An early Electrocardiograph
Einthoven’s first published
EKG, 1902
“I do not however imagine that the
string galvanometer…is likely to
find any very extensive use in the
hospital”
August D. Waller, 1909
The Electrocardiogram
(ECG/EKG)
Most Commonly Utilized
Cardiovascular Lab Test
100 Million Performed per Year
$5 Billion Cost per Year
Reimbursements have dropped
Key to Therapy for ACS/MI
Diagnosis of Arrhythmias
Indications For An ECG
Chest or Epigastric Altered Mental State
Pain or Sensation (Coma, CVA)
CHF Signs or Drug Overdose
Symptoms Chest Trauma
Abnormal Pulse Syncope or Near
Hypotension Syncope
Unexplained Systemic Illness
Weakness Metabolic Disease
Screening??
P’s and Q’s of
Electrocardiography
Ventricular
Depolarization
Ventricular
Repolarization
Atrial
Depolarization
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RL/LL- side does not matter, place anywhere below umbilicus
The Electrocardiogram
(ECG/EKG)
Rhythms
ST Segments
1
LAD 95%
1
LAD 95%
1
LAD 95%
1
1
LAD 0%
Post PCI
Basic Principles of ECG
Interpretation
Place electrodes correctly (??)
Be Careful to Get Correct Data
Consider Clinical Context/Setting
Chest pain? … consider ST segments
Compare to Previous ECG
Be Systematic
Rate, Rhythm, ?Pacemaker Spikes
QRS duration, Other intervals
Axis
Q waves
Pattern read
QRS Prolongation
(=>120msec, 3 40 msec boxes)
Ventricular Origin
PVCs
Ventricular Tachycardia
Ventricular Electronic Pacemaker
SVT with Aberrant Conduction
Bundle Branch Block
Right (rabbit ears on the right)
Left (rabbit ears on the left)
WPW
IntraVentricular Conduction Delay
Why is QRS Prolongation so
important except for RBBB???
Q waves not diagnostic
ST Depression not diagnostic
Possibly Ventricular Origin
Usually High Risk
1.000
QR
0.750
Survival
0.500
1 (<110ms): N=38,943 (1.1%)
2 (110-120ms): N=4,787 (2.6%)
0.250
3 (120-130ms): N=481 (4.6%)
4 (>130ms): N=61 (6.6%)
0.000
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0
Follow-up (yrs)
FUpYears
Rabbit Ears
Inverted
Twave
RBBB
LBBB
Rabbit Ears
Inverted
Twave
IVCD
WPW
WPW
RA&LA Left Axis
Extreme
Axis
+I/-AVF
-AVF
-I +I
•RA LA
Right Axis Normal
+AVF
-I/+AVF +I/+AVF Axis
RAD
LAD
S1S2S3
Criteria For Infarction Q
Waves
Equal or Greater than .04 seconds (one
millimeter box horizontal width, 40
milliseconds)
Q Wave Amplitude must be 25% or
greater of following R Wave
Pathophysiology: no muscle to generate
R wave
Basic Principles of ECG
Interpretation
Place electrodes correctly (??)
Be Careful to Get Correct Data
Consider Clinical Context/Setting
Chest pain? … consider ST segments
Compare to Previous ECG
Be Systematic
Rate, Rhythm, ?Pacemaker Spikes
QRS duration, Other intervals
Axis
Q waves
Pattern read
inverted
Qw, P/T
up or
down
Right Left ventricular
ventricular involvement:
involvement: LVH, LBBB
RVH, RBBB
Pattern Reading of the ECG
Diagonal Line Rule
box around aVR (everything inverted)
line thru III, aVL, V1
every thing else upright
Parallel Line Rule
R waves increase then drop off in V6
S waves decrease from greatest in V1
Rabbit ears on right side (V1-2) for RBBB,
on left side for LBBB
The 5 Commandments of ECG
Interpretation
• Be systematic
• Put into the clinical context
• Find an old ECG
• Watch
Watch outout fordata
for bad bad
data
– Strive for good data
• Do NOT be afraid to get help
Watch for bad data!!
RA/LA reversed
V1/V3 reversed
What happened?
Basic Principles of ECG Interpretation
Be Systematic
Rate: Fast-Normal-Slow
Rhythm: Sinus, Blocks, Atrial, Ventricular
Axis: Normal, Right, Left
Intervals and Durations
Intervals and Durations:
Short ? Long ?
Intervals, segments, and durations
Intervals
• PR Interval
• QRS Duration
• QT Interval
PR interval QRS duration QT Interval
Normal: .12-.20 sec Normal (corrected for
Normal: .07-
(3-5 small boxes) rate or QTc): .440-.470
.10 sec
sec
Intervals: Conduction
System Abnormalities
Congenital Syndromes
Electrolyte/Metabolic
Abnormalities
Intrinsic Cardiac Disease
Medications
CNS Disorders
Systemic Illnesses
Electrolyte Abnormalities and
the ECG
Potassium
Hyper: tall, peaked T waves (also
ischemia), atrial arrest
Hypo: prominent U waves, low T wave
Calcium
Hyper: short QT
Hypo: long QT (also Quinidine, ischemia)
Magnesium
Hyper: short QT interval
Hypo: long QT interval
Long QT intervals
(>50% of the RR interval)
• Congenital Ischemia
HypoMg/CA Phenothiazines
anti-arrhythmics Tricyclics
Myocarditis CNS--Subarachnoid
Hemorrhage
Hypokalemia
Torsades des Pointes
The QT interval
Long QT
(>50% of the RR interval)
Congenital Short QT
Hypomagnesium Hypercalcemia
Hypocalcemia
Hypermagnesium
IA anti-arrhythmics
Hyperkalemia
Ischemia
Digoxin
Torsades de Pointes
Phenothiazines Thyrotoxicosis
Tricyclics
Myocarditis
Hypokalemia
Other Patterns
• Atrial Abnormalities
• R>S V1
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SA
Node
Atrial Abnormalities
Right (P-pulmonale)
Right atrium right heart border, first hump
tall, peaked in inferior leads (>2.5mm)
Left (P-mitrale)
Left atrium posterior, second hump
broad P wave (>120msec) with negative
component in V1-2 (> 1mm x 1mm)
Normal=2.5x2.5 boxes (100msec x .25Mv)
P pulmonale or
RAA
P mitrale or LAA
Survival Plot
Computerized LAA with/without P wave prolongation
1.0
0.8
Survival
0.6
Survival
a. LAA (-), P duration <120ms n=33,827 (1.3%)
b. LAA (-), P duration >120ms n=4,476 (2.0%)
0.4
c. LAA (+), P duration <120ms n=1,273 (3.5%)
d. LAA (+), P duration >120ms n=407 (4.7%)
0.2
Years Follow up
0.0
0.0 2.0 4.0 6.0 8.0 10.0
R>S V1
RVH
RBBB
Inferior Posterior MI
WPW
Normal Variant
