Anterior leads : V1-4

Inferior leads : II, III, AVF

left lateral leads : I, AVL, V5, V6
P-wave : atrial depolarisation
QRS : ventricular depolarisation, 120 ms (3blocks)
T-wave : ventricular repolarisation
Calculate axis - which leads : I and AVF
RAD : -I, +AVF
LAD : +I, -AVF
lead placement : V1+2 = 4ICS RSB/LSB, V3 = bw V2/4, V4 = 5ICS MCL, V5 = bw V4/6,
V6 = 5ICS MAL
length of small block : 40 ms
meaning of Q_waves : septal depolarisation, if prominent = old infarct, transmural
infarct
interval lengths - PR, QRS : PR = 200 ms, QRS = 120 ms
RVH : leads - V1, V6 ; reversal or R-wave progression ; V1 - R > S ; V6 - S > R ;
(2nd repolarisation artefacts) = V1 convex-sloping ST dep + T-inv ; eti - COPD,
pulm htn, pulm stenosis
LVH : leads - V1, V6, AVL ; incr R amp overlying LV ; incr S amp overlying RV ;
[V1-Samp + V5-Ramp] > 35 mm (7 big blocks); AVL-Ramp > 13 mm ; (2nd repolarisation
artefacts) = V6 convex-sloping ST dep + T-inv ; eti - systemic htn, AS
RAH : II, V1 ; II amplitude > 2.5 mm (2.5 small blocks) and is right skewed
(leaning), V1 (biphasic) has larger upstroke then downstroke; eti = P-pulmonale,
TS, restrictive lung dz
LAH : II, V1 ; II stepped/bifid + prolonged > 120 ms ; V1 (biphasic) has
larger/longer downstroke portion > 1 mm below iso / 40 ms ; eti = MS (P-mitrale)
nodal rates : SA 60-100, atrial 60-75, AV 40-60, ventricular 30-45
junctional escape ? : arrest/bradycardic escape, AVN, retrograde-P ;
depolarisation initiating at the AV node (below the atria) - therefore NO normal P-
wave progression - but there is a retrograde-P usually notched into the T-wave
(depolarisaiton starts at AVN and moves backward into atria)
Ectopic rhythms : arise from other than SA ; they are sustained (vs escape
beats) ; eti - enhanced automaticity of non sinus node site which overdrives the
normal SA mechanism - most common cause = digitalis
wide QRS : > 120 ms ; ventricular or SVT with aberrancy
narrow QRS : < 120 ms ; at or above AVN
5 types of sustained supraventricular arrhythmias : PSVT (=AVN-reentrant tachy),
Atrial flutter, Atrial fibrillation, Multifocal atrial tachy, paroxysmal atrial
tachycardia (=ectopic atrial tachycardia)
PSVT (AVN-reentrant tachy) : II, V1 ; II or III - retrograde 'P' ; V1 - pseudo 'R'
which is actually superimposed P-wave ; regular rhythm ; initiated by premature
supraventircular beat (atrial or junctional) ; eti - etoh, coffee,
excitement/emotion ; termiated by carotid massage / valsalva (vagal input slows
conduction through AVN) ; can often arise from a re-entrant mechanism
Atrial flutter : 'saw tooth'/flutter P-waves @ >250 bpm ; only some of the P-waves
are conducted ; 2/1 block most common; Carotid massage MAKES IT WORSE (bc atrial
flutter originates above the AVN); discrete baselines separated by a flat baselie
are not seen ; eti - a single re-entrant circuit that runs around the annulus of
the tricuspid is responsible
Atrial fibrillation : No P-waves ; AVN conducts only some of the atrial/ectopic
(>500) pulses = irregularly irregular = 120-180 bpm; if slower consider that the
patient is rate controlled eg BB; carotid massage slows it down only ; eti -
multiple re-entrant circutis occurring in a chaotic fashion = mitral valve disease,
CAD, hyperthryoid, pulmonary emboli, pericarditis
MAT : multiple P wave morphologies (bc they originate from different sites in the
atria) ; 100-200 bpm (if <100 bpm = wandering atrial pacemaker); carotid massage
has NO EFFECT; eti - random firing of several different ectopic atrial foci = COPD
Paroxysmal atrial tachycardia : regular, 100-200 bpm ; warm up and warm down to
irregularity/automaticity; carotid massage has NO EFFECT
Premature ventricular contractions : wide + bizarre QRS, then paused ; no P
waves ; PVC + AMI = can trigger VT/VF
Bigeminy : ratio of 1 sinus beat to 1 PVC (trigeminy = 2 sinus / 1 PVC)
Ventricular tachycardia : > 3 PVCs ; 120-200 bpm ; types eg Torsade de Pointe
(prolonged QT)
Ventricular fibrillation : preterminal event ; no cardiac outpute generated ;
resusc + defib required
Torsades (type of VT due to long QT) : QRS spiral around baseline changing axis
and amplitude; eti - HYPO (calcemia, mangesemia, kalemia), AMI, drugs (TCA,
phenothiazine, combined antifungal/antihistamine + erythromycin or quinolones) ;
Torsades is initiated by PVC falling during elongated T waves
Supraventricular beat with aberrancy : wide bizarre QRS but with P-wave preceding
QRS (the Pwave may be hidden in the T-wave before it) ; carotid massage -
TERMINATES ; eti - atrial premature beat conducted down Purkinje fibre bundle
branches, but one of the branches (usually right bundle branch) is still
refractory, so the LBB is depolarised, which can then move to depolarise the RBB =
wide/bizaree QRS
How do you tell a ventricular beat vs supraventricular beat with aberracncy? :
both have wide/bizarre QRS; SVT-aberrancy has P-wave before it (maybe hidden in T-
wave before it); SVT terminated by carotid massage ; VT has AV dissociation (and
therefore canon A-waves in JVD); VT has fusion beats
sick sinus syndrome : brady-tachy sdrome = alternating SVT (eg AF) with
bradycardia
Block 1 : PR > 120 ms ; conduction is only delayed (not really blocked)
Block 2.1 : wenckeback / mobitz type 1 = progressively lengethening PR then
dropped QRS ; eti - block withi the AVN
Block 2.2 : mobitz type 2 = PR all same length, yet every so often a beat/QRS is
dropped ; eti- block within the bundle of HIS ; can progress spontaneously to Block
3/complete
Block 3 : complete ; AV dissociation with Ventricular rate slower than sinus or
atrial rate ; escape PVCs are wide/bizarre ; atria beating at 60-100, ventricles at
30-45; eti- degeeration of conduction system, MI; require pacemakers ; emergency
RBBB : wide QRS + MORROW/(ST dep/T inv + reciprocal) = RSR' + STdep/T-inv in V1/2
(+ reciprocals in laterals) and deep-S in laterals ; RSR' eti - LV depol then that
depols the RV = R' ; QRS > 120ms
LBBB : wide QRS + LAD + WILLIAM(ST dep/T inv + reciprocal) = deep-S in V1/2 and
broad-notched "R" in laterals (with ST-dep, T-inv and reciprocals in V1/2) ; QRS
>120ms
Left (bundle) anterior fascicle HEMI-BLOCK : LAD + neg II/AVF (and QRS NOT
prologed, and NO ST segment/T-wave changes); LAD here must < -30degrees = neg II
AND neg AVF (here use II instead of I for axis calculation - if II is negative than
axis must be < -30 degrees ie bw -30 and -90 for sure)
Left (bundle) posterior fascicle HEMI-BLOCK : RAD (and QRS NOT prolonged, and NO
ST segment/Twave changes))
pre-excitation syndromes : accessory pathways by which current can bypass AVN and
arrive at the ventricles ahead of time - the pathways act as short circuits ; 2
types = wolf parkinson white, lown-ganong-levine ; also assoc with male
preponderance, MVP, HCOM
WPW : pre-excitation (accessory pathway shortcircuit = BUNDLE OF KENT) ; PR <
120ms ; delta-wave + QRS > 100 ms ; the delta/wide QRS complex actually represents
a fusion beat of normal conduction pathway depolzn + bundle of kent pathway depolzn
; can predispose to tachyarrhythmias = PSVT and AF ; PSVT = accessory pathway
causes rapid cycling/circuiting ; AF = accessory pathway is an unimpeded pathway
for AF to have worse effects than normal and can degenerate quickly into VT.
Lown-ganong-levine : pre-excitation (accessory pathway shortcircuit is INTRANODAL
= JAMES fibres within the AVN ypas the delay of the ABN) ; PR < 120 ms ; NORMAL QRS
and NO delta wave (all ventricular conduction occurs through the usual ventricular
conduction pathways)
AMI evolution : acute = peak T, 2 hr = T-inv, hrs = ST-el, wks = Q
T-inv : ischemia only, not alone diagnostic of MI ; in MI they are inverted
symmetrically
J-point elevation : a type of ST elevation seen in normal hearts = T-wave has own
independent waveform and starts after the ST-segment has apparently plateaued at
its higher baseline ; compare MI/ST-el = the QRS/ST/T-wave complex is bowed and
looks like a "U".
Q-waves : >40 ms ; depth > 1/3 height of R ; irreversible myocardial cell death;
diagnostic of MI ; NORMAL TO HAVE VERY DEEP Q-wave in AVR
Posterior infarction : RCA ; ST dep + R in anterior leads, V1
ECG taken during an angina attack will show : ST segment depression or T-inversion
Pinzmetal angina (vasospastic) : ST-el, but the ST-segment has a sort of vertical
sigmoid shape going from the elevated QRS deflectio point to the peak T
ECG and stress testing : assess presence and severity of CAD; positive if ST-dep >
1 mm or downsloping AND > 80 ms ; stress testig indicated for - 1. ddx of chest pai
in someone with a normal baseline ecg, 2. recent infarction and need to assess
prognosis and need for cardiac catheterization, 3. in >40 yo who has RF for CAD;
contraindic = systemic illness, AS, uncontrolled CHF, severe htn, unstable angina,
arythmia
Hyperkalemia : diffuse peak-T - prolong PR - P-flat - QRS widen - VF
Hypokalemia : ST-dep, flat T, U
Hypocalcemia : QT long - torsades - VT
Hypothermia : sinus brady, prolonged PR QRS QT, J-wave/Osborne wave = type of
downsloping ST-el that looks like = RSr'-downslope-Tinv
Percarditis : diffuse ST-el and T-flat/inversion ad PR-depression/downsloping; T-
inv occurs after ST has normalised
Effusion : dampening/low voltage, electrical alternans (varyig axis, varyig
amplitde, dampening)
HCOM : LVH, LAD, lateral + inferior Q
PE : sinus tachy, RBBB, S1Q3Tinv3
CNS dz : (SAH, infarction/stroke) diffuse T-inv and prominent U and sinus brady