 STEMI
• THIS HAPPENS DUE TO COMPLETE BLOCKAGE OF ONE OR MORE
MAJOR CORONARY ARTERY CAUSING MYOCARDIAL ISCHAEMIA AND
SIGNIFIES THAT THE HEART MUSCLE IS IN THE PROCESS OF DYING.
• THE LEADS AFFECTED DETERMINE THE SITE OF INFARCT
 CRITERIA FOR ST
ELEVATION MI
• NEW ST ELEVATION AT J-POINT IN TWO CONTIGUOUS LEADS WITH
THRESHOLD GREATER THAT 1mm IN ALL LEADS EXCEPT V2 AND V3
• IN LEADS V2 AND V3, THE THRESHOLD IS MORE THAN 2mm FOR MEN
OLDER THAN 40YRS AND MORE THAN 2.5mm FOR MEN UNDER
40YRS. FOR WOMEN, THE THRESHOLD IS MORE THAN 1.5mm
REGARDLESS OF AGE
• PRESENCE OF LBBB WITH POSITIVE SMITH MODIFIED SGARBOSSA
CRITERIA
 ECG CHANGES IN
STEMI
• WITHIN HOURS:
- T WAVE MAY BECOME PEAKED
- ST SEGMENT MAY BEGIN TO RISE
• WITHIN 24HRS:
- ST SEGMENT REACHES PEAK
-T WAVE INVERTS (MAY OR MAY NOT PERSIST)
- Q WAVE STARTS
• WITHIN A FEW DAYS:
- ST SEGMENT NORMALISES
- IF LEFT VENTRICULAR ANEURISM FORMS, ST SEGMENT MAY PERSIST
- Q WAVE PERSISTS
•
PATIENT PRESENTS WITH LEFT
CHEST PAIN….?
 POSTERIOR WALL
STEMI
• POSTERIOR WALL OF THE HEART IS NOT REPRESENTED ON 12 LEAD ECG. THIS
MEANS THAT THE DIAGNOSIS IS OFTEN MISSED
• POSTERIOR MYOCARDIAL INFARCTION ACCOMPANIES 15-20% OF STEMI
• ISOLATED POSTERIOR MI IS LESS COMMON
• USUALLY OCCURS IN THE CONTEXT OF INFERIOR OR LATERAL INFARCTION AND
USUALLY IMPLIES A LARGER AREA OF MYOCARDIAL DAMAGE WITH INCREASED
RISK OF LEFT VENTRICULAR DYSFUNCTION AND DEATH.
• ALWAYS EXAMINE CLOSELY FOR EVIDENCE OF POSTERIOR INFARCTION IN ANY
PATIENT WITH LATERAL OR INFERIOR MI
• THIS IS DONE BY DONE BY LOOKING FOR RECIPROCAL CHANGES IN THE
ANTERO-SEPTAL LEADS (V1-V3)
 RECIPROCAL CHANGE
• A LEAD VIEW OCCASSIONALLY PROVIDES MIRROR-LIKE
REPRESENTATION FOR THE OPPOSITE SURFACE OF THE HEART. Eg.
• ST ELEVATION IN LATERAL LEADS MAY PRESENT AS RECIPROCAL
CHANGES AS ST DEPRESSION IN INFERIOR LEADS
• ST ELEVATION IN POSTERIOR LEADS MAY HAVE RECIPROCAL ST
DEPRESSION IN ANTERIOR LEADS
ECG FINDING SUSPICIOUS
POSTERIOR STEMI
• HORIZONTAL ST DEPRESSION IN V1-V3
• TALL BROAD R WAVE IN V1-V3
• UPRIGHT T WAVE IN V1-V3
 CONFIRMATION OF
POSTERIOR MI
• LEADS V7-9 ARE PLACED ON THE POSTERIOR CHEST WALL IN THE
FOLLOWING POSITIONS:
- V7 LEFT AXILLARY LINE IN THE SAME HORIZONTAL PLANE AS V6
- V8 TIP OF THE LEFT SCAPULA IN THE SAME HORIZONTAL PLANE AS V6
- V9 LEFT PARASPINAL REGION IN THE SAME HORIZONTAL PLANE AS V6
- THE DEGREE OF ST ELEVATION SEEN IN V7-9 IS TYPICALLY MODEST,
ONLY 0.5mm OF ST ELEVATION IS REQUIRED TO MAKE THE DIAGNOSIS
OF POSTERIOR MI
 WELLENS SYNDROME
• THIS IS A CLINICAL SYNDROME CHARACTERISED BY BIPHASIC OR
DEEPLY INVERTED T WAVES IN V2-V3, PLUS A HISTORY OF RECENT
CHEST PAIN NOW RESOLVED.
• IT IS HIGHLY SPECIFIC FOR CRITICAL STENOSIS OF THE LEFT ANTERIOR
DESCENDING ARTERY (LAD).
• PATIENT MAY BE PAIN FREE BY THE TIME THE ECG IS TAKEN.
HOWEVER, THEY ARE EXTREMELY HIGH RISK FOR EXTENSIVE
ANTERIOR WALL MI WITHIN SUBSEQUENT DAYS TO WEEKS.
 DIAGNOSTIC
CRITERIA
• DEEPLY INVERTED OR BIPHASIC T WAVE IN V2-V3 (MAY EXTEND TO
V1-V6)
• ECG PATTERN PRESENT IN PAIN FREE STATE
• ISOELECTRIC ST SEGMENT
• NO PRECORDIAL Q WAVE
• RECENT HISTORY OF ANGINA
• NORMAL OR SLIGHTLY ELEVATED SERUM CARDIAC MARKERS
 PERICARDITIS
• PERICARDITIS CAUSES WIDESPREAD ST ELEVATION IN ALMOST ALL
THE LEADS EXCEPT IN LEADS aVR AND V1 +/-V2 WHERE THERE IS A
RECIPROCAL ST DEPRESSION
• NOTE: IT IS A DIAGNOSIS OF EXCLUSION