Simon

Simon
Abou
Abou
Jaoud
Jaoud

Cardiology Department Cardiology Department

Htel Htel- -Dieu Dieu
ECG reading: the
common and dangerous
ECG reading: the
ECG reading: the
common and dangerous
common and dangerous
Review essential technical aspects of ECG recording Review essential technical aspects of ECG recording
Content and Objectives
Content and Objectives
Distinguish between Distinguish between normal normal and and abnormal abnormal ECG findings ECG findings
List the criteria for heart blocks and WPW List the criteria for heart blocks and WPW
Recognize arrhythmia type during sustained tachycardia Recognize arrhythmia type during sustained tachycardia
Identify main ECG abnormalities caused by MI and ischemia Identify main ECG abnormalities caused by MI and ischemia
common technical pitfalls
common technical pitfalls
Lead placement
Lead placement
F
F
I
I
L
L
T
T
E
E
R
R
O
O
N
N
Paper Speed
Paper Speed
50 mm/sec
25 mm/sec
0,04 sec
0,2 sec
TEMPS
V
O
L
T
A
G
E
25mm/sec
1
0

m
m
/
m
V
0,04 sec
motion
motion
artifact
artifact
-
-
breathing
breathing
stop breathing stop breathing
Auto mode Auto mode
Lead Inversion
Lead Inversion
L
R
Normal ECG ??
Normal ECG ??

62 y
62 y

emergency department
emergency department

chest pain
chest pain
62 y 62 y
emergency department emergency department
chest pain chest pain
T wave polarity depends on
T wave polarity depends on
T wave axis
T wave axis
I
II
III
Frontal Plane
Frontal Plane
T wave is always positive in leads I and II
T wave is always positive in leads I and II
may be negative in lead III.
may be negative in lead III.
T wave is always positive in
T wave is always positive in
precordial
precordial
leads.
leads.
(except V1: may be negative)
(except V1: may be negative)
75 y W
elective cholecystectomy
pre op ECG
Normal ECG ??
Normal ECG ??
I
Expiration Expiration Inspiration Inspiration
Positional Q waves ( Positional Q waves (septal septal Q waves) Q waves) often disappears with often disappears with
change in heart orientation associated with deep inspiration change in heart orientation associated with deep inspiration
33 y M
ER
chest pain x 3 hours
Normal ECG ??
Normal ECG ??

Early Repolarisation Syndrome

Early Repolarisation Syndrome

High take
High take
-
-
off ST segment
off ST segment

Tachycardia
Tachycardia
Atrial Fibrillation
Tachycardia
Tachycardia (HR > 100/min) (HR > 100/min)
Regular Regular
Irregular Irregular
Atrial Fibrillation
SVT
SVT
Tachycardia
Tachycardia (HR > 100/min) (HR > 100/min)
Regular Regular
Irregular Irregular
Atrial Fibrillation
Narrow Narrow QRS tachycardia QRS tachycardia
(< 0.12 sec) (< 0.12 sec)
Wide Wide QRS tachycardia QRS tachycardia
(> 0.12 sec) (> 0.12 sec)
SVTs SVTs
Sinus Tachycardia
Atrial Tachycardia
Atrial Flutter
AVNRT-AVRT
(Bouveret)
VT VT
SVTs SVTs
+ WPW
+ BBB
VT
VT
P wave ?
Identifying P wave: several approaches
- Spontaneous on surface ECG
(compare with previous tracings)
- Lewis lead (DI on chest)
- Esophageal lead
- Epicardiac lead (post open heart)
- CSM, ATP, Adenosine Adenosine
Analyze P wave
- Morphology
- Timing
- Rate

SVTs
SVTs

(Regular, Narrow QRS tachycardia)

Analyze P wave
- Morphology
- Timing
- Rate
sinus morphology: positive P wave in leads I and Vf
P

P

w
a
v
e
w
a
v
e
I
I
aVf
aVf
Analyze P wave
- Morphology
- Timing
- Rate
P wave rate
120-150 250 350 /min
Sinus Atrial Atrial Atrial
tachy tachy flutter fibrillation
sinus tachycardia
Regular narrow QRS tachycardia at 150/min Regular narrow QRS tachycardia at 150/min Adenosine Adenosine
Regular P waves at 150/min Regular P waves at 150/min
Adenosine Adenosine
1/1 Atrial Tachycardia
ATP ATP
Regular P waves at 300/min Regular P waves at 300/min
Regular tachycardia at 150 / min Regular tachycardia at 150 / min
2/1 Atrial Flutter
AVNRT
Adenosine Adenosine
Adenosine
2003 ACC/AHA/ESC Guidelines for Management of SVA
ECG in CAD
ECG in CAD
define
define
-
-
type
type
of ischemic changes
of ischemic changes
-
-
localization
localization
of ischemic changes
of ischemic changes
ECG in CAD
ECG in CAD
Q wave Q wave
ST changes ST changes
T wave T wave
changes changes
depolarization depolarization
abnormalities abnormalities
irreversible irreversible
I nf ar c t i on:
I nf ar c t i on:
1/ elevated ST 1/ elevated ST
2/ depressed ST 2/ depressed ST
repolarisation repolarisation
abnormalities abnormalities
reversible reversible
I nj ur y :
I nj ur y :
1/ inverted T wave 1/ inverted T wave
2/ Peaked T wave 2/ Peaked T wave
repolarisation repolarisation
abnormalities abnormalities
reversible reversible
I sc hemi a :
I sc hemi a :
-
-
type
type
of ischemic changes
of ischemic changes
ECG in CAD
ECG in CAD
Inverted T wave
Inverted T wave
Peaked T wave
Peaked T wave
Elevated ST
Elevated ST
Depressed ST
Depressed ST
I sc hemi a
I sc hemi a
I nj ur y
I nj ur y
antero-apical postero-inferior
antero-lateral
anterior
antero-septal
RV
postero-basal
Lateral Lateral
view view
Localization of ischemic changes
Localization of ischemic changes
anterior anterior
view view
V1 V1
V2 V2
V3 V3
V4 V4
V5 V5
V6 V6
VL VL
lead lead I I
II III VF
II III VF
V4r V4r
V3r V3r
+
+
+
+
antero-septal : V1 V2
apical : V3 V4
lateral : V5 V6
high lateral : I -VL
anterior : V1 - V6
postero-inferior : II -III -VF
postero-basal : V7 V8 V9
RV : V3r V4r
Localization of ischemic changes
Localization of ischemic changes
Heart blocks and WPW
Heart blocks and WPW
AV
node
His
-
-
Sinus dysfunction
Sinus dysfunction
-
-
AV Block
AV Block
Heart blocks
Heart blocks
PR > 0,2 sec
PR > 0,2 sec
1
st
degree AV block
progressive progressive AV block AV block
Mobitz 1 AV block
constant PR constant PR
blocked P wave blocked P wave
Mobitz 2 AV block
P wave P wave
QRS QRS
Complete AV block
AV dissociation AV dissociation
sinus arrest sinus arrest
junctional junctional escape rhythm escape rhythm
Sinus dysfunction
KENT KENT
Wolf Parkinson White Syndrome
Wolf Parkinson White Syndrome
Zone ventriculaire prexcite
Zone excite normalement
Wolf Parkinson White Syndrome
Wolf Parkinson White Syndrome