Abnormality ECG sign Seen in Pathology

regular p waves, and each p All leads

(best to look
Sinus rhythm wave is followed by a QRS. at the rhythm
None
60-100bpm strip)
Does not represent cardiac patholoy.
All leads May be a sign of anxiety, dehydration,
Same as above, except (best to look
Sinus Tachycardia at the rhythm
recent exercise, or general illness (e.g.
>100bpm
strip) sepsis, pneumonia, respiratory
pathology, other illness)
All leads
Same as above except (best to look
Sinus bradycardia at the rhythm
This is normal in young fit people
<60bpm
strip)
Because the cardiac axis has shifted
from 11-5 o’clock to 1-7 o’clock, thus lead
Right ventricular I which measures laterally from right to
Negative QRS Lead I
hypertrophy left now gets a negative signal because
the signal is going from left to right. This
axis shift is called right axis deviation.
Because lead III measures vertically but
also slightly left to right, and this is pretty
Lead III – much the exact direction of the new
becomes
Taller QRS taller than shifted axis. Lead II, measuring from right
Right ventricular lead II arm to left leg is no longer lined up as
hypertrophy well. This axis shift is called right axis
deviation.
Transition point moved to the Equally
sized R and
left – equal sized R and S S now seen
(normally seen in V3/V4) in V5/V6
Left axis deviation – this is often the
Left Ventricular Small lead I QRS, negative
Leads I-III results of a conduction defect, and not an
Hypertrophy leads II and lead III QRS
increased bulk of left ventricular tissue.
Absent P waves – just an As well as no p waves, the rhythm will be
some?
irregular baseline. irregularly irregular. There will be a
Irregularly Irregular, irregular fibrillating baseline due to uncoordinated
Atrial fibrillation QRS (but QRS is normal Rhythm strip activity.
shape) The causes of atrial fibrillation are:
1 Ischaemic heart disease
2 Thyrotoxicosis (hyperthyroidism)
3 Sepsis
4 Valvular heart disease
5 Alcohol excess
Might look messy! E.g. Generally
6 PE

Note that AF can also co-exist with

Atrial Flutter Tachycardia
Can’t 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
complete heart block, in which case the
QRS will be regular!
Rhythm strip There will be saw tooth p waves that
Lead where occur at 300bpm, but the QRS
p waves are complexes will only be at 150, 100 or 75
most easily bpm due to various blocks. The QRS can
visible – you
should use be regular or irregular.
drugs to It can be very difficult to see t waves –
slow down what looks like a T wave will probably

>150bpm, p waves
Atrial tachycardia superimposed over t waves of
preceding beat, normal QRS
P waves very close to QRS,
Junctional tachycardia or no QRS visible. QRS is
normal
1st degree heart block
PR interval >0.2s (one big
square)
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
Mobitz type 2
Absent QRS every now and
again
This is the ratio of P:QRS
2:1 and 3:1 conduction
90 P waves/min, only about
38 QRS/min, and not
Complete (third relationship between the P
degree) heart block 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
the heart just be a p wave. The p waves occur at
rate to see very regular intervals.
what is going
on
Any where p
Caused by a foci of the atria (outside of
waves are
best seen the SA node) depolarising quickly
Due to a ‘re-entry’ loop; there is an area
of depolarisation near the AV node; this
Anywhere
not only transmits a signal throughout the
rest of the ventricles to depolarise them
This is an AV node block
Allover – Can be caused by CAD, acute rheumatic
best in I or carditis, digoxin toxicity, or electrolyte
V1 disturbance
It is NOT an medical emergency
This can be an AV node block (nearly
always), or an SA node block. usually
benign and generally doesn’t require
specific treatment. can be caused by
Anywhere
CHD or acute MI.
It is usually symptomless, but can
present with:
- Dizziness / light-headedness /
syncope
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
Anywhere
escape rhythm; and thus this needs
treatment! the definitive treatment is an
implanted pacemaker.
Can be caused by CHD or MI
May require a pacemaker, particularly if
Anywhere
the rate is slow
This is an AV node block. Atrial activity
will be completely normal, but this
conductivity does not pass into the
Best in II and
V1
ventricles.
This always indicates underlying disease
– the disease is often fibrosis rather than
ischaemia, but it can occur in MI.
 rhythm of the ventricles is the
escape rhythm.
ECG may appear normal. In
some people there may be 2
R waves. This creates a
distinctive pattern:
RBBB – right bundle V1 – there is an M shaped
branch block QRS – this is sometimes
called an RSR pattern
V6 – there is a W shaped
QRS
Wide QRS (120ms)
V1 – there is an W shaped
QRS
V6 – there is a M shaped
QRS
LBBB – left bundle
Wide QRS (>120ms)
branch block
The axis can be deviated
either way in BBB’s, but it is
most commonly normal
Sinus bradycardia Normal rhythm <60bpm
Sinus Tachycardia Normal rhythm >100bpm
Supraventricular This is any rhythm that
rhythms originates outside the ventricle
Ventricular rhythms Wide QRS complexes
(aka escape rhythms) Abnormal p wave (e.g.
Atrial escape inverted)
Normal QRS
Some normal beats after the
abnormal one
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
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.
Associated with; athletic training, fainting,
hypothermia, myxedema
Anywhere
(hypothyroidism), seen immediately after
MI
Associated with; exercise, fear, pain,
Anywhere
haemorrhage, thyrotoxicosis
Examples include:
- Sinus rhythms
- LBBB
- RBBB
Anywhere
This occurs when the SA node fails to
depolarise. Instead, some other part of
Anywhere
the atrium depolarises and sends the
signal to the ventricles.
Junctional escape 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
No p waves resulting bradycardia reduces cardiac
Normal QRS output and can cause symptoms similar
Slightly slow rate (max to other bradycardias such as:
75bpm) - Dizziness
- Light-headedness
- Syncope
- Hypotension
Ventricular escape Usually the bradycardia can be tolerated
as long as it is above 50bpm
Two types:
- Many p waves per QRS
Somewhere along the line the p waves
(complete heart block)
isn’t getting conducted to the ventricles,
- Occasional missing p
and thus the ventricles depolarise at their
wave, followed by long gap,
normal escape rate.
and then a ventricular QRS,
Accelerated then normal rhythm
idioventricular rhythm Don’t confuse this with ventricular
Wide QRS
tachycardia – which requires a HR of
Rhythm of about 75bpm
>125pbm. Otherwise it looks very similar.
No p waves
Usually benign and does not need to be
Abnormal T waves
treated. Also associated with MI
Extrasystoles 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.
(aka ectopics) 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.
Inferior MI II, III,
The ST elevation in these leads is often accompanied
aVF (the
(probably the right ST elevation by ST depression in the antero-lateral leads – V1-V6,
inferior
coronary artery) and possibly in lead I and aVL
leads)
Anterior MI V2-5 –
the This will also cause deep q waves. The presence of Q
(probably the left ST elevation anterior waves implies a full thickness infarction.
anterior descending) leads
Posterior MI is unusual! The changes that occur are
opposite to the changes of other type of MI. thus the
Posterior MI ST depression, tall R waves V1-V3 tall R waves are the opposite of Q waves (remember
Q waves are negative), and ST depression occurs in
place of ST elevation
T wave
inversion
occurs
ST elevation >2mm in 2+ within a
few
chest leads OR >1mm in 2+ hours of Both factors, if they occur, are usually permanent. In a
limb leads, MI, full thickness infarction then there are pathological Q
ST elevation MI
T-wave inversion (after pathologi waves, and T wave inversion, but in a non-full
(STEMI) cal Q thickness MI then there is only T wave inversion. The
several hours) differentiation between full /thickness and non full
waves
Pathological Q waves (24 occur thickness is pretty much the same as ST elevation /
hours +) several non-ST elevation
days
after
initial MI
NSTEMI Pathological Q waves only
Ventricular tachycardia Wide QRS, no p waves, T ? Can be difficult to differentiate from BBB. BBB has p
 waves difficult to identify, rate
>200bpm
Supraventricular
Narrow QRS
tachycardia
No discernable pattern, no
Ventricular fibrillation
QRS, no P, no T
Delta waves present, right
Wolff-Parkinson-White
axis deviation, short PR
SYndrome
interval, short QRS
Depression of ST, inverted T
The digoxin effect
waves
T wave inversion (rare: also
Pericarditis
ST elevation)
Tall ,peaked T waves, p wave
P pulmonale
height >2mm in lead II
P waves with two peaks,
Bifid P waves (‘P-
broad – looks like an ‘M’;
Mitrale’)
hence the name ‘Mitrale’
Bi-phasic T waves T waves with t peaks
Prolonged QT interval Prolonged QT
Wide, tall, ‘tented’ T waves,
shortened/absent ST
Hyperkalaemia
segment, small or absent p
waves, wide QRS
S wave in V1 or V2 >35mm AND R wave in V5 or V6 >35mm
Left ventricular R in aVL >11mm
hypertrophy >45mm
R in lead I >12mm
Occasional P waves, not
related to QRS, QRS precede
Pacemaker
by large spike, QRS
complexes broad
Links 728x15
Axis deviation
Lead I Lead II
+ +
+ -
- Either
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.
waves, and a QRS generally 120-160ms. VT is more
likely scenario after MI, and has QRS >160ms
Patient is very likely to lose consciousness – thus the
diagnosis is easy!
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.
This causes a sloping ST segment that has a
‘reversed tick’ look. This occurs because digoxin
widespre blocks the na/K pump, which increases intracellular
ad Ca2+ concentrations. (similarly, ischaemia causes
reduced production of ATP, and thus reduced pump
activity)
If ST elevation does occur, then the ST waves will
appear ‘saddle shaped’ thus helping you to
Widespre
ad
differentiate it from MI. also, the elevation in MI tends
to be confined to a certain area, but in pericarditis, it is
widespread
Seen in cor pulmonale, or pretty much anything that
Lead II causes right atrial enlargement (or hypertrophy) –
such as tricuspid stenosis or pulmonary hypertension
? Left ventricular hypertrophy
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
R in aVF >20mm
Any chest lead
The large spike is pacemaker stimulus.
? The QRS’s are wide because the
stimulus originates in the ventricles
Axis
Normal
LAD
RAD
 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-ecg-
abnormalities#sthash.5g6RCyVB.dpuf