Abnormality

ECG sign

Sinus rhythm

regular p waves, and each

p wave is followed by a
QRS. 60-100bpm

All leads
(best to
look at the
rhythm
strip)

None

Same as above, except

>100bpm

All leads
(best to
look at the
rhythm
strip)

Does not represent cardiac

patholoy. May be a sign of anxiety,
dehydration, recent exercise, or
general illness (e.g. sepsis,
pneumonia, respiratory pathology,
other illness)

Same as above except

<60bpm

All leads
(best to
look at the
rhythm
strip)

This is normal in young fit people

Lead I

Because the cardiac axis has

shifted from 11-5 oclock to 1-7
oclock, thus lead I which measures
laterally from right to left now gets a
negative signal because the signal
is going from left to right. This axis
shift is called right axis deviation.

Taller QRS

Lead III
becomes
taller than
lead II

Because lead III measures vertically

but also slightly left to right, and this
is pretty much the exact direction of
the new shifted axis. Lead II,
measuring from right arm to left leg
is no longer lined up as well. This
axis shift is called right axis
deviation.

Transition point moved to

the left equal sized R
and S (normally seen in
V3/V4)

Equally
sized R
and S now
seen in
V5/V6

Sinus Tachycardia

Sinus bradycardia

Right ventricular
hypertrophy

Negative QRS

Right ventricular
hypertrophy

Left Ventricular
Hypertrophy
Atrial fibrillation

Pathology

Seen in

Small lead I QRS,

negative leads II and lead
III QRS

Leads I-III

Left axis deviation this is often the

results of a conduction defect, and
not an increased bulk of left
ventricular tissue.

Absent P waves just an

some?

As well as no p waves, the rhythm

irregular baseline.
Irregularly Irregular,
irregular QRS (but QRS is
normal shape)

Rhythm
strip

Might look messy! E.g.

Generally

will be irregularly irregular. There will

be a fibrillating baseline due to
uncoordinated activity.
The causes of atrial fibrillation are:
Ischaemic heart disease
Thyrotoxicosis (hyperthyroidism)
Sepsis
Valvular heart disease
Alcohol excess
PE
Note that AF can also co-exist with
complete heart block, in which case
the QRS will be regular!

Atrial Flutter

Atrial tachycardia

Junctional
tachycardia

1st degree heart

block

Tachycardia

Rhythm
strip

Cant tell if T/P waves are

present rhythm is too
fast (250bpm). Often
associated block; i.e.
there are QRS complexes
at a lower rate than the p
waves

Lead
where p
waves are
most
easily
visible
you should
use drugs
to slow
down the
heart rate
to see
what is
going on

>150bpm, p waves
superimposed over t
waves of preceding beat,
normal QRS

Any where
p waves
are best
seen

Caused by a foci of the atria

(outside of the SA node)
depolarising quickly

P waves very close to

QRS, or no QRS visible.
QRS is normal

Anywhere

Due to a re-entry loop; there is an

area of depolarisation near the AV
node; this not only transmits a
signal throughout the rest of the
ventricles to depolarise them

PR interval >0.2s (one big

square)

Allover
best in I or
V1

There will be saw tooth p waves that

occur at 300bpm, but the QRS
complexes will only be at 150, 100
or 75 bpm due to various blocks.
The QRS can be regular or
irregular.
It can be very difficult to see t waves
what looks like a T wave will
probably just be a p wave. The p
waves occur at very regular
intervals.

This is an AV node block

Can be caused by CAD, acute
rheumatic carditis, digoxin toxicity,
or electrolyte disturbance

It is NOT an medical emergency

2nd degree heart

block
Mobitz type 1 Wencebach

Progressive lengthening
of the PR interval followed
by absent QRS, then
cycle repeats. Cycles are
variable in length. R-R
interval shortens with
lengthening of PR interval

Anywhere

This can be an AV node block

(nearly always), or an SA node
block. usually benign and generally
doesnt require specific treatment.
can be caused by CHD or acute MI.
It is usually symptomless, but can
present with:
Dizziness / light-headedness /
syncope

Absent QRS every now

and again

Anywhere

This can be an SA node block, or

far more commonly infra-Hisian
block (distal block). It can progress
to complete heart block, from which
there is often no escape rhythm;
and thus this needs treatment! the
definitive treatment is an implanted
pacemaker.
Can be caused by CHD or MI

This is the ratio of P:QRS

Anywhere

May require a pacemaker,

particularly if the rate is slow

90 P waves/min, only
about 38 QRS/min, and
not relationship between
the P waves and the QRS
complexes. QRS will often
have an abnormal shape,
and be broad (>120ms).
However, the P-P intervals
will be regular, as will the
R-R intervals they are
just not in time with each
other. The rhythm of the
ventricles is the escape

Best in II
and V1

Mobitz type 2

2:1 and 3:1

conduction
Complete (third
degree) heart block

This is an AV node block. Atrial

activity will be completely normal,
but this conductivity does not pass
into the ventricles.
This always indicates underlying
disease the disease is often
fibrosis rather than ischaemia, but it
can occur in MI.

rhythm.

RBBB right
bundle branch
block

LBBB left bundle

branch block

ECG may appear normal.

In some people there may
be 2 R waves. This
creates a distinctive
pattern:
V1 there is an M shaped
QRS this is sometimes
called an RSR pattern
V6 there is a W shaped
QRS
Wide QRS (120ms)

These are infra-Hisian blocks. In

bundle branch blockages, the wave
of depolarisation can still reach the
IV septum, then the PR interval will
be normal and it is. However, the
time taken for the depolarisation to
spread throughout the ventricles is
longer thus QRS complex duration
is lengthened.
In the acute setting it may be
caused by MI
RBBB may indicate right sided
disease. The two R waves indicate
the depolarisation of the right and
left sides of the heart at different
times (the right depolarises after the
left).
You can remember the pattern with
the word MarroW there is M in V1,
and W in v6, and the rr tells you it
is on the right!
There is NOT specific treatment,
and it is often caused by an atrial
septal defect.
In the acute setting it may be
caused by MI

V1 there is an W
shaped QRS
V6 there is a M shaped
QRS
Wide QRS (>120ms)
The axis can be deviated
either way in BBBs, but it
is most commonly normal

Sinus bradycardia

Normal rhythm <60bpm

LBBB often indicates left sided

heart disease. Remember the
pattern with WillaM.
Causes:
Aortic stenosis, dilated
cardiomyopathy, acute MI, CAD
Symptoms:
Syncope, and in more severe
cases; heart failure. Those with
syncope and / or heart failure will
usually be treated with a
pacemaker.
Anywhere

Associated with; athletic training,

fainting, hypothermia, myxedema

(hypothyroidism), seen immediately
after MI
Sinus Tachycardia

Normal rhythm >100bpm

Wide QRS complexes

Anywhere

Abnormal p wave (e.g.

inverted)
Normal QRS
Some normal beats after
the abnormal one

Anywhere

Junctional escape

No p waves
Normal QRS
Slightly slow rate (max
75bpm)

Ventricular escape

Two types:
Many p waves per
QRS (complete heart
block)
Occasional missing
p wave, followed by long
gap, and then a
ventricular QRS, then
normal rhythm
-

Accelerated
idioventricular
rhythm

Associated with; exercise, fear, pain,

haemorrhage, thyrotoxicosis
Examples include:
Sinus rhythms
LBBB
RBBB

This is any rhythm that

originates outside the
ventricle

Supraventricular
rhythms
Ventricular rhythms
(aka escape
rhythms)
Atrial escape

Anywhere

This occurs when the SA node fails

to depolarise. Instead, some other
part of the atrium depolarises and
sends the signal to the ventricles.
The escape occurs somewhere at
the AV junction. It occurs when the
rate of depolarisation of the SA
node falls below the rate of the AV
node, thus the AV node starts the
beat instead. The resulting
bradycardia reduces cardiac output
and can cause symptoms similar to
other bradycardias such as:
Dizziness
Light-headedness
Syncope
Hypotension
Usually the bradycardia can be
tolerated as long as it is above
50bpm
Somewhere along the line the p
waves isnt getting conducted to the
ventricles, and thus the ventricles
depolarise at their normal escape
rate.

Dont confuse this with ventricular

tachycardia which requires a HR
of >125pbm. Otherwise it looks very
similar.
Usually benign and does not need
to be treated. Also associated with
MI

Wide QRS
Rhythm of about 75bpm
No p waves
Abnormal T waves

Extrasystoles
(aka ectopics)

Inferior MI
(probably the right
coronary artery)
Anterior MI
(probably the left
anterior
descending)

Posterior MI

These are easy they are the same as ventricular escapes, except that where in escapes the
escape beat comes after a pause in the rhythm, in extrasystole, there is an abnormal beat
earlier than expected.
The QRS complexes are the same as those of sinus rhythm, but there are usually abnormal p
waves that tend to come immediately before or immediately after the QRS.

ST elevation

II, III,
aVF
(the
inferior
leads)

The ST elevation in these leads is often

accompanied by ST depression in the anterolateral leads V1-V6, and possibly in lead I and
aVL

ST elevation

V2-5
the
anterior
leads

This will also cause deep q waves. The

presence of Q waves implies a full thickness
infarction.

ST depression, tall R
waves

ST elevation MI
(STEMI)

ST elevation >2mm in 2+
chest leads OR >1mm in
2+ limb leads,
T-wave inversion (after
several hours)
Pathological Q waves (24
hours +)

NSTEMI

Pathological Q waves only

V1-V3

T wave
inversio
n
occurs
within a
few
hours
of MI,
patholo
gical Q
waves
occur
several
days
after
initial
MI

Posterior MI is unusual! The changes that

occur are opposite to the changes of other type
of MI. thus the tall R waves are the opposite of
Q waves (remember Q waves are negative),
and ST depression occurs in place of ST
elevation

Both factors, if they occur, are usually

permanent. In a full thickness infarction then
there are pathological Q waves, and T wave
inversion, but in a non-full thickness MI then
there is only T wave inversion. The
differentiation between full /thickness and non
full thickness is pretty much the same as ST
elevation / non-ST elevation

Can be difficult to differentiate from BBB. BBB

has p waves, and a QRS generally 120-160ms.
VT is more likely scenario after MI, and has
QRS >160ms

Ventricular
tachycardia

Wide QRS, no p waves, T

waves difficult to identify,
rate >200bpm

Supraventricular
tachycardia

Narrow QRS

Ventricular
fibrillation

No discernable pattern, no
QRS, no P, no T

Patient is very likely to lose consciousness

thus the diagnosis is easy!

Delta waves present, right

axis deviation, short PR
interval, short QRS

Accessory pathway, usually from the left atria to

the left ventricle allows direct transition of the
signal, bypassing the AV node, hence the
shortened PR interval. It has a risk of mortality
as it can cause re-entry tachycardia; however,
most patients are symptomless and live with no
problems.

Depression of ST, inverted

T waves

widespr
ead

This causes a sloping ST segment that has a

reversed tick look. This occurs because
digoxin blocks the na/K pump, which increases
intracellular Ca2+ concentrations. (similarly,
ischaemia causes reduced production of ATP,
and thus reduced pump activity)

Widesp
read

If ST elevation does occur, then the ST waves

will appear saddle shaped thus helping you to
differentiate it from MI. also, the elevation in MI
tends to be confined to a certain area, but in
pericarditis, it is widespread

Lead II

Seen in cor pulmonale, or pretty much anything

that causes right atrial enlargement (or
hypertrophy) such as tricuspid stenosis or
pulmonary hypertension

Left ventricular hypertrophy

Wolff-ParkinsonWhite SYndrome

The digoxin effect

Pericarditis

T wave inversion (rare:

also ST elevation)

P pulmonale

Tall ,peaked T waves, p

wave height >2mm in lead
II

Bifid P waves (PMitrale)

P waves with two peaks,

broad looks like an M;
hence the name Mitrale

Bi-phasic T waves

T waves with t peaks

Prolonged QT
interval

Prolonged QT

Hyperkalaemia

Wide, tall, tented T

waves, shortened/absent
ST segment, small or
absent p waves, wide
QRS

Can occur as a result of MI

The corrected QT, is the QT interval as it would
be at 60bpm. if this is long, then there is a risk
of sudden cardiac death. It can be congenital,
but also caused by drugs

Can lead to VF and AF

Left ventricular
hypertrophy

S wave in V1 or V2 >35mm AND R wave in V5 or V6 >35mm

aVF >20mm
R in aVL >11mm
chest lead >45mm
R in lead I >12mm

Pacemaker

Occasional P waves, not

related to QRS, QRS
precede by large spike,
QRS complexes broad

R in
Any

The large spike is pacemaker

stimulus. The QRSs are wide
because the stimulus originates in
the ventricles

Links 728x15

Axis deviation
Lead I

Lead II

Axis

Normal

LAD

Either

RAD

aVR should always be negative!

If it is positive,it is called north-west axis. it could be due to incorrect limb lead placement,
dextrocardia, or artificial pacing, due to the pacemaker wire - this enters the heart at the apex.
Carotid sinus pressure
By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via vagal stimulation. This
will reduce the frequency of discharge of the SA node, and increase the time of conduction across the AV
node.
Thus, by applying pressure to the carotid sinus you can:

Reduce the rate of some arrhythmias

Completely stop some arrhythmias

It will have NO EFFECT ON VENTRICULAR TACHYCARDIAS thus is can help you differentiate.
Applying the pressure basically reduces the frequency of QRS complexes, and allows the underlying
atrial arrhythmia to become more visible.
- See more at:
http://almostadoctor.co.uk/content/systems/cardiovascular-system/ecgs/summary-ecgabnormalities#sthash.5g6RCyVB.dpuf