ELECTROCARDIOGRAPHY

ECG ABNORMALITIES
AXIS DEVIATION

 RAD : R wave in III is

taller than R wave in II.
Lead I RS type complex
with deeper S
 LAD: Tall R wave in I,
deep S wave in III. Lead II
either biphasic RS or QS
complex. Lead I, AVL show
R wave.

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th ed.
St. Louis: Mosby Year Book, 2006
Indeterminate Axis

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th ed.
St. Louis: Mosby Year Book, 2006
 ATRIAL ENLARGEMENT

• Abnormality in P wave
morphology (Normal
height= <0,25 mV, width
<0.12 s.
• P pulmonale, tall P 
RAH
• P mitrale, broad and
notch P  LAH
• Lead II, V1

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th
ed. St. Louis: Mosby Year Book, 2006
VENTRICULAR ENLARGEMENT
RVH :
1. Tall R wave in V1, equal or larger than the S wave in that lead.
2. Often with RAD
3. T inverted in the right to middle chest lead.

Goldberger AL, Goldberger E.

Clinical Electrocardiography:
A Simplified Approach. 7th ed.
St. Louis: Mosby Year Book,
2006
VENTRICULAR ENLARGEMENT
LVH :
1. S wave in V1 + R wave in V5 or V6 > 35 mm
2. High voltage R wave in V1, when QRS axis is horisontal.
3. Repolarization abnormalities include T inverted in leads with
tall R wave (similar finding occur with ischemia)
4. other finding : LAH, LAD, LV conduction delay (wide QRS),
which may eventually progress to incomplete or complete LBBB

Goldberger AL, Goldberger E.

Clinical Electrocardiography:
A Simplified Approach. 7th ed.
St. Louis: Mosby Year Book,
2006
AV CONDUCTION BLOCK

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed.

St. Louis: Mosby Year Book, 2006
First Degree AV Block

Constant PR interval prolongation.

Prolonged PR interval can also occur in hyperkalemia, digitalis, acute rheumatic
fever

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Second Degree AV Block

Mobitz Type I (Weckenbach), characteristics :

1. Sequence of a progressive lengthening of the PR interval followed by a
nonconducted P wave.
2. shortening of the PR interval in the beat immediately after nonconducted
one.
Location : AV node

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Second Degree AV Block

Mobitz Type II haracteristics :

Sudden appearance of a single, non conducted sinus P wave without (1)
progressive prolongation of PR interval (2) shortening of PR interval in the beat
after the non conducted P wave.
Location : His bundle or bundle branches

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Third Degree AV Block (Total AV Block)

Third degree AV block characteristics :

• P waves are present, with a regular atrial rate faster than the ventricular rate.
• QRS complexes are present, with a slow (usually fixed) ventricular rate.
• P waves bear no relation to the QRS complexed, PR intervals are completely
variable.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
BUNDLE BRANCH BLOCKS

Left Bundle Branch Block :

• V1 wide, entirely negative QS
complex (rarely, a wide rS complex),
W shape characteristics
• Lead V6, tall wide R wave without
q wave
• T wave in the left precordial leads

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
BUNDLE BRANCH BLOCKS

Right Bundle Branch Block :

• V1 rSR’ complex with wide R’ wave
•V6 qRS pattern with wide S wave
•T wave in the right precordial leads

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Complete and
Incomplete Block :
• Complete : QRS
duration > 0,12
• Incomplete : QRS
duration 0,1 -0,12

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
BUNDLE BRANCH BLOCKS

Left Anterior Fascicular Block :

• Axis -45° or more negative (S wave in AVF equal or exceeds R wave in V1.
• QRS width <0,12 s
• AVL qR complexes, rS in II,III,AVF (or QS wave if there is myocardial infarct)

Left Posterior Fascicular Block :

• Axis +120 ° or more
• QRS <0,12s
•rS complexes in I, qR in II,III,AVR
•LPFB can be considered if other common cause of RAD have been excluded

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
BRADYARRHYTHMIAS/BRADYCARDIA

Bradycardia Simplified Classification

• Sinus Bradycardia, excluding sinoatrial block
• AV junctional escape rhythm
• Atrial fibrillation or flutter with slow ventricular
response.
• Idioventricular escape rhythm
Sinus Bradycardia :
sinus rhythm with rate < 60 beat/mnt.
Each P wave is followed by QRS complex

AV Junctional Escape Rhythm :

• P wave (if seen) is negative in II and positive
in AVR (retrograde P waves)
• retrograde P wave immediately precede or
follow QRS complex
• P wave dissapeared (burried) within QRS
complex.
Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified
Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Atrial Fibrillation with a slow ventricular response
A very slow ,regularized ventricular response in AF suggest
the present of underlying complete AV block.

Idioventricular Rhythm :
• SA node and AV junctional pacemaker fail to function
• very slow pacemaker in ventricular conduction
• rate < 45 beats/mnt
• QRS wide without any preceding P wave

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
TACHYARRHYTHMIAS/TACHYCARDIA

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Narrow Complex Tachycardia

Sinus Tachycardia : Sinus Rhythm with QRS rate 100 -130 bpm

Atrioventricular Nodal Reentrant

Tachycardia
• The most commont cause of a
paroxysmal, narrow, regular QRS
tachycardia
• ECG diagnostic points : (1) rapid,
regular rhythm 150-225 bpm.A rate
>230 bpm be aware of WPW syndrome
• more than 50% care the P waves are
hidden
• 45% cases P waves appear hidden,
but on careful observation they are
visible in the end of QRS complex,
pseudo S wave in II,III,AVF. Pseudo r’
wave in V1.

Khan,G., Rapid ECG Interpretation 3rd

ed.,New Jersey: Humana Press,2003
Khan,G., Rapid ECG Interpretation 3rd
ed.,New Jersey: Humana Press,2003
Atrial Flutter: Atrial Fibrillation:
• “saw tooth “flutter wave • rapid irregular undulation of the
• Constant or variable ventricular rate baseline (fibrillatory waves) instead of
• The most commont cause of a P waves.
paroxysmal, narrow, regular QRS • ventricular rate is usually irregular’
tachycardia

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Multifocal Atrial Tachycardia
• Multiple ectopic foci stimulating the atria.
• P waves with different shapes at rate > 100 bpm.
“flutter wave
• Constant or variable ventricular rate
• The most common cause of a paroxysmal, narrow, regular QRS tachycardia

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Wide Complex Tachycardia

Differential diagnosis :
• VT (B)
• SVT with aberrancy due to bundle branch block
and WPW preexitation (A)

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Diagnostic Clues VT v.s SVT with aberrancy
1. VT has AV dissociation
2. The shape of QRS in V1/V2 and V6. When QRS shape resembles an
RBBB pattern in V1 suggest SVT. single broad R wave or qR,QR, or RS in
V1 suggest VT. QRS resembles LBBB in V1 or V2 or QR complex in V6
suggest VT
3. QRS duration
> 0,14 with RBBB confiquration or >0,16 with LBBB configuration
suggest VT

Sick Sinus Syndrome and The Brady-Tachy Syndrome

•have alternating episodes of tachycardia and bradicardia

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Ventricular fibrillation
 Chaotic, wide, ventricular tachyarrythmia with grossly irregular
morphology
 No consistent identifiable QRS complexes
MYOCARDIAL ISCHEMIA AND INFARCTION
ECG changes associates with acute ischemia and infarction :
1. peaking T waves  hyperacute T –waves changes
2. ST segment elevation and/or depression
3. changes in QRS complex
4. Inverted T waves

ST segment changes : “injury currents”, generated by the voltage gradients

across the boundary between ischemic and non-ischemic myocardium during
the resting and plateau phases of the ventricular action potential, which
correspond to the TQ and ST segments of the ECG.

STEMI : ST elevation
NSTEMI : ST depression, lesser amounts of ST elevation, abnormal ST
segment elevation in less than 2 contiguous lead, T wave inversion, or no
abnormality at all
Threshold values for ST segment changes

Current ECG standards for diagnosing Acute ischemia and infarction require :
ST elevation in ≥ 2 contiguous leads and the elevation at J point >0,2 mV (2 mm in
standard calibration) in V1,V2,V3 and >0,1 mV in other leads.
However, this threshold values are dependent on gender, age, and ECG lead. In
healthy individuals, the amplitude of the ST junction is generally highest in leads V3
and V3 and is greater in men than woman.
• ST elevation  reciprocal ST segment depression in leads whose
positive pole is directed opposite (180°) to the leads that show the ST
segment elevation and vice versa.
• Reciprocal may be absent in leads it would be expected to have , if the
voltage is inadequate to meet the diagnostic criteria. Can be occur in
following conditions (in addition to ischemia or infarct) (1) LVH with
associated ST T changes, (2) intraventricular conduction disturbance with
secondary ST-T changes or (3) pericarditis.

• eq. ST depression in V1 and V2, in which the positive pole is located

anteriorly, is the reciprocal of and similar in meaning to the ST segment
elevation in posterior electrode V8,V9.
 Khan,G., Rapid
ECG Interpretation
3rd ed.,New
Jersey: Humana
Press,2003

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Goldberger AL, Goldberger E. Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
LOCATION OF ISCHEMIA/INFARCTION

Anterior wall infarct : invariably due to occlusion of LAD leads V1-V6.

If occlusion in proximal part above the first septal and first diagonal
branches  ST elevation in V1-V4, I,AVL, and often AVR. Reciprocal in
II,III,AVF, often V5. More ST elevation in AVL than AVR and more ST
depression in III than II

If occlusion between first septal and first diagonal branch  ST

segment will not elevated in V1, ST elevation prominent in AVL and ST
depression prominent in lead III.

If occlusion is located more distally, below both branches : ST elevation

will be prominent in V3-V6 and less prominent in V2. ST elevation may
occur in II,III,AVF also.
Khan,G., Rapid ECG Interpretation 3rd ed.,New Jersey: Humana Press,2003
Inferior wall infarct  ST segment elevation II,III,AVF. Occlusion of RCA or LCx.

If RCA is occluded : ST elevation in III more prominent than lead II. Often
associated with St depression in I,AVL.
If RCA is occluded in proximal part  RV infarction may occur. ST elevation in V3R,
V4R, often also V1.
Posterior ischemia/infarction : ST segment depression in V1,V2,V3 that
occurs in association with an inferior wall infarction. Occlusion either RCA or
LCx.
DIAGNOSIS OF ISCHEMIA /INFARCTION IN THE SETTING OF
INTRAVENTRICULAR CONDUCTION DISTURBANCE

Criteria for infarction

in the presence of
LBBB :
1. ST elevation ≥ 0,1
mV in leads with
positive QRS
complex
2. ST depression ≥ 0,1
mV in V1-V3 that is,
leads with
dominant S wave.
3. ST elevation ≥ 0,15
mV in leads with
negative QRS
complex.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Evolving Phase is characterized bt deeply inverted T waves in the
leads that showed the hyperacute T waves and ST elevation.

New pathologic Q wave of Mi generally appear within the first

day or so of infarct.

Goldberger
AL,
Goldberger E.
Clinical
Electrocardio
graphy: A
Simplified
Approach. 7th
ed. St. Louis:
Mosby Year
Book, 2006
PREEXCITATION

Wolf –Parkinson- White Preexcitation

• Short PR
• Wide QRS
• Delta Wave

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 WPW Syndrome

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006

Lown- Ganong- Levine Syndrome

• Short PR interval < 0,12 s
• QRS complex is not widened
• No delta wave

Thaler, M.S., The Only ECG Book You’ll Ever Need

5th ed. Lippincott,2007
QT INTERVALS ABNORMALITY

• Prolonged QT interval : electrolyte disturbance

(hypokalemia or hypocalcemia), drug effects
(quinidine, procainamide, amiodarone, sotalol) or
myocardial ischemia with T invertion
• Shortened QT : hypercalcemia and digitalis
effect.
Goldberger AL, Goldberger E. Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
PERICARDITIS AND MYOCARDITIS

Pericarditis :
• Diffuse ST segment elevations, usually in one or more of
the chest leads and also in I,AVL,II,AVF.
• PR segment elevation AVR and PR segment depression
in other leads.
Myocarditis :
• Non Specific ST segment changes similar with
pericarditis and myocardial ischemia
Pericarditis

Goldberger AL, Goldberger E.

Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis:
Mosby Year Book, 2006
ELECTROLYTES ABNORMALITIES

Hyperkalemia
• Affecting of both depolarization (QRS complex) and repolarization (ST-T
segment)
• First changes : Tall T with “tented” or “pinched “ shape.
• Prolonged of PR interval and P wave is dissappear
• Further increase : intraventricular conduction blocks and widening QRS
complex
• Lethal concentration : undulating (sine-wave pattern ) and asystole

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified

Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Hypokalemia
• ST depression with prominent U waves
• Prolonged repolarization

Goldberger AL, Goldberger

E. Clinical
Electrocardiography: A
Simplified Approach. 7th ed.
St. Louis: Mosby Year
Book, 2006
Hypocalcemia and Hypercalcemia

Hypocalcemia : shortening QT interval by

shorten ST segmen
Hypercalcemia : lengthening QT interval by
stretching ST segment

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
PACEMAKER DYSFUNCTION

1. Failure to sense : observing pacemaker spikes despite

patient’s own adequate rate. Common cause : (1)
dislodgement of the pacemaker wire (2)excessive fibrosis
around the tip of pacing wire

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed.

St. Louis: Mosby Year Book, 2006
2. Failure to pace : observing pacemaker spikes without
subsequent QRS complex (“failure to capture”) or by finding
no pacemaker spikes even though the patient has an
excessively slow heart rate.
Common cause : dislodgement of the pacemaker wire or fibrosis
in the tip of the pacemaker wire.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed.

St. Louis: Mosby Year Book, 2006