Introduction to
ECG
And clinical
correlation
For Medical PGs/HOs/Final
years
Dr A – Bari
FCPS resident
Introduction – Wiring diagram of
Heart
Introduction – ECG paper & basic
waves
Introduction – tracing ECG waves
on real ECG paper
12/25/2024
Introduction – square
measurements
2
3
5
ECG segments & intervals
12/25/2024
ECG intervals
Calculation of heart rate on ECG
HR = ____ 300_________
Number of large squares b/w 2 R waves
HR = ____ 1500_________
Number of small squares b/w 2 R waves
Calculate heart rate??
Normal ECG appearance
Deflections on ECG
Positive deflection
R>S
Negative deflection
S>R
Shape of QRS complex in chest
leads
Septum is depolarized first, from left to right
Shape of QRS complex in chest
leads
Depolarization of ventricles. Left right
Shape of QRS complex in chest
leads
Ventricles completely depolarized.
Normal QRS in chest leads
Transition point Movement of TP
• Where R and S waves are equal • If TP has moved to V4/5 or V5/6
• Clock wise rotation
Cardiac axis
-900
-150
1800 00
600
+ 120
+900
Cardiac axis
-900
-150
1800 00
600
+ 120
+900
Cardiac axis
RIGHT AXIS DEVIATION
RIGHT AXIS DEVIATION
LEFT AXIS DEVIATION
P wave abnormalities
BIFID P WAVE
P wave > 3mm or 0.12s
Left atrial hypertrophy
P wave abnormalities
P PULMONALE
P wave > 2.5 mm
Right atrial hypertrophy
P wave abnormalities
DEPRESSED PTa SEGMENT
Segment between P wave & Q wa
•Acute pericarditis
•Atrial infarction
QRS abnormalities
NORMAL QRS COMPLEX
•Duration no greater than 120 [Link] (3 small squares)
•S wave is greater than R wave in lead V1
•R wave is greater than S wave in lead V5
•Q wave no deep than 2 mm and no wide than 1mm
QRS abnormalities – Right
ventricular hypertrophy
1. R > S wave in lead V1 ( R wave > 7mm in lead v1)
2. Deep S wave in lead V5 or 6 ( S wave > 7mm deep)
3. Right axis deviation
4. Peaked p wave
5. Inverted t wave in lead V1 - 3
Introduction
Introduction
R > 7mm in lead V1
Deep S wave > 7mm in lead V 5
Right axis deviation
Inverted T waves in lead V1 , 2, 3
QRS abnormalities – left
ventricular hypertrophy
Tall R wave > 25 mm in lead V5 or 6
Sum of R wave in lead V 5 + S wave in lead V 1 or
2 = > 35mm
Deep S wave in lead V1 or 2
Inverted T waves in lead I, V5 – 6, or
sometimes lead V 4
Left axis deviation
Introduction
Introduction
Tall R wave > 25 mm in lead V5 or
6
Sum of R wave in lead V 5 + S wave in
lead V 1 or 2 = > 35mm
Deep S wave in lead V1 or 2
Inverted T waves in lead I, V5 – 6,
or sometimes lead V 4
Left axis deviation
QRS abnormalities – pulmonary
embolism
Sinus tachycardia
Peaked P wave
Right axis deviation
Tall R wave in V1
Inverted T wave in T 3 & V 1
Shift of transition point to left – V5
– V6
Q wave in lead III resembling inferior wall
MI
Introduction
Introduction
Myocardia
l ischemia
ST segment
ST segment elevation or depression
>2mm depression or elevation – ischemia, MI, (chest
leads)
> 1 mm depression or elevation – ischemia , MI,
ST segment depression
1. Horizontal depression
– with upright T wave is
sign of ischemia
2. Up slopping
depression - ischemia
3. Down slopping –
digoxin side effects
12/25/2024
STEMI
ECG criteria for diagnosis of STEMI
New ST elevation
>2mm in chest or > 1mm in limb leads ( 2 contiguous
leads)
New onset of LBBB
Shapes of ST elevation
1. ST segment elevation caused by ischemia produces
straight, horizontal, upsloping, or convex ST
segment.
2. Concave ST segment are much less likely caused by
ischemia
Findings of acute MI on ECG
Reciprocal changes– sign of
distant ischemia
Patients with new Q wave
and ST elevation may have ST
segment depression in other
territories
These additional ST changes
implies ischemia in territory
other than infarction, termed as
ischemia at distance or
reciprocal changes
For example ST segment
depression in anterior leads
may be seen in setting of acute
inferior STEMI
Wallens pattern– sign ofischemia
Deep coronary T wave inversion in
multiple pre-cordial leads V1 – V4
This finding is associated with high grade
stenosis in Proximal LAD coronary arterial
system
T wave inversion may be preceded by ST
segment elevation that might resolve by the
time patient arrives hospital
This pattern of T wave inversion in setting
of unstable angina correlates with segmental
hypokinesia of anterior wall and suggest
myocardial stunning syndrome
De winter’s sign
• When hyperacute T waves
persist for hours
accompanied by ST segment
depression (1 – 3 mm in
leads V1-6)with upsloping
ST segments is termed as De
Winter sign.
• It is a sign of proximal LAD
occlusion
12/25/2024
Poor R wave progression – sign of
ischemia
1. Normal R wave progression implies that R wave amplitude increase gradually
from V1-V5 and then diminish in V6.
2. Abnormal R wave progression implies that gradual increase from V1-V5 is absent.
It may be broken.
12/25/2024
Site of MI
Site of MI Leads ECG findings
Anterior wall MI V2 – V4 ST elevation
(reciprocal
depression)
Inferior wall MI II, III, avF, ST elevation
Reciprocal
depression
Lateral wall MI I, avL, V5. V6 ST elevation
Posterior wall MI V1 – V2 Reciprocal
depression only
V8,9 ST elevation >
2mm
12/25/2024
12/25/2024
12/25/2024
Detailed localization of occluded coronary artery
12/25/2024
ECG findings MI pattern Artery blocked
ST ↑ in lead V1 – V6, I, aVL, Anterior Proximal LAD (proximal
Fasicular or bundle branch block to first septal)
ST ↑ in lead V1 – V6, I, aVL, Anterior Mid LAD (proximal to
large diagonal but distal
to septal)
ST ↑ in lead V1 – V4, or I, aVL, V5,V6 Anterolateral Distal LAD or diagonal
ST segment ↑in I, aVL High Lateral Diagonal or proximal LCx
ST segment ↑in I, aVL, V5-V6 Lateral LCx
Reciprocal changes in V1
12/25/2024
1. ST segment ↑ V1 – V2 Septal Septal branches - LAD
1. ST segment ↑ in lead III exceeds lead II Inferior wall MI Proximal to mid RCA
accompanied by ST ↑ in lead V1 (or right sided
leads)
1. ST segment ↑ in lead II exceeds or equals to that Inferolateral wall MI Distal dominant RCA
of lead III accompanied by ST ↓ in lead V1-V3 or LCX
ST ↑ in lead I, aVL
1. ST↑ in right sided leads (V1) RV infarction Proximal RCA
2. V4R – V6R ST ↑
3. QS/QR pattern in lead V3R/V4R (less accurate)
1. ST segment ↑ in lead aVR and V1 (especially with Left main disease
ST ↓ in other leads) Multiple coronary arteries
1. ST ↓ in V1 – V4 Posterior RCA
2. Tall R wave (R/S ratio > in lead V1-V2
3. ST ↑ in lead V7-9
12/25/2024
Causes of T wave inversion
1. Normal
2. Ischemia
3. Ventricular hypertrophy
4. Bundle branch block
5. Digoxin
6. Pulmonary embolism
Conduction defects – Heart blocks
First degree heart block
PR prolongation
Conduction defects – Heart blocks
First degree heart block
PR prolongation
Conduction defects – Heart blocks
Second degree heart block – MOBITZ TYPE
1
When some excitation fail to pass thru
AV node or bundle of his
Conduction defects – Heart blocks
Conduction defects – Heart blocks
MOBITZ TYPE 2
Constant PR interval
Occasional P wave is not followed by QRS
Conduction defects – Heart blocks
MOBITZ TYPE 2
Constant PR interval
Occasional P wave is not followed by QRS
Conduction defects – Heart blocks
Third degree or complete heart
block
•No beat is conducted to ventricles
•Escape mechanism generate pace
maker below atria
Conduction defects – Heart blocks
12/25/2024
ECG criteria for RBBB
• QRS duration > 120 [Link]
• V1/2 – M pattern or rSR pattern
• V5/6 or I, aVL – deep, broad S
wave, duration of S wave > R wave
duration or S wave duration > 40
msec
• ST/T changes
12/25/2024
Conduction defects – RBBB
1. No conduction occur in Right bundle branch
2. Septum is depolarized as usual from left to right (step1)
3. Then depolarization spread to left ventricles causing S wave
in lead V1 and R wave in lead v 6 (step 2)
Conduction defects – RBBB
• It takes longer time for
excitation to reach right
ventricle because of failure
of normal pathways
therefore right ventricle
depolarizes after left causing
another R wave in lead V1
12/25/2024
Conduction defects – RBBB
ECG criteria for LBBB
• QRS duration > 120
[Link]
• V1/2 – deep and broad
S wave. Notched S
wave. Appear W
pattern
• V5/6 or I, aVL –
broad, clumsy,
completely positive,
often notched R waves
• ST/T changes in V5/6
12/25/2024
LBBB
12/25/2024
Causes of LBBB
12/25/2024
12/25/2024
Conduction defects –LBBB
1. No conduction occur in left bundle branch
2. Septum is depolarized from right to left
3. Rt ventricle depolarize before left
Conduction defects –LBBB
Bradyrythm
Atrial escape & rhythm
Nodal escape & rhythm
Ventricular escape &
rhythm
12/25/2024
Atrial escape
12/25/2024
Atrial escape
12/25/2024
Nodal escape
12/25/2024
Nodal escape
12/25/2024
Nodal Rhythm
12/25/2024
Ventricular
escape
12/25/2024
Ventricular
escape
12/25/2024
Ventricular
rhythm
12/25/2024
Rapid ventricular rhythm
Extr-asystoles – Premature beats
Atrial extrasystole
Nodal extrasystole
Ventricular
extrasystole
12/25/2024
Atrial premature
beat
12/25/2024
Atrial premature
beat
12/25/2024
Junctional
premature beats
12/25/2024
Junctional
premature beats
12/25/2024
Ventricular
premature beat
12/25/2024
Tachy arrhythmias
Atrial tachycardia
Nodal tachycardia
Ventricular tachycardia
12/25/2024
Atrial tachycardia
Nodal tachycardia
Ventricular tachycardia
12/25/2024
Torsades de pointes
VF
Atrial fibrillation
Atrial fibrillation
Introduction
Atrial fibrillation
Atrial flutter
QT interval
12/25/2024
Thanks Thanks
