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16/12/2008 ECG samples 10 /Ghazi �
Principles of ECG Diagnosis 10
Reading the ECG
Dr Ghazi Ahmad RadaidehMD,FRCP
Rashid HospitalDubai - UAE
16/12/2008 ECG samples 10 /Ghazi �
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
16/12/2008 ECG samples 10 /Ghazi �
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
16/12/2008 ECG samples 10 /Ghazi �
Examples how to Interpret the ECG
16/12/2008 ECG samples 10 /Ghazi �
2. A 50 year old patient presented with chest pain for 2 h
16/12/2008 ECG samples 10 /Ghazi �
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
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the rhythm? Sinus Rhythm FOR ATRIA
No relation between P and R
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(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
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the QRS axis? Normal axis (+ in I, + in II)
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(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 ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is there evidence of atrial enlargement? No (no peaked, notched or negatively
deflected P waves)
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is there evidence of ventricular hypertrophy? No (no tall R waves in V1/V2 or V5/V6)
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Are there abnormal Q waves? ? ?
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Is the ST elevation or depression?
Yes! Elevation in II, III and AVF and
ST depression in I and AVL
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Are there T wave changes?
Part of reciprocal changes in I, AVL
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(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
16/12/2008 ECG samples 10 /Ghazi ��
3. A 30 year old patient with longstanding HT attended your clinic for routine assessment
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the rate? Approx. 85 (300 /3.5)
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the rhythm? Sinus Rhythm , Regular
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the QRS axis? Normal axis (+ in I, and II)
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What are the PR, QRS and QT intervals? PR = 0.16 , QRS = 0.11 s, QTc = 0.42 s
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is there evidence of atrial enlargement?
In lead II ? Peaked P wave
In lead V1 biphasic P with ? negative phase > positive
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(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
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Are there abnormal Q waves? No
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Is the ST elevation or depression?
No ST elevation
St Depression is part of Strain pattern
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Are there T wave changes?
T waves changes is part of Strain pattern
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)ECG analysis: Normal sinus Rhythm at 85bpm with evidence of LVH
16/12/2008 ECG samples 10 /Ghazi ��
9. 29 Year old man with Palpitation
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the rate? Approx. 200bpm
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the rhythm? Not sinus. P wave not seen
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is it Regular? Regular
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the QRS axis? Normal
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What are the PR, QRS and QT intervals?
QRS = 0.08s (Narrow complex), QTc = 0.36s
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is there evidence of atrial enlargement? No
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is there evidence of ventricular hypertrophy? No (no tall R waves in V1/V2 or V5/V6)
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Are there abnormal Q waves? ST elevation or depression?T waves inversion?
No
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)ECG analysis: Tachycardia at 200bpm, narrow QRS complex, regular and no P wave seen SVT- AVNRT
16/12/2008 ECG samples 10 /Ghazi ��
10. 60 Years old lady with dizziness and 2 episodes of syncope
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the rate? Approx. 35 bpm
16/12/2008 ECG samples 10 /Ghazi �
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the rhythm? Sinus Rhythm
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is it Regular? Regular for both P-P and R-R
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What is the QRS axis? Normal
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)What are the PR, QRS and QT intervals?
PR = 0.18., QRS 0.10s, QTc = normal
Every second P not followed by R
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is there evidence of atrial enlargement? No (no peaked, notched or negatively
deflected P waves)
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Is there evidence of ventricular hypertrophy?
No (no tall R waves in V1/V2 or V5/V6)
Frequent Abnormal beats
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(RAWIHI)Infarct: Are there abnormal Q waves? ST elevation or depression? T wave changes?
No
16/12/2008 ECG samples 10 /Ghazi ��
Rate Rhythm Axis Waves Intervals Hypertrophy Infarct
(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
16/12/2008 ECG samples 10 /Ghazi ��
Difficult ECG
16/12/2008 ECG samples 10 /Ghazi �
What is the Diagnosis?
• Acute inferior MI, PVB and Mobitz I
16/12/2008 ECG samples 10 /Ghazi �
What is the diagnosis and what is the QRS axis?
AF with Right axis
16/12/2008 ECG samples 10 /Ghazi ��
50 years old man with chest pain. This is the ECG with Right sided chest leads
Acute inferior , posterior and RV infarction
16/12/2008 ECG samples 10 /Ghazi ��
Antidromic AVRT
What is the Diagnosis?
16/12/2008 ECG samples 10 /Ghazi ��