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Electrocardiogram Interpretation: A Brief Overview
Wissam Alajaji, MD
•Objectives:1. Basic principles for ECG interpretation2. Normal ECG3. Abnormal ECG examples
Know that This presentation will not cover “ECG dilemmas”Should you code Q wave in V1, V2 or only when it involves all V1, V2, V3.”A: only when V3 is involved“in LBBB should you code acute MI?”A: No
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
13 slides
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Basic principles for ECG interpretation• Before you look at the ECG:• Indication
- Muscle thickness, QT, arrhythmia- Chamber size and its complications- ischemia and its complications- electrolytes, drug toxicity
- 20 YO man with syncope- 50 YO man with acute chest pain- 65 YO woman with HTN and chronic SOB- 70 YO man with ESRD medications include digoxin, coming with altered level of consciousness
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Basic principles for ECG interpretation
• Screen the ECG for quality:• Verify patients name, MRN, and date• Make sure that voltage is 10 mm/mv and calibrated• Screen for quality, correct lead placement, noise
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Na, TCA
Ca Disturbance, DigoxinK Disturbance
Nothing is Random in
Life
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Basic principles for ECG interpretation• Know how to calculate the HR, PR, QRS, and QT• Know what is a normal sinus morphology and identify abnormal• Know what is normal axis, normal voltage, normal vs pathologic Q,
juvenile patterns, normal variants
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Nomenclature
Waves -P wave -T wave -U wave
Complex -QRS
Segments -PR segment -ST segment
Intervals -PR interval -QT interval
Point -J point
1 “little box” = 0.04 seconds (or 40 msec)
1 “big box” = 0.2 seconds (or 200 msec)• 5 “little boxes” = 1 “big box”• 5 “big boxes” = 1 second
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
• Step 1:• Locate RR interval: HR
• Step 2:• Rhythm & its origin
• Can be difficult and complex• Most common mistake made by
computer interpretation
For Boards
• Expected not to miss a serious/deadly finding/diagnosis• ST elevation• Hyperkalemia• Drug toxicity• Major pathology: heart block, arrhythmia, HCM……………………..
Usually, your indication is your guide
• Do not worry about controversial or minor findings
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
ECG Coding Sheet:
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Unexpectedly "normal"
Inverted lead I in absence of Dextrocardia
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Abnormally, normal avR
Rhythm
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
• So Far:
• You learned to ask about/present the indication before interpretation
• Scan for quality and lead placement
• Know the various electrical waves/intervals and what is normal ECG
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Chamber Abnormality
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
24 year old man with syncope
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
45 year old man with HTN
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
LVH Criteria:
• The Cornell criteria:• R wave in aVL + S wave in V3 > 28 mm in males and > 20 mm in females of the
voltage criteria. • Therefore, the best policy is know most or all of the
• Sokolow:• S in V1 or 2+ R in V5 or V6 > 35 mV• R avL > 11 mV
• ST and/or T wave abnormalities, “strain” pattern
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:07 Sinus rhythm37 Right axis deviation (> +100 msec)41 Right ventricular hypertrophy43 RBBB, complete67 ST and/or T wave abnormalities secondary to hypertrophy
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Chest pain/SOB
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:10 Sinus tachycardia43 RBBB, complete46 Left posterior fascicular block53 Anterior or anteroseptal Q wave MI (age recent or acute)57 Inferior Q wave MI (age recent or acute)65 ST and/or T wave abnormalities suggesting myocardial injury
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q1• Significant ST segment elevation consistent with myocardial injury or
infarction is defined by:• ≥ 1 mm STE in leads V1, V2, or V3• ≥ 2 mm STE in leads V1, V2, or V3• ≥ 2 in other leads• ≥ 1 in other leads
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q1• Significant ST segment elevation consistent with myocardial injury or
infarction is defined by:• ≥ 1 mm STE in leads V1, V2, or V3• ≥ 2 mm STE in leads V1, V2, or V3• ≥ 2 in other leads• ≥ 1 in other leads
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q2• Repolarization abnormality that suggest Acute or recent Myocardial
infarction include:• Peaked T waves followed by T wave inversion• ST elevation followed by peaked T waves• Deeply inverted T waves• Dominant R wave and ST depression in V1-V3
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q2• Repolarization abnormality that suggest Acute or recent Myocardial
infarction include:• Peaked T waves followed by T wave inversion• ST elevation followed by peaked T waves• Deeply inverted T waves• Dominant R wave and ST depression in V1-V3
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q3• Which parameter obtained on initial ECG independently predict 30 day all-cause
mortality in acute myocardial infarction:• Sinus tachycardia• Sum of absolute ST segment deviation elevation and or depression • QRS duration > 100 msec• Rightward axis deviation
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q3• Which parameter obtained on initial ECG independently predict 30 day all-cause
mortality in acute myocardial infarction:• Sinus tachycardia• Sum of absolute ST segment deviation elevation and or depression • QRS duration > 100 msec• Rightward axis deviation
Hathaway WR, et al. JAMA 1996, 273: 387-391.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:06 Left atrial abnormality/enlargement10 Sinus tachycardia36 Left axis deviation (> –30o)47 LBBB, complete
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q1• A QRS duration ≥ seconds is necessary for the diagnosis of complete
LBBB:• 0.10• 0.11• 0.12• 0.13
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q1• A QRS duration ≥ seconds is necessary for the diagnosis of complete
LBBB:• 0.10• 0.11• 0.12• 0.13
When LBBB morphology is present and the QRS duration measures > 0.10 seconds but < 0.12 seconds, incomplete LBBB should be coded.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q2• LBBB is commonly seen in normal hearts:
• True• False
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Q2• LBBB is commonly seen in normal hearts:
• True• False
Never normal findingLBBB often occurs in various forms of organic heart disease, including ischemic and non-ischemic cardiomyopathy, valvular heart disease, LVH, and congenital heart disease. It is rarely seen in normal heartsShould not call it STEMIShould not call LVH: 80% patients with LBBB have abnormally increased LV mass
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Bradycardia:
• A very big book in ECG
• Just on fun example
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:07 Sinus rhythm13 Atrial premature complexes
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Tachycardia:
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Codes:Sinus tachycardiaParoxysmal SVT
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Killer
24 year old man with stressful life
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
Electrolyte/Drug toxicity:
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
65 year old man ESRD on dialysis presented with acute confusion Peaked T waves
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.
17 year old female found by her room mate unconscious
Wissam Alajaji, Electrocardiogram Interpretation: A Brief Overview, July-21, 2015.