Abnormal ECG
Introduction
• ECG stands for electrocardiogram.
• P waves represent depolarisation of the atria.
• QRS complexes represent depolarisation of
ventricles.
• T waves represent repolarisation of ventricles.
• There is no wave for repolarisation of atria
because this process is masked by depolarisation
of ventricles.
Conduction Abnormalities
• The pattern of conduction:
• SA node ≫ AV node ≫ His Bundle ≫ bundle branches
• Conduction abnormalities, look at whichever lead shows p waves most
clearly, usually lead II or V1.
• The PR interval time taken for depolarisation to spread from SA node
to ventricular muscle, should not be greater than 0.2s – i.e. 1 big
square.
First degree Heart block
• If PR interval is greater than 0.2s, then we call it first degree AV node
block.
• All waves will still be present, however a larger gap (pause) between p
wave and QRS complex.
• It can be a sign of coronary artery disease, acute rheumatic carditis,
digoxin toxicity or electrolyte disturbance, but does not usually require
treatment.
Second degree Heart block
• An intermittent absence of QRS complexes – and thus an indication
that there is a blockage somewhere between AV node and ventricles.
• There are two types:
• Mobitz type 1 phenomenon –
• Mobitz type 2 phenomenon –
• Wenckebach phenomenon ( Mobitz type 1) – progressive
lengthening of PR interval followed by an absence of QRS,
Mobitz type 2 phenomenon – there is a regular rhythm, and a constant
PR interval, but every P is not followed by QRS , basically for every
QRS, there are 2 or 3 P waves.
Causes:-
• Acute – MI
• Chronic – heart disease (CHD)
Management- block may require a pacemaker (temporary or
permanent), especially if ventricular rate is slow.
Third degree Heart block – complete heart block
• This occurs when atrial contraction is normal, but no beats are
conducted to ventricles.
• Ventricles are still excited by their own internal ‘ectopic pacemaker’
system.
Definition of complete heart block is:
1. P wave ~90/min (more p waves than QRS complexes) QRS ~36/min
2. Variable PR intervals
3. No relationship between P wave and QRS complexes, but both are
present.
4. Abnormally shaped QRS due to abnormal spread of conduction
throughout ventricles
5. Escape rhythms present (more on these later)
Causes:-
1. MI – it will occur acutely, and is often transient.
2. Chronic – often due to fibrosis around Bundle of His, or bundle
branch block of both branches.
3. Always indicates underlying disease – more often fibrosis then
ischaemia.
4. Patients with AV block can be haemodynamically stable; however
they should require an urgent pacemaker because this situation can
change at any time
5. If number of atrial and ventricular complexes is equal then we call it
AV dissociation, and not AV block.
Bundle Branch Block:-
• Depolarisation to spread throughout ventricles is altered because of
block, thus duration of QRS is lengthened. So, in bundle branch block
there is:
• Normal PR interval
• Lengthened QRS duration (greater than 120ms – >3 little squares)
• QRS complexes are often distinctive shapes.
Right BBB (RBBB):
This creates a distinctive pattern on ECG:
• V1 – creates an ‘M’ shaped QRS –
• This is also known as an ‘RSR’ pattern – there is an up (‘R’) then a
down (‘S’), then another up (‘R’)
• V6 – creates a ‘W’ shaped QRS –
• MarroW – because V1 can look like an “M”, and V6 makes a “W”
Right BBB (RBBB):
Left Bundle Branch Block (LBBB)
• QRS sign, exact opposite of that in RBBB, so sign is opposite.
• Can use word WillaM to try and remember this one!
• RBBB – you may only see ‘M’ in lead V1
• LBBB – you may only see ‘M’ in lead V6
• Causes-
• Ischaemic disease – LBBB is likely to indicated MI
• Aortic stenosis
Left BBB (LBBB):
Rhythm Abnormalities:
• Rhythms can originate in 3 places in heart – SA node, AV node (known as
nodal, or junctional rhythm), or ventricular muscle
• Sinus Rhythm-This means that rhythm of heart is being controlled by SA
node – i.e. this is ‘normal’ rhythm of heart.
• It is possible have a sinus tachycardia, sinus bradycardia, and also sinus
arrhythmias.
• There is one P wave per QRS
• There is a constant PR interval.
Sinus arrhythmia
1]Sinus tachycardia
• Associated with; exercise, fear, pain, haemorrhage, thyrotoxicosis
2] Sinus bradycardia
• Associated with; athletic training, hypothermia, myxoedema, seen
immediately after MI
Atrial escape
• This is a supraventricular rhythm. It occurs when normal
depolarisation of SA node has not occurred, and some part of atrium
starts depolarisation instead.
• An abnormal p wave – because excitation has begun somewhere away
from the SA node
• Normal QRS
Ventricular escape
• A condition where ventricles of heart take over pacing of the heartbeat
when natural pacemaker (sinoatrial node) fails to generate an electrical
impulse.
• This results in a slow heart rate (20-40 bpm) with wide QRS
complexes on an electrocardiogram (ECG)
• Ventricular escape beats act as a safety mechanism, preventing cardiac
arrest when the normal heart rhythm fails.
• Caused by various factors, including heart attacks, electrolyte
imbalances, and medications.
Extrasystoles
• Extrasystoles are premature heartbeats that occur earlier than normal heartbeat.
• Cause: caused by abnormal electrical impulses in heart that trigger a premature
contraction of heart muscle.
• Types: two main types :
• Atrial extrasystoles - originate in upper chambers (atria) of the heart.
• Ventricular extrasystoles - originate in lower chambers (ventricles) of the heart.
Supraventricular Tachycardia
• Atrial tachycardia >150bpm , P waves superimposed on t wave.
• QRS complexes are same shape as normal.
• The AV node cannot conduct faster than 200bpm. if rate of atrial
depolarisation is faster , then atrioventricular block occurs, some p
waves, not followed by QRS complexes.
• Differentiating from 2nd degree heart block , the rhythm is roughly
sinus rhythm
• In atrial tachycardia, the rhythm is fast
Atrial flutter
• Rate >250bpm
• No flat lines between P waves (‘saw tooth p waves’)
• Often associated block –
• P waves may be difficult to differentiate from T waves –
Fibrillation
• This occurs when individual muscle fibres contract of their own
accord.
• No p waves – just an irregular baseline
• Normal shape QRS – because conduction through the AV node is
normal
• Normal T waves
Ventricular fibrillation
• No discernable pattern – no QRS, no P, no T
• Patient is very likely to lose consciousness – thus the diagnosis is easy!
• Not compatible with life for any sustainable period of time – patient
needs urgent defibrillation!
Wolff-Parkinson-White Syndrome (WPW syndrome)
• In normal heart only route from atria to ventricles is through AV
bundle.
• In some individuals there exists an accessory pathway through which
conduction is able to travel, and is not delayed by AV node, and thus
there is pre-excitation of ventricles.
• A congenital heart condition that causes heart to beat abnormally fast
due to an extra electrical pathway.
