The ECG findings include: 1) Atrial fibrillation with rapid ventricular rate 2) Old inferior myocardial infarction 3) Poor

R wave progression 4) ST segment abnormality, consider myocardial ischemic (lateral in leads V6, I, and aVL)

1) Normal sinus rhythm 2) Left atrial enlargement with P-mitrale pattern 3) Premature ventricular contraction (PVC)

1) Sinus bradycardia 2) Inferior and posterior ST segment elevation myocardial infarction 3) Left atrial enlargement

1) Monomorphic sustained ventricular tachycardia When describing ventricular tachycardia, the following should be mentioned: 1) Monomorphic versus polymorphic (Torsades) 2) Sustained versus non-sustained (sustained defined as > 30 seconds in duration or symptomatic) 3) The heart rate at which it is occurring (electrophysiologist use the "cycle length" or the number of milliseconds between the QRS complexes)

1) Normal sinus rhythm 2) T wave abnormality consistent with ischemia 3) Prolonged QT interval

1) Sinus bradycardia 2) Left atrial enlargement (LAE)

Left Atrial Enlargement (LAE)

Right Atrial Enlargement (RAE)

When left atrial enlargement occurs, it takes longer for cardiac action potentials to travel through the atrial myocardium, thus the P wave length becomes longer. Thus the criteria for diagnosing LAE on ECG is as follows: 1) The P wave length in lead II greater than 120 milliseconds OR 2) The downward deflection of the P wave in lead V1 greater than 40 milliseconds in length AND greater than 1 millimeter negative deflection (less than -1 millimeter in amplitude).

When right atrial enlargement occurs, it does not take longer for cardiac action potentials to travel through the atrial myocardium (such as in LAE), however the amplitude of the P wave is exagerated since the hypertrophied right atrial myocardium is so close the the SA node (referred to as ppulmonale since lung disease can causes severe right heart strain and RAE). Thus the thus the P wave height becomes larger. Thus the criteria for diagnosing RAE on EKG is as follows: 1) The P wave amplitude in lead II greater than 2.5 millimeters OR 2) The upward deflection of the P wave in lead V1 greater than 1.5 millimiters in amplitude.

1) Sinus bradycardia 2) Dextrocardia 3) Premature atrial contractions Dextrocardia occurs when the heart is positioned in the right side of the chest instead of the left (a rare congenital anamoly). The ECG findings include: 1) Predominately negative P wave, QRS complex, and T wave in lead I 2) Low voltage in leads V3-V6 (since these leads are placed on the left side of the chest) The one thing that can mimic #1 above is limb lead reversal (the left arm lead being put on the right arm and vice-versa) A Premature Atrial Contraction (PAC) occurs when a focus in the atrium (not the SA node), generates an action potential before the next scheduled SA node action potential. When every other QRS complex is a PAC, then the rhythm is referred to as "atrial bigeminy". There are four main characteristics of PACs: 1) They are premature. That is they occur earlier than you would expect if you were to measure the previous P to P intervals. 2) They are ectopic. Meaning originating outside of the SA node. Thus the P wave morphology would be different than the normal sinus P wave. 3) They are narrow complexes. Since they come from the atrium, they will eventually travel through the AV node and use the normal conduction system to spread to the ventricules. Unlike a premature ventricular contraction, which is wide-complexed since it does not use the normal ventricular

conduction system. 4) There is a compensatory pause after the PAC. The extra atrial action potential causes the SA node to become refractory to generating its next scheduled beat. Thus it must "skip a beat" and it will resume exactly 2 P to P intervals after the last normal sinus beat. At times the extopic P wave is difficult to see as it could be flattened or there may actually be a "premature supraventricular complex" present. A premature supraventricular complex occurs with the ectopic area that is creating the action potential is close to or within the AV node, thus the P wave may be seen just before the QRS complex, buried within the QRS complex, or just after the QRS complex.

1) Sinus tachycardia 2) Ventricular couplet 3) Right bundle branch block and left anterior fascicular block (together termed a bifascicular block) 4) Premature supraventricular complex (10th beat from left)

The ECG criteria for a right bundle branch block include: 1) QRS duration of > 120 milliseconds 2) rsR' "bunny ear" pattern in precordial leads 3) Slurred S waves in leads I, V5, and V6. Note: An incomplete right bundle branch block occurs when criteria #2 and 3 of the above are met, but the QRS duration is 80-119 milliseconds.

1) Normal sinus rhythm 2) Left bundle branch block 3) ST changes consistent with myocardial infarction according to Sgarbossa criteria Traditionally it has been taught that myocardial infarction is not able to be diagnosed via ECG in the presence of a left bundle branch block (LBBB), however Sgarbossa et al in 1996 described some ECG changes seen in those with LBBB and concominant myocardial infarctions and devised a point scoring system. 1) ST elevation > 1 mm and in the same direction (concordant) with the QRS complex. 5 points 2) ST depression > 1 mm in leads V1, V2, or V3. 3 points 3) ST elevation > 5 mm and in the opposite direction (discordant) with the QRS. 2 points A score of 3 points is required to diagnose an acute myocardial infarction. Criteria #3 is under debate as to its usefullness, so basically you need to have either criteria 1 or criteria 2. Our patient just made 1 mm ST elevation in lead V5 and about 0.5 mm ST elevation in V6. This ECG was indeed from a patient with an acute left anterior descending thrombosis.

left bundle branch block occurs when this conducting tissue becomes diseased or infarcted. This results in delayed activation of the left ventricule (since conduction gets to the right ventricle almost immediately, then the action potentials have to travel from myocyte to myocyte to reach the left ventricle). This delay results in a widened QRS complex. The ECG criteria for a left bundle branch block include: 1) QRS duration of > 120 milliseconds. 2) Absense of Q wave in leads I, V5, and V6.

3) Monomorphic R wave in I, V5, and V6. 4) ST and T wave displacement opposite to the major deflection of the QRS complex. Note: If the QRS duration is between 100-119 milliseconds with criteria 2, 3, and 4 of the above, an incomplete left bundle branch block is present.

1) Normal sinus rhythm 2) Old inferior myocardial infarction 3) Left posterior fascicular block 4) Poor R wave progression

1) Normal sinus rhythm 2) Possible old inferior myocardial infarction 3) Low voltage 4) Left atrial enlargement (LAE

2) Symmetric T wave inversions consistent with myocardial ischemia or cerebral injury 3) Prolonged QT interval ECG abnormalities have been seen during or after an acute brain injury including intracranial hemorrhage, subarachnoid hemorrhage, head trauma, massive ischemic stroke, and after carotid endarterectomy. The ECG can show deep, symmetrically inverted T waves with a prolonged QT interval. Remember that myocardial ischemia can also cause symmetric inverted T waves and QT prolongation, so the clinician always has to look at the patient and not just the ECG.

1) Atrial fibrillation with rapid ventricular response There are three common heart rhythm disorders that cause an irregularly irregular rhythm: 1) atrial fibrillation, 2) atrial flutter with variable conductance, and 3) multifocal atrial tachycardia (MAT). With atrial fibrillation, no descrete P waves can be seen, however sometimes coarse "fibrillitory waves" are present. In atrial flutter a "sawtooth" pattern is seen. In MAT there are at least 3 distinct P wave morphologies present.

1) Normal sinus rhythm 2) Premature atrial contractions 3) Old lateral wall myocardial infarction 4) Non-specific ST-T wave abnormality

1) Normal sinus rhythm 2) Early repolarization changes

1) Sinus tachycardia 2) 1st degree AV block 3) Left bundle branch block (LBBB) 4) T wave changes consistent with hyperkalemia