Expanded Clinical Skills

The value of ECG in Clinical Practice

HEART RHYTHM SERVICE
Drs. Abdollah, Baranchuk, Michael, Redfearn & Simpson
Queens University

NORMAL ECG

Rhythm
Heart rate
Axis

P-PR
qrs-QT
ST-T

Case 1

Rhythm: sinus vs. non-sinus

- P-waves in the inferior leads

HR: 300 / # of large squares
Axis: use Lead I and aVF

Axis: how to calculate it.

both I and aVF +ve = normal axis

both I and aVF -ve = axis in the Northwest Territory
lead I -ve and aVF +ve = right axis deviation
lead I +ve and aVF -ve
lead II +ve = normal axis
lead II -ve = left axis deviation

Representation of the cardiac cycle

on the ECG

PR interval: 120-200 ms
qRs interval: 110 ms
QT interval: 460 ms

Twave: ventricular repolarization

qRs: ventricular depolarization
P wave: atrial depolarization
PR interval: conduction over the
AV node

Waves and Intervals: normal limits &

frequent abnormalities
Normal P-wave
Height:<2.5 mm in lead II
Width: 110 ms in lead II
Abnormal P-wave
Height: PA pressure (ie PE)
Width: Interatrial block (IAB= P-wave >120 ms)
Tall P-waves

IAB

Normal

Normal PR Interval
Normal:120 ms to 200 ms
Abnormal PR interval
Short: preexcitation syndrome (WPW)
Long 1st degree AV block

Short PR + Delta wave= WPW

1sr degree AV block

Normal QRS Interval

Normal: up to 110 ms
Abnormal QRS interval (120 ms): Bundle Branch Block
RBBB
LBBB

RBBB

LBBB

Bundle Branch Blocks

RBBB
V1

LBBB

Once again

Normal QT Interval
Men: 440 ms
Women: 460 ms
Abnormal QT interval: Long QT syndrome
Congenital: LQTS 1, LQTS2, LQTS3
Acquired

Case 4

 Ischemia

Bradycardia
Antiarrhythmic drugs

Causes of

- Amiodarone

- Quinidine

Long QT syndrome

- Sotalol
Antibiotics

Antipsychotics
Antidepressants

Bazetts formula

Electrolyte disorders

Clinical Cases
Case 1

A 58 year old man with hypertension and diabetes presents with chest pain.

What else do you want to know from his history?

What do you want to know about his physical examination?
What investigations are needed?

Whats your ECG diagnosis?

Anterior MI

ST Elevation MI: Management

Think about primary angioplasty if available
Preferred in those with contraindications to Tpa or in
cardiogenic shock
Anti-platelet
ASA
Plavix
Beta blockers
Fibrinolytics

Heparin iv (dont give with Streptokinase)

Nitroglycerin
Avoid in hypotension & inferior infarct complicated by RV
infarction
Morphine: to control pain

A frequent differential diagnosis of MI is

Infarct

Pericarditis

Case 2

An 85 year old woman with hypertension treated with Diltiazem and Metoprolol
presents with syncope.

What else do you want to know from her history?

What do you want to know about her physical examination?
Any bedside maneuvers?
What do you think is the role of the drugs in this case?
What investigations are needed?

Whats your ECG diagnosis?

Complete AV Block

 Usually see complete AV dissociation because

the atria and ventricles are each controlled by
separate pacemakers.
Narrow QRS rhythm suggests a junctional
escape focus for the ventricles
block above the His level
(less dangerous, not always requires pacemaker)

Wide QRS rhythm suggests a ventricular

escape focus (i.e., idioventricular rhythm).
block usually below the His level
(more dangerous, always requires pacemaker)

Other AV Blocks

Second degree Mobitz II type

First degree AV Block

Second degree Wenckebach type

Case 3

A 45 year old woman presented with rapid palpitations

BP 110/75 mmHg

What else do you want to know from her history?

What do you want to know about her physical examination?
Any bedside maneuvers?
What investigations are needed?

Whats your ECG diagnosis?

Other SV tachycardias

narrow complex
regular
- retrograde p-waves (RP<PR)

Typical AVNRT

Case 4

A 77 year old man presented with nausea and presyncope

BP 100/64 mmHg

What else do you want to know from his history?

What do you want to know about his physical examination?
What investigations are needed?

Whats your ECG diagnosis?

Peak & tall T-waves

Junctional rhythm

Hyperkalemia
(K: 7.8 meq/L)

Case 5

A 62 year old man, HTN (Ramipril 10 mg/day) presented for routine check up
BP 140/95 mmHg

What else do you want to know from his history?

What do you want to know about his physical examination?
What investigations are needed?

Whats your ECG diagnosis?

LVH: ST depression
Sokolow-Lyon Index: S in V1 or V2 + R in V5 or V6 > 35 mm