Abnormal

Electrocardiography

dr. Andi Sulistyo Haribowo, Sp.PD.

Program Studi Pendidikan Dokter

UNIVERSITAS ISLAM MALANG
2014
 What types of pathology can we identify
and study from EKGs?

Arrhythmias
Myocardial ischemia and infarction
Pericarditis
Chamber hypertrophy
Electrolyte disturbances (i.e. hyperkalemia,
hypokalemia)
Drug toxicity (i.e. digoxin and drugs which
prolong the QT interval)
Cardiac Conduction
Cardiac Conduction

R
P T
Q S
Cardiac Conduction

ST
Seg.

Q
PR R
.12 - .20 s S <.12 s
Normal Sinus Rhythm
Normal Sinus Rhythm
Normal features of the electrocardiogram.
Rhythms/Arrhythmias
Sinus

Atrial

Junctional

Ventricular
 Rhythms/Arrhythmias

CONTRIBUTING FACTORS (ACLS):

6Hs: Hypovolemia, Hydrogen ions
(Acidosis), Hypoxia, Hypo-/hyperkalemia,
Hypoglycemia, Hypothermia
5Ts: Toxins, Tamponade (cardiac), Tension
pneumothorax, Thrombosis
(coronary/pulmonary), Trauma
(hypovolemia)
Sinus Arrhythmias: Criteria/Types
P waves upright in I, II, aVF
Constant P-P/R-R interval
Rate
Narrow QRS complex
P:QRS ratio 1:1
P-R interval is normal and constant
Sinus Arrhythmias: Criteria/Types

Normal Sinus Rhythm

Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
 Normal Sinus Rhythm

Rhythm: Regular
Rate: 60-100 BPM
P Waves: Upright/Normal
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex: .04-.12 s (40-120 ms)
Normal Sinus Rhythm

Rate is 60 to 100
 Sinus Bradycardia

Rhythm: Regular
Rate: < 60 BPM
P Waves: Upright/Normal
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex: .04-.12 s (40-120 ms)
 Sinus Bradycardia

Can be normal variant

Can result from medication
Look for underlying cause
 Sinus Tachycardia

Rhythm: Regular
Rate: > 100 and < 160 BPM
P Waves: Upright/Normal
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex: .04-.12 s (40-120 ms)
 Sinus Tachycardia

May be caused by exercise, fever,

hyperthyroidism
Look for underlying cause, slow the
rate
 Sinus Dysrhythmia

Rhythm: Irregular
Rate: 60-100 BPM
P Waves: Upright/Normal
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex: .04-.12 s (40-120 ms)
 Sinus Arrhythmia

Seen in young patients

Secondary to breathing
Heart beats faster
 Sinus Arrest

Rhythm: Irregular
Rate: Normal - slow
P Waves: Upright/Normal
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex: .04-.12 s (40-120 ms)
Atrial Arrhythmias: Criteria/Types
P waves inverted in I, II and aVF
Abnormal shape
Notched
Flattened
Diphasic
Narrow QRS complex
Atrial Arrhythmias: Criteria/Types

Premature Atrial Contractions

Ectopic Atrial Rhythm
Wandering Atrial Pacemaker
Multifocal Atrial Tachycardia
Atrial Flutter
Atrial Fibrillation
 Premature Atrial Contractions

Rhythm: Irregular (PACs);Non-compensatory

Rate: Depends on underlying rhythm
P Waves: Upright/Normal
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex: .04-.12 s (40-120 ms)
 Premature Atrial Contraction

QRS complex narrow

RR interval shorter than sinus QRS
complexes
P wave shows different morphology
than sinus P wave
 Atrial Flutter

Rhythm: Atrial: Regular; Ventr.: Varies

Rate: Atrial: 250-300; Ventr.: Varies
P Waves: Big F-Waves Saw tooth pattern
P-R Interval: Normally constant may vary
(Q)RS Complex: .04-.12 s (40-120 ms)
 Atrial Flutter

Regular ventricular rate 150 bpm

Varying ratios of F waves to QRS

complexes, most common is

4:1
Tracing shows 2:1 conduction
 Atrial Flutter

Tracing shows 6:1 conduction

 Atrial Fibrillation

Rhythm: Irregularly irregular ventricular

Rate: Atrial: 350-750; Ventr.: Varies
P Waves: Little F-Waves no pattern
P-R Interval: No discernable P waves
(Q)RS Complex: .04-.12 s (40-120 ms)
 Atrial Fibrillation

Tracing shows irregularly irregular

rhythm with no P waves
Ventricular rate usually > 100 bpm
 Atrial Fibrillation

Tracing shows irregularly irregular

rhythm with no P waves

Ventricular rate is 40
(Paroxysmal) Atrial Tachycardia

Rhythm: Regular
Rate: > 150-250 BPM
P Waves: Upright/Normal
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex: .04-.12 s (40-120 ms)
 Supraventricular Tachycardia

Rhythm: Regular
Rate: > 150-250 BPM
P Waves: Indiscernible
P-R Interval: None seen
(Q)RS Complex: .04-.12 s (40-120 ms)
 Rate Summary

Sinus Tachycardia - 100-160 BPM

Atrial Tachycardia - 150-250 BPM

Atrial Flutter - 150-250 BPM

Junctional Tachycardia - 100-180 BPM

 AV Nodal Blocks

Delay conduction of impulses from

sinus node
If AV node does not let impulse
through, no QRS complex is seen
AV nodal block classes:
1st, 2nd, 3rd degree
 First Degree AV Block

Rhythm: Regular; can be irregular

Rate: Usually 60-100 BPM; Rhythm dep.
P Waves: Upright/Normal
P-R Interval: > .20 s (200 ms); Constant
(Q)RS Complex: .04-.12 s (40-120 ms)
1st Degree AV Block

PR interval constant
>.2 sec
All impulses conducted
 Second Degree AV Block
(Type I)

Rhythm: Atrial: Reg.; Ventr.: Regularly irreg.

Rate: Atrial: Normal; Vent.: Norm./Slow
P Waves: Normal: extra P waves
P-R Interval: Not constant; Lengthens - drops beat
(Q)RS Complex: Usually .04-.12 s (40-120 ms)
 2nd Degree AV Block Type 1

AV node conducted each impulse

slower and finally no impulse is
conducted
Longer PR interval, finally no QRS
complex
 Second Degree AV Block
(Type II) Classical

Rhythm: Atrial: Reg.; Ventr.: Regular or irreg.

Rate: Atrial: Normal; Ventricular: Slow
P Waves: Normal; extra P waves
P-R Interval: Constant on conducted beats
(Q)RS Complex: Usually .04-.12 s (40-120 ms)
 Second Degree AV Block
(Type II) Variable

Rhythm: Atrial: Reg.; Ventr.: Regular or irreg.

Rate: Atrial: Normal; Ventricular: Slow
P Waves: Normal; extra P waves
P-R Interval: Constant on conducted beats
(Q)RS Complex: Usually .04-.12 s (40-120 ms)
2nd Degree AV Block Type 2

Constant PR interval
AV node intermittently conducts
no impulse
 Third-Degree AV Block

Rhythm: Atrial & Ventricular: Regular

Rate: Atrial: Normal; Vent.: 40-60; < 40
P Waves: Normal: extra P waves
P-R Interval: No Atrial/Ventricular Relationship
(Q)RS Complex: <.12 s (120 ms) Junct.;> .12 Ventr.
 3rd Degree AV Block

AV node conducts no impulse

Atria and ventricles beat at intrinsic
rate (80 and 40 respectively)
No association between P waves
and QRS complexes
 Ventricular Arrhythmias:
Criteria/Types
Premature Ventricular
Wide QRS Contractions
complex Idioventricular Rhythm
Accelerated IVR
Rate :
variable Ventricular Tachycardia

No P waves Ventricular Fibrillation

 Premature Ventricular
Contractions

Rhythm: Irregular (PVCs); Compensatory

Rate: Depends on underlying rhythm
P Waves: None on premature beat
P-R Interval: None on PVCs
(Q)RS Complex: > .12s (120 ms) on PVC
Premature Ventricular Contraction

Occurs earlier than sinus beat

Wide, no P wave
 Ventricular Tachycardia

Rhythm: Usually Regular

Rate: 100-250 BPM
P Waves: If present, not associated
P-R Interval: None
(Q)RS Complex: > .12s (120 ms)
Ventricular Tachycardia

Rate is > than 100 bpm

 Torsades de Pointes

Occurs secondary to prolonged

QT interval
Ventricular Tachycardia/Fibrillation

Unorganized activity of ventricle

 Ventricular Fibrillation

Rhythm: Chaotic;no set rhythm;fine/coarse

Rate: None
P Waves: Absent
P-R Interval: Absent
(Q)RS Complex: No discernable; medium F-waves
Ventricular Fibrillation
 Asystole

Rhythm: No electrical activity

Rate: No electrical rhythm
P Waves: Absent
P-R Interval: Absent
(Q)RS Complex: Absent
 Pacemaker Rhythm

Rhythm: Paced: Reg.; Demand: Irregular

Rate: Varies with pacemaker rate
P Waves: May be present
P-R Interval: No relationship
(Q)RS Complex: > .12 s (120 ms);Ventricular
Chamber Enlargements
Left Ventricular Hypertrophy (LVH)
Differential Diagnosis
Hypertension (HTN)
Aortis Stenosis (AS)
Aortic Insufficiency (AI)
Hypertrophic Cardiomyopathy (HCM)
Mitral Regurgitation (MR)
Coarctation of the Aorta (COA)
Physiologic
Left Ventricular Hypertrophy (LVH)
False positive
Thin chest wall
Status post mastectomy
Race, Sex, Age
Left Bundle Branch Block (LBBB)
Acute MI
Left Anterior Fascicular Block
Incorrect standardization
Estes Criteria: Diagnosis of LVH
Right Ventricular Hypertrophy: Causes

Chronic Obstructive Pulmonary Disease

Pulmonary HTN
Primary
Pulmonary Embolus
Mitral Stenosis
Mitral Regurgitation
Chronic LV failure
Right Ventricular Hypertrophy: Causes

Tricuspid Regurgitation
Atrial Septal Defect
Pulmonary Stenosis
Tetralogy of Fallot
Ventricular Septal Defect
Right Ventricular Hypertrophy
 Right Ventricular Hypertrophy

Reversal of precordial pattern

R waves prominent in V1 and V2

S waves smaller in V1 and V2
S waves become prominent in V5 and V6
Strain
Left Atrial Enlargement: Causes
Mitral Stenosis
Mitral Regurgitation
Left ventricular hypertrophy
Hypertension
Aortic Stenosis
Aortic Insufficiency
Hypertrophic Cardiomyopathy
Left Atrial Enlargement: Criteria
P wave

Notch in P wave
Any lead
Peaks > 0.04 secs

V1
Terminal portion of P wave > 1mm deep
and > 0.04 sec wide
Lead II
P Wave: Left Atrial Enlargement
Left Atrial Enlargement
Right Atrial Enlargement: Causes
CHD
Tricuspid Stenosis
Pulmonary Stenosis
COPD
Pulmonary HTN
Pulmonary Embolus
Mitral Regurgitation
Mitral Stenosis
Right Atrial Enlargement: Criteria

Tall, peaked P wave

> 2.5 mm in any lead

Most prominent P waves in leads I, II

and aVF
Right Atrial Enlargement
Bundle Branch Blocks
 Bundle Branch Blocks

Left
Complete Complete
Incomplete QRS > .12 secs

Right Incomplete
Complete QRS .10 - .12 secs
Incomplete
Left Bundle Branch Block: Causes
Normal variant
Idiopathic degeneration of the
conduction system
Cardiomyopathy
Ischemic heart disease
Aortic Stenosis
Hyperkalemia
Left Ventricular Hypertrophy
 Criteria for Left Bundle Branch
Block (LBBB)
Bizarre QRS Morphology
High voltage S wave in V1, V2 & V3
Tall R wave in leads I, aVL and V5-6
Often LAD
QRS Interval
ST depression in leads I, aVL, & V5-V6
T wave inversion in I, aVL, & V5-V6
Left Bundle Branch Block
Right Bundle Branch Block:
Causes
Idiopathic degeneration of the conduction
system
Ischemic heart disease
Cardiomyopathy
Massive Pulmonary Embolus
Ventricular Hypertrophy
Normal Variant
Criteria for Right Bundle Branch
Block (RBBB)
QRS morphology
Wide S wave in leads I and V4-V6
RSR pattern in leads V1, V2 and V3
QRS duration
ST depression in leads V1 and V2
T wave inversion in leads V1 and V2
Right Bundle Branch Block
Right Bundle Branch Block
Anterior Septal with RBBB
Ischemia and Infarction
Normal Complexes and Segments
J Point
Measurements
 Ischemia

T wave inversion, ST segment depression

Acute injury: ST segment elevation
Dead tissue: Q wave
EKG Changes: Ischemia
Acute Injury Infarction
Chest Leads
 Position of Anterior Leads
V1 V4
Right 4th ICS Left MCL
V2 5th ICS
Left 4th ICS V5
V3 Anterior axillary line
Left Sternal 5th ICS
border V6
Between V2 and Mid axillary line
V4 5th ICS
Blood Supply to the Myocardium

Left Anterior Descending (LAD) artery

Bulk of LV
Anterior wall
Apex
Part of lateral wall
Part of septum
Blood Supply to the Myocardium

Right Coronary Artery (RCA)

Right Ventricle
Sinus Node 60% of the time
Right Atrium
Posterior Descending Artery (PAD) 90% of
the time
 Blood Supply to the Myocardium
Left Circumflex (LCFLX) artery
Lateral Wall & Posterior Wall of LV & LA
SA node 40% of the time
PDA 10% of the time
Posterior Descending Artery (PAD)
Off RCA 90%/LCFLX 40%
AVN, prox BB, IW/PW, basal septum
 View of the Leads
II, III, aVF V1 & V2
Inferior Wall//RV Intraventricular
RCA distribution septum
Proximal LAD
I, aVL
V3 & V4
Lateral Wall
Anterior wall
LCFLX/distal LAD Mid LAD
distribution V5 & V6
aVR Lateral wall
R side of heart Distal LAD
Arrangement of Leads on the EKG
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
Standard EKG
Anterior MI
Anterior-septal MI
Inferior AMI
Right Sided Leads
Right Ventricular AMI
Lateral MI
Posterior Leads
Posterior AMI
Inferior-RV-Posterior AMI
ST-T Wave Changes
Strain in Hypertrophy
Strain in LVH
Strain in RVH
Strain vs Infarction
Pericarditis
Digoxin Changes
Ventricular Aneurysm
T waves
TIME FOR
SOME
PRACTICE
 REMEMBER!!!
Use a systematic approach
Go through all the steps
Take your time!
Compare with your characteristics list
Interpret the dysrhythmia
 Atrial Flutter

Rhythm: Irregular
Rate: 70
P Waves: Big F (Flutter) Waves
P-R Interval: .20 s
(Q)RS Complex: Normal; .04-.12 s
 Sinus Dysrhythmia

Rhythm: Irregular
Rate: 60 BPM
P Waves: Normal; upright
P-R Interval: .16 s
(Q)RS Complex: Normal
 Third Degree Heart Block

Rhythm: Regular
Rate: 37 BPM
P Waves: Normal; upright; extra
P-R Interval: Non-constant; No relationship
(Q)RS Complex: Normal
 Sinus Tachy with PVCs (UF)

Rhythm: Irregular (due to ectopics)

Rate: 110 BPM
P Waves: Present underlying; none ectopics
P-R Interval: .16 s
(Q)RS Complex: Normal; .16 for ectopics
 Sinus Arrest

Rhythm: Regularly Irregular; loses complexes

Rate: 40 BPM
P Waves: Normal; upright
P-R Interval: .16 s
(Q)RS Complex: Normal
 Sinus Rhythm with PAC

Rhythm: Irregular (due to ectopics)

Rate: 60
P Waves: Normal; upright; present for ectopic
P-R Interval: .18 s; .14 s for ectopic
(Q)RS Complex: Normal for all complexes
 Sinus Rhythm with V-Tach

Rhythm: Irregular (due to ectopics)

Rate: 80 BPM
P Waves: Normal; upright none for ectopics
P-R Interval: .14 s; none on ectopics
(Q)RS Complex: Normal; .14 s on ectopics
Acute Anterior MI
 Summary

You need to learn the definitive

characteristics
Use a complete, systematic approach to
dissect the rhythm
Take your time
Mistakes are made when steps are skipped
Practice! Practice! Practice!
THANK YOU