INTERPRETATION of ELECTROCARDIOGRAMS

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INTERPRETATION of ELECTROCARDIOGRAMS

• BRIAN D. LE, MD
• Presbyterian Hospital
• CIVA

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Outline

• Approach to interpretation of ECGs
• Cases illustrating approach principles
• Unusual Cases

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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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INTERVALS PR lt 200 ms QRS lt 120 ms QTc Men lt 440
ms, Women lt 460 ms
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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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• Left Ventricular Hypertrophy
• Cornell R (aVL)Sw(V3)gt24mm (male) gt20mm
  (female)
• Sokolow S(V1) R(V5)32mm
• Rw (aVL)gt11mm
• Rw (I)gt14mm

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• Right Ventricular Hypertrophy
• 1. RADgt100
• 2. IRBBB
• 3. RgtS V1
• 4. RltS V6
• 5. R in V1gt7mm
• 6. R V1 S V5 or V6 gt10mm
• 7. RAE
• 8. strain pattern in rt precordial leads

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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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ANATOMICAL LOCALIZATION ANTERIOR V1-V4, SEPTAL
V1-V2 LATERAL V5-V6, I, Avl INFERIOR II, III,
aVF
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Seven Step Approach

• Rate
• Rhythm
• Axis
• Intervals
• Hypertrophy
• ST/Tw changes, Q waves
• Conduction system

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• LBBB
• QRS gt 0.12 sec
• wide monophasic R in I, V5 and V6
• (usually notched or slurred)
• no Q in I, V5 and V6
• Left Anterior Fascicular Block
• LAD gt -30', I, aVR, -II/III/aVF
• qR in I and L
• rS in II, III and aVF
• Left Posterior Fascicular Block
• RAD gt 100'
• small R in I and aVL, Q in II, III, aVF
• S1 Q3 pattern
• RBBB
• QRSgt0.12 sec
• R' gt r in right precordium
• wide S in I, V5 and V6

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Normal Variants- Juvenile Tw inversions
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Nuts and Bolts
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Electrode Misplacement
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Amplitude Artifact
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Parkinsons Tremor
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CASES
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Case 1 21 yo presents for routine
physical exam
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DEXTROCARDIA
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Case 2 38 yo with one week of URI presents
with chest pain
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Acute Pericarditis

• Stage I--ST elevation, Tw upright,
• PR depression
• Stage II--ST baseline, flattened Tw
• Stage III--inv Tw
• Stage IV--Tw baseline, days to wks

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Case 3 48 yo homeless man found unresponsive
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Hypothermia
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Case 4 34 yo ESRD missed three days of
dialysis
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Hyperkalemia
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Case 5 28 yo woman s/p neck surgery
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Hypocalcemia
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Case 6 32 yo female on antidepressants had
syncope
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Acquired Long QT Syndrome
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Case 7 60 yo man with chest pain
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Inferior MI with RV infarction and 21 and
complete heart block
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21 Heart block with ventriculophasic effect
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Case 8 80 yo man with syncope
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Aflutter with complete heart block
Aflutter with complete heart block
Aflutter with normal conduction
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Aflutter with 11 conduction
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Aflutter with carotid sinus massage
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Counter-clockwise Aflutter
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Clockwise Aflutter
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Case 9 50 yo man with DCM
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Biventricular pacing
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Case 10 25 yo man with palpitations
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Pre-excited Atrial Fibrillation- right sided
postero-septal pathway
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Wolf-Parkinson-White Left anterolateral pathway
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Postero-septal pathway pre-ablation
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Post-ablation with repolarization abn due to
memory effect
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Case 11 25 yo female with lightheadedness
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AV Node Re-entrant Tachycardia(AVNRT)
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Case 12 75 yo man with ischemic DCM and
syncope
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Ventricular Tachycardia

• BRUGADA'S CRITERIA- Circulation '91
• 1. Absence of all RS complex in all precordial
  leads S 21, SP 100
• 2. R to S interval gt 100ms in one precordial lead
  S 65, SP 98
• 3 A-V Dissociation, fusion, capture beats S 82,
  SP 98
• 4. Morphologic criteria in V12, 6

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Ventricular Tachycardia
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Ventricular Tachycardia AV dissociation, RS
gt100ms
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Case 13 18 yo Asian man with family history of
SCD presents with syncope
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Brugada Syndrome

• Genetic mutation in SCNA5
• Predominantly in Asian males
• Syncope and sudden cardiac death
• Three types

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Brugadas Type II- Saddle back
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Case 14 28 yo man with syncope
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Arrythmogenic Right Ventricular Dysplasia (ARVD)
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Case 15 28 yo man with syncope
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Short-coupled Torsades
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Case 16 34 yo woman with fatigue, weight gain,
and abn menstrual period
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Myxedema
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Case 17 84 yo man with skipped beats
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Sino-atrial exit block Type I
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Case 18 64 yo woman presents for routine exam
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Retrograde concealed conduction into the AV node