ECG 101

Yale University School of Medicine

Section of Cardiovascular Medicine

james.revkin@yale.edu

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Basic analysis
Rate (fast or slow) Rhythm (atrial, ventricular, regular, irregular) Axis Conduction disease (atrial or ventricular) Hypertrophy Ischemia, infarction Other abnormalities (QT interval, repolarization changes)

EKG history

Charles Einthoven

electrophysiology

ECG as an imaging tool

ECG as an imaging tool

Right side

Left side

Basic ECG

P wave

Septal Q Wave

Q R wave

repolarization

Basic ECG

Basic analysis
Rate (fast or slow) Rhythm (atrial, ventricular, regular, irregular) Axis Conduction disease (atrial or ventricular) Hypertrophy Ischemia, infarction Other abnormalities (QT interval, repolarization changes)

Normal 12 Lead ECG

300 bpm
150 bpm 100 bpm 75 bpm 60 bpm

50 bpm
~ 45 bpm

Calculating rate of an irregular rhythm

Count number of beats in two 3 sec intervals ( = 6 sec total) and multiply times 10 Rate approx 60 bpm

Normal Frontal Axis

Lead I

Lead aVF

Lead V1

Normal precordial Axis

Lead V6

1F

Frontal Plane Axis Calculator

1G

Precordial Axis

1H

Frontal Plane Axis Calculation

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Session 1 ECGs

1A

1B

1C

1D

1E

1I

1J

1K

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

electrophysiology

PR Interval

PR

A V Block
At level of A-V node
1st degree
Prolongation of PR interval > 0.2 ms

2nd degree
Mobitz Type I - Wenckebach, progressive prolongation of PR interval, then dropped beat Mobitz Type II

3rd degree
Complete heart block, independent atrial and ventricular rates

QRS Interval

QRS

Ventricular (bundle branch) blocks

LBBB
Hemiblocks
Left anterior fascicular block (left anterior hemiblock) Left posterior fascicular block (left posterior hemiblock

RBBB

LBBB

RBBB

Hemi-blocks
Within the Left Bundle
Hemiblocks
Left anterior fascicular block (left anterior hemiblock) Left posterior fascicular block (left posterior hemiblock

Left anterior hemi-block

Left posterior hemi-block

Hypertrophy
Atrial
Left atrial hypertrophy Right atrial hypertrophy

Ventricualr
LVH RVH

Left Atrial Hypertrophy

Right Atrial Hypertrophy

Ventricular Hypertrophy
RVH
R > S in V1 Right axis deviation

LVD
R wave 15 mm high in lead I Sum deepest S wave V1 or V2 and add to tallest R wave in V5 or V6 > 35 mm

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Session 2 ECGs

2A

2B

2C

2D

2E

2F

2G

2H

2I

2J

2K

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Sinus arrhythmia

Non-sinus atrial rhythm

Multi-focal atrial tachycardia (MAT)

Junctional rhythm

Paroxysmal supraventricular tachycardia PSVT

atrial flutter

atrial fibrillation

Session 3 ECGs

3A

3B

3C

3D1

3D2

3E

3F

3G

3H1

3I-1

3I-2

3I-3

3J

3K1

3K2

3L1

3L2

3M

3N

3O

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

ECG Basics
What does the QRS complex represent? What should the axis of a normal QRS complex be:
in the frontal plane? in the precordial plane?

What would make the QRS complex wide?

Assessment of WCT
definition of wide complex tachycardia
QRS duration greater than 0.12 seconds heart rate greater than 100 bpm

differential diagnosis of WCT

supraventricular tachycardia with:
preexisting bundle branch block aberrant conduction (rate related) accessory pathway

ventricular tachycardia

ECG Basics
What does the QRS complex represent? What should the axis of a normal QRS complex be:
in the frontal plane? in the precordial plane?

What would make the QRS complex wide?

Normal Frontal Axis

Lead I

Lead aVF

Lead V1

Normal precordial Axis

Lead V6

LBBB

RBBB

Stepwise Assessment of Wide Complex Tachycardia

Goal: develop easier more accurate criteria for analysis. Applied guidelines to 554 WCT patients whod had previous EP studies (384 VT and 170 SVT). Analyze ECGs using a four step algorithm. Observers would stop when a positive analysis of VT was made. SVT with aberrant conduction was the diagnosis of exclusion.
Brugada P, Brugada J, et al Circulation 1991;83:1649-1659

Stepwise Assessment of Wide Complex Tachycardia

Are RS complexes absent in all precordial leads? Does any RS interval exceed 100 msec in the precordial leads? Is A-V dissociation present? Do the QRS complexes in V1/V2 fulfill the classic criteria?

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (384 VT, 170 SVT with aberration)

Are RS complexes absent in all precordial leads?

83 Yes 83 VT SN = 0.21 SP = 1.0

471 No

Go to next step

Absence of precordial RS complexes

V1

V6

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (384 VT, 170 SVT with aberration)

Are RS complexes absent in all precordial leads?

83 Yes 83 VT SN = 0.21 SP = 1.0

471 No

Go to next step

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (83 VT, 471 unknown)

RS Interval > 100 ms in one precordial lead?

175 Yes 172 VT 3 SVT SN = 0.66 SP = 0.98

296 No

Go to next step

Hypothesis: prolongation of the intrinsicoid deflection-RS interval > 0.1 sec-could be a marker for VT

RS Interval: measured from beginning of R wave to nadir of the S wave.

RS = 0.080 or 80 ms

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (83 VT, 471 unknown)

RS Interval > 100 ms in one precordial lead?

175 Yes 172 VT 3 SVT SN = 0.66 SP = 0.98

296 No

Go to next step

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (255 VT, 3 SVT, 296 unknown)

Is AV Dissociation Present?

59 Yes 59 VT SN = 0.82 SP = 0.98

237 No

Go to next step

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (314 VT, 3 SVT, 237 unknown)

Are classic morphology criteria for VT present in both V1- V2 and V6?

68 Yes 65 VT 3 SVT SN = 0.987 SP = 0.965

169 No
164 SVT 5 VT SN = 0.965 SP = 0.987

Classic Criteria Suggesting VT

QRS duration > 0.14 s Superior QRS axis Morphology in precordial leads:
RBBB-like pattern V1 LBBB-like pattern
V1 r = 30 ms notched S wave RS > 70 ms

V6 R/S ratio < 1

V6 :qR

Classic Criteria Suggesting SVT

QRS duration < 0.14 s Normal QRS axis Morphology in precordial leads:
RBBB-like pattern
V1:

LBBB-like pattern absent or narrow R wave no S wave notch steep S wave descent
V6 : no Q wave

V1: triphasic
V6 R/S ratio > 1

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (314 VT, 3 SVT, 237 unknown)

Are classic morphology criteria for VT present in both V1- V2 and V6?

68 Yes 65 VT 3 SVT SN = 0.987 SP = 0.965

169 No
164 SVT 5 VT SN = 0.965 SP = 0.987

Treatment of Wide Complex Tachycardia of indeterminate etiology

Is patient unstable?
Immediate synchronized cardioversion 100, 200, 300, 360 joules

Borderline or stable?
amiodarone

Stepwise Assessment of Wide Complex Tachycardia

Are RS complexes absent in all precordial leads? Does any RS interval exceed 100 msec in the precordial leads? Is A-V dissociation present? Do the QRS complexes in V1/V2 fulfill the classic criteria?

Session 4 ECGs

4A

4B

4C

4D

4E

4G1

4G2

4H1

4H2

4I1

4J

4K

4L

4M1

4M2

4M3

4N1

4N2

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

ECG Basics
What does the QRS complex represent? What should the axis of a normal QRS complex be:
in the frontal plane? in the precordial plane?

What would make the QRS complex wide?

Assessment of WCT
definition of wide complex tachycardia
QRS duration greater than 0.12 seconds heart rate greater than 100 bpm

differential diagnosis of WCT

supraventricular tachycardia with:
preexisting bundle branch block aberrant conduction (rate related) accessory pathway

ventricular tachycardia

ECG Basics

What does the QRS complex represent? What should the axis of a normal QRS complex be:
in the frontal plane? in the precordial plane?

What would make the QRS complex wide?

Normal Frontal Axis

Lead I

Lead aVF

Lead V1

Normal precordial Axis

Lead V6

LBBB

RBBB

Stepwise Assessment of Wide Complex Tachycardia

Goal: develop easier more accurate criteria for analysis. Applied guidelines to 554 WCT patients whod had previous EP studies (384 VT and 170 SVT). Analyze ECGs using a four step algorithm. Observers would stop when a positive analysis of VT was made. SVT with aberrant conduction was the diagnosis of exclusion. Brugada P, Brugada J, et al
Circulation 1991;83:1649-1659

Stepwise Assessment of Wide Complex Tachycardia

Are RS complexes absent in all precordial leads? Does any RS interval exceed 100 msec in the precordial leads? Is A-V dissociation present? Do the QRS complexes in V1/V2 fulfill the classic criteria?

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (384 VT, 170 SVT with aberration)

Are RS complexes absent in all precordial leads?

83 Yes 83 VT SN = 0.21 SP = 1.0

471 No

Go to next step

Absence of precordial RS complexes

V1

V6

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (384 VT, 170 SVT with aberration)

Are RS complexes absent in all precordial leads?

83 Yes 83 VT SN = 0.21 SP = 1.0

471 No

Go to next step

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (83 VT, 471 unknown)

RS Interval > 100 ms in one precordial lead?

175 Yes 172 VT 3 SVT SN = 0.66 SP = 0.98

296 No

Go to next step

Hypothesis: prolongation of the intrinsicoid deflection-RS interval > 0.1 sec-could be a marker for VT

RS Interval: measured from beginning of R wave to nadir of the S wave.

RS = 0.080 or 80 ms

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (83 VT, 471 unknown)

RS Interval > 100 ms in one precordial lead?

175 Yes 172 VT 3 SVT SN = 0.66 SP = 0.98

296 No

Go to next step

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (255 VT, 3 SVT, 296 unknown)

Is AV Dissociation Present?

59 Yes 59 VT SN = 0.82 SP = 0.98

237 No

Go to next step

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (314 VT, 3 SVT, 237 unknown)

Are classic morphology criteria for VT present in both V1- V2 and V6?

68 Yes 65 VT 3 SVT SN = 0.987 SP = 0.965

169 No
164 SVT 5 VT SN = 0.965 SP = 0.987

Classic Criteria Suggesting VT

QRS duration > 0.14 s Superior QRS axis Morphology in precordial leads:
RBBB-like pattern V1 LBBB-like pattern
V1 r = 30 ms notched S wave RS > 70 ms

V6 R/S ratio < 1

V6 :qR

Classic Criteria Suggesting SVT

QRS duration < 0.14 s Normal QRS axis Morphology in precordial leads:
RBBB-like pattern
V1:

LBBB-like pattern absent or narrow R wave no S wave notch steep S wave descent
V6 : no Q wave

V1: triphasic
V6 R/S ratio > 1

Stepwise Assessment of Wide Complex Tachycardia

N = 554 (314 VT, 3 SVT, 237 unknown)

Are classic morphology criteria for VT present in both V1- V2 and V6?

68 Yes 65 VT 3 SVT SN = 0.987 SP = 0.965

169 No
164 SVT 5 VT SN = 0.965 SP = 0.987

Treatment of Wide Complex Tachycardia of indeterminate etiology

Is patient unstable?
Immediate synchronized cardioversion 100, 200, 300, 360 joules

Borderline or stable?
amiodarone

Stepwise Assessment of Wide Complex Tachycardia

Are RS complexes absent in all precordial leads? Does any RS interval exceed 100 msec in the precordial leads? Is A-V dissociation present? Do the QRS complexes in V1/V2 fulfill the classic criteria?

Wide Complex Tachycardia Case 1

66 year old retired businessman with a history of hypertension and a subarachnoid hemorrhage who presented with dizziness and an episode of chest pain. Patient has a lipid disorder, smokes 2 packs of cigarettes a day, and has a son with coronary disease. Exam showed HR of 210 BPM, BP 70/50, resp 12/min

Case 1

Case 1

Stepwise Assessment of Wide Complex Tachycardia: Case 1

Are RS complexes absent in all precordial leads?

Stepwise Assessment of Wide Complex Tachycardia: Case 1

Does any RS interval exceed 100 msec in the precordial leads?

Stepwise Assessment of Wide Complex Tachycardia: Case 1

Is A-V dissociation present?

Stepwise Assessment of Wide Complex Tachycardia: Case 1

Do the QRS complexes in V1/V2 fulfill the classic criteria? Case 1 Typical RBBB

Wide Complex Tachycardia Case 1

Received adenosine 6 mg, 12 mg Received lidocaine 100 mg, then 2 mg/min, converting briefly to NSR. Labs showed normal electrolytes and CK. Received bretylium 200 mg, then 500 mg. Received procainamide 1 gm, then 2 mg/min and metoprolol Cardiac catheterization showed total RCA occlusion and 90% LAD stenosis.

Case 1: normal sinus rhythm

Case 1

NSR Frontal Axis

Case 1

NSR precordial Axis

Wide Complex Tachycardia Case 2

76 yr. old woman with an extensive history of coronary artery disease presented with palpitations. had CABG in 1992, recent history of cough felt to be bronchitis, treated with amoxicillin, history of hypothyroidism. Exam showed HR of 180 BPM, BP 120/100, resp 32/min labs: K+ 3.7; Mg2+; T4 10.3; TSH 0.05

Case 2

Case 2

Stepwise Assessment of Wide Complex Tachycardia: Case 2

Are RS complexes absent in all precordial leads?

Stepwise Assessment of Wide Complex Tachycardia: Case 2

Does any RS interval exceed 100 msec in the precordial leads?

Stepwise Assessment of Wide Complex Tachycardia: Case 2

Is A-V dissociation present?

Stepwise Assessment of Wide Complex Tachycardia: Case 2

Do the QRS complexes in V1/V2 fulfill the classic criteria? Case 2 Typical LBBB

Wide Complex Tachycardia Case 2

Treated with adenosine 6 mg, repeated once, then NSR Loaded with digoxin, 0.5 mg, then 0.25 mg, and final dose of 0.25 mg

Case 2: normal sinus rhythm

Case 2

NSR Frontal Axis

Case 2

NSR precordial Axis

Wide Complex Tachycardia Case 3

29 yr. old previously healthy woman, noted dizziness and fatigue at work. Shed had similar symptoms, episodically, over the prior two weeks. Medications included Zoloft, oral contraceptives, and occasional Sudafed. She rarely used cocaine Exam showed HR of 280 BPM, BP 120/70, resp 18/min

Case 3

Case 3

Stepwise Assessment of Wide Complex Tachycardia: Case 3

Are RS complexes absent in all precordial leads?

Stepwise Assessment of Wide Complex Tachycardia: Case 3

Does any RS interval exceed 100 msec in the precordial leads?

Stepwise Assessment of Wide Complex Tachycardia: Case 3

Is A-V dissociation present?

Stepwise Assessment of Wide Complex Tachycardia: Case 3

Do the QRS complexes in V1/V2 fulfill the classic criteria? Case 3 Typical LBBB

Wide Complex Tachycardia Case 3

Treated with adenosine 6 mg, 12 mg
Received Versed 1 mg, then direct current cardioversion 100 J, without success Received Versed 1 mg, then direct current cardioversion 200 J, without success Received Propofol, then direct current cardioversion 350 J, with success

Case 3: normal sinus rhythm

Case 3

NSR Frontal Axis

Case 3

NSR precordial Axis

Stepwise Assessment of Wide Complex Tachycardia

Are RS complexes absent in all precordial leads? Does any RS interval exceed 100 msec in the precordial leads? Is A-V dissociation present? Do the QRS complexes in V1/V2 fulfill the classic criteria?

Wide Complex Tachycardia summary

WCT can be VT or SVT Knowledge of basic appearance of normal RBBB and LBBB can be helpful Hemodynamic stability does NOT help make the diagnosis If hemodynamically stable and in doubt, treat as VT If unstable, apply direct current cardioversion

Session 5 ECGs

5A

5B

5C

5D

5E

5F

5G

5H

5I

5J

5K

5L

5M

5N

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Session 6 ECGs

6A

6B

6C

6D

6E

6F

6G

6H1

6H2

6H3

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Session 7 ECGs

7A

7B

7C

7D

7E

7F1

7F2

7F3

7F4

7F5

7G1

7G2

7G3

7H

7I

7J

7K

7L1

7L2

7L3

7M

Course Outline
Basic ECG analysis and sinus rhythm Intervals, Bundle Branch Block, Hypertrophy and Enlargement Supraventricular arrhythmias Ventricular arrhythmias Bradyarrhythmias Heart Blocks Ischemia and Infarction Miscellaneous Abnormalities

Session 8 ECGs

8A

8B

8C

8D

8E

8F

8G

8H

8I

8J

8K

8L

8M

8N

8O1

8O2

8P1

8P2