ECG10

16/12/2008 ECG samples 10 /Ghazi �

Principles of ECG Diagnosis 10

Reading the ECG

Dr Ghazi Ahmad RadaidehMD,FRCP

Rashid HospitalDubai - UAE


Steps Used in Reading 12-Lead ECGs (RAWIHI)

1.Measure the Rate, Rhythm and Regularity 2. Determine the QRS Axis

3. Evaluate the Waves (P,QRS,T ) and Intervals (PR,ST,QT)

4. Evaluate for chamber Hypertrophy5. Look for myocardial Infarction and Ischemia

6. Interpret the ECG


Tachyarhythmias

Narrow complex Wide complex

Regular Irregular Regular Irregular

•ST

•AT

•SVT

•AFL

•AF

•MAT

•AFL /AT with

variable AV

conduction

•VT

•SVT With aberrant

conduction

AF with

accessory

pathway


Examples how to Interpret the ECG


2. A 50 year old patient presented with chest pain for 2 h


Rate Rhythm Axis Waves Intervals Hypertrophy Infarct

(RAWIHI)What is the rate? Approx. 48 bpm for R (300/6.5 (6.5 big

boxes between RR) and 100bpm for P



(RAWIHI)What is the rhythm? Sinus Rhythm FOR ATRIA

No relation between P and R



(RAWIHI)Is it Regular? Yes for P –P, Yes for R -R

No relation between P and R

16/12/2008 ECG samples 10 /Ghazi


(RAWIHI)What is the QRS axis? Normal axis (+ in I, + in II)



(RAWIHI)What are the PR, QRS and QT intervals? PR = ??, QRS = 0.08 s, QTc = 0.42 s

16/12/2008 ECG samples 10 /Ghazi ��


(RAWIHI)Is there evidence of atrial enlargement? No (no peaked, notched or negatively

deflected P waves)



(RAWIHI)Is there evidence of ventricular hypertrophy? No (no tall R waves in V1/V2 or V5/V6)



(RAWIHI)Infarct: Are there abnormal Q waves? ? ?



(RAWIHI)Infarct: Is the ST elevation or depression?

Yes! Elevation in II, III and AVF and

ST depression in I and AVL



(RAWIHI)Infarct: Are there T wave changes?

Part of reciprocal changes in I, AVL



(RAWIHI)ECG analysis: CHB with narrow QRS ( INTRANODAL), at 48 bpm, normal axis deviation, and evidence of ST elevation infarction in the inferior Leads.

Acute Inferior MI with CHB


3. A 30 year old patient with longstanding HT attended your clinic for routine assessment



(RAWIHI)What is the rate? Approx. 85 (300 /3.5)



(RAWIHI)What is the rhythm? Sinus Rhythm , Regular



(RAWIHI)What is the QRS axis? Normal axis (+ in I, and II)



(RAWIHI)What are the PR, QRS and QT intervals? PR = 0.16 , QRS = 0.11 s, QTc = 0.42 s



(RAWIHI)Is there evidence of atrial enlargement?

In lead II ? Peaked P wave

In lead V1 biphasic P with ? negative phase > positive



(RAWIHI)Is there evidence of ventricular hypertrophy?

Yes: ( tall R waves in V5/V6, I , AVL and Deep S in V1-V2.

SV2 + RV5= 55 mm & Strain Pattern V3-V6



(RAWIHI)Infarct: Are there abnormal Q waves? No



(RAWIHI)Infarct: Is the ST elevation or depression?

No ST elevation

St Depression is part of Strain pattern



(RAWIHI)Infarct: Are there T wave changes?

T waves changes is part of Strain pattern



(RAWIHI)ECG analysis: Normal sinus Rhythm at 85bpm with evidence of LVH


9. 29 Year old man with Palpitation



(RAWIHI)What is the rate? Approx. 200bpm



(RAWIHI)What is the rhythm? Not sinus. P wave not seen



(RAWIHI)Is it Regular? Regular



(RAWIHI)What is the QRS axis? Normal



(RAWIHI)What are the PR, QRS and QT intervals?

QRS = 0.08s (Narrow complex), QTc = 0.36s



(RAWIHI)Is there evidence of atrial enlargement? No



(RAWIHI)Is there evidence of ventricular hypertrophy? No (no tall R waves in V1/V2 or V5/V6)



(RAWIHI)Infarct: Are there abnormal Q waves? ST elevation or depression?T waves inversion?

No



(RAWIHI)ECG analysis: Tachycardia at 200bpm, narrow QRS complex, regular and no P wave seen SVT- AVNRT


10. 60 Years old lady with dizziness and 2 episodes of syncope



(RAWIHI)What is the rate? Approx. 35 bpm



(RAWIHI)What is the rhythm? Sinus Rhythm



(RAWIHI)Is it Regular? Regular for both P-P and R-R



(RAWIHI)What is the QRS axis? Normal



(RAWIHI)What are the PR, QRS and QT intervals?

PR = 0.18., QRS 0.10s, QTc = normal

Every second P not followed by R



(RAWIHI)Is there evidence of atrial enlargement? No (no peaked, notched or negatively

deflected P waves)



(RAWIHI)Is there evidence of ventricular hypertrophy?

No (no tall R waves in V1/V2 or V5/V6)

Frequent Abnormal beats



(RAWIHI)Infarct: Are there abnormal Q waves? ST elevation or depression? T wave changes?

No



(RAWIHI)ECG analysis: Sinus Rhythm at 35bpm,Regular, PR constant, Every second P not followed by R, Narrow QRS

Second degree AV block Mobitz II


Difficult ECG


What is the Diagnosis?

• Acute inferior MI, PVB and Mobitz I


What is the diagnosis and what is the QRS axis?

AF with Right axis


50 years old man with chest pain. This is the ECG with Right sided chest leads

Acute inferior , posterior and RV infarction


Antidromic AVRT

What is the Diagnosis?


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