ECG Interpretation

Hung-Fat Tse, MD, FRCP, FACC

Department of Medicine
The University of Hong Kong
Queen Mary Hospital
Hong Kong
Basic ECG Measurements

- Rate (ventricular; and atrial in some

cases); paper speed 25mm/sec or
50mm/sec
- P wave duration
- PQ interval
- QRS duration
- QT interval
- plus determination of the QRS axis
Electrical Cardiac Cycle
 Analysis of Rhythm
Sinus Rhythm

Other supraventricular rhythm

- Nonsinusal p waves: atrial rhythm
- No p waves or retrograde atrial excitation: AV
junctional rhythm: AV reentry rhythms (tachycardias)
- Atrial flutter waves: atrial fibrillation
- Additional aberration: broad QRS (>120 msec):BBB
- Additional AV block 1°, 2°or 3° (possible in all
supraventricular beats except in AV reentry
tachycardias)
 Analysis of Rhythm
Ventricular rhythm (in most cases: AV
dissociation)
-Tachycardia: ventricular tachycardia
- Bradycardia: ventricular escape rhythm

Premature beats:
-Small QRS: SVPBs
-Broad QRS (> 120msec): VPBs
-Differential diagnosis: SVPBs with aberration

Arrhythmias not fulfilling the criteria

mentioned above
Analysis of Rhythm: Step 1
Regular or irregular?
- Regular:
1. in most cases normal SR
2. pathologic regular rhythms: escape rhythms,
SVT or VT
- Irregular:
1. the most frequent reason is regular SR with
SVPBs and VPBs;
2. complete irregularity of the R-R intervals: atrial
fibrillation
Analysis of Rhythm: Step 2
P waves?
- Normal (sinusal p) wave present
!SR
- Abnormal (nonsinusal) p waves
present ! atrial rhythm
- No p waves ! AV junctional
rhythm
- Replacement of p waves by other
atrial waves ! atrial flutter or atrial
fibrillation
Analysis of Rhythm: Step 3
R waves?
- Ventricular rate:
Eventually rate of the
abnormal (nonsinusal) p
waves or flutter waves
- QRS duration normal (<90
msec) or prolonged?
- QRS>120 msec: pattern of
BBB
- Tachycardia
- Bradycardia
Analysis of Rhythm: Step 4
Narrow Complex Tachycardia
- Measure rate and regularity
- Look for P-QRS relationship
- If p > QRS ! atrial arrhythmia
- If p = QRS ! look for timing of p
waves
p in ST segment ! AVRT, p fused with QRS ! AVNRT

- If p < QRS ! junctional tachycardia

Analysis of Rhythm: Step 5
Wide Complex Tachycardia
• VT
• SVT with:
Aberrant ventricular conduction
Preexisting left or right bundle branch block
Preexisting intraventricular conduction defect
Antegrade conduction through AP
Analysis of Rhythm: Step 6
Wide Complex Tachycardia
- AV dissociation
- Capture or fusion beats
- QRS axis between -90 and +180
- Positive QRS deflections in all of the
precordial leads
- LBBB with right axis deviation or R in V1-
V2 > 0.03s
- notching of downstroke of S in V1-V2
 A-V Dissociation, Fusion, and
Capture Beats in VT
V1 E F C

ECTOPY FUSION CAPTURE

Fisch C. Electrocardiography of Arrhythmias. 1990;134.
Analysis of Rhythm: Step 7
PQ interval- ? prolongation or
shortening
- P waves are partially conducted, and
partially not conducted, in variable
manners: in the three forms of AV block
- No p wave is conducted: This means that
the atria and ventricles are working
independently from each other, in the
presence of AV block 3 (complete AV
block)
- P waves are twisting around the QRS
complexes (in the special forms of AV
dissociation)
AV Block
 Morphologic analysis of
components of the ECG: Step 1
P wave
1. Normal (sinusal)? (P duration 90-110 msec);
note that a negative p in lead I means ’false
poling’ of the limb leads in 99% of the cases
2. Pathological p-waves
• p duration >110 msec, accentuated terminal
negativity in lead V1: LA enlargement
• P voltage > 2.5 mm in leads III and aVF: RA
enlargement
• Summation of both LA and RA enlargement:
biatrial enlargement
P waves
P waves
 Morphologic analysis of
components of the ECG: Step 2
QRS
1. Frontal QRS axis
2. Broad QRS?
– Typical configuration of aberration: RBBB (QRS>
120 msec) or LBBB (>140 msec);
– more or less typical BBB (>160 msec): suspicious
for severe hyperkalemia
– Typical pattern of bilateral BBB (RBBB+ LAFB or
RBBB + LPFB)
– Atypical BBB-like configuration (QRS>150 msec):
suspicious for ventricular origin of rhythm, generally
with AV dissocation1. 2.
 Morphologic analysis of
components of the ECG: Step 3
Pathologic Q or QS waves?
1. Typical for old MI? (combined with symmetric
negative T waves)
2. Atypical for old MI? (combined with asymmetric
discordant T waves)
Differential Dx:
• Artifact: Q/QS in lead: false poling of limb leads (differential
diagnosis: sinus inversus)
• Normal variant:
• LVH [QR or QS in lead (‘QIII’)]
• Pre-excitation (QS in III, a VF)
• Hypertrophic (obstructive) cardiomyopathy
• LBBB (QS in III, aVF, V1 to V4, with duration>140msec)
 Morphologic analysis of
components of the ECG: Step 4
ST elevation
• Normal variants: ST (in V2/V3)’early
repolarization’
• Pathologic: typical for acute MI:
• Pathologic: Typical for acute pericarditis:
frontal ST vector about +70. ST elevations in
leads aVF, II and I
• Pathologic: typical for mirror images of ST
depression: e.g. in LVH; systolic LV
overload
 ECG Diagnosis of AMI
! Pathological Q wave (can be normal in III and aVR): Limb
leads – 25% R Wave, 0.04s
• ST segment elevation occurs within 24h and may last 2 weeks
" Significant ST segment elevation: "1mm (0.10 mV) in two or
more limb leads or precordial leads V4-V6 or "2mm (0.20 mV)
in two or more precordial leads V1-V3.
" The ST segment elevation of myocardial infarction is usually
upwardly convex.
• T wave inversion
• Others – ST depression, axis shift, new onset left bundle
branch block, arrhythmias
ECG Localization of MI
Acute Anteroseptal MI
Acute Inferior MI
Acute Pericarditis
 AMI vs. Pericarditis
• Leads with ST segment elevation in AMI are
more localize than the diffuse changes in
pericarditis
• the presence of reciprocal ST depression
over other leads during AMI
• PR segment depression during acute
pericarditis
Typical ECG of
Brugada
syndrome:
Note the pattern
resembling a
right bundle
branch block,
the P-R
prolongation and
the ST elevation
in leads V1-V3.
 Morphologic analysis of
components of the ECG: Step 5

ST depression
• Ischemic
• LVH-LV overload
• Related to BBB or other conditions
• digoxin
ECG Changes during Ischemia
 Left Ventricular Hypertrophy
• S (in V1) + R (in V5 or V6) >35mm (7 big squares)
" Downsloping ST depression and asymmetrical T wave inversion-
“strain pattern” are present.
• [Limb lead criteria : R (in I) + S (in III) > 25mm]

Hampton, 1998
Digoxin Effect
 Morphologic analysis of
components of the ECG: Step 6
T (and U) waves
1. Asymmetric T negativity?
• Normal in lead V1; normal in vertical axis in a VF,
III (II); normal in left axis: in aVL
• Pathologic in LVH; LV overload; pre-excitation ;
BBB
2.Symmetirc T negativity?
• Often ischemic, other DDx: Later stage of
pericarditis; LVH; LV overload; acute pancreatitis;
drugs etc
 Morphologic analysis of
components of the ECG: Step 7
T (and U) waves
3. High and symmetric T?
• Ischemia (rare, because short-lasting)
• Hyprkalemia
4. U negativity?
• Ischemic
Hyperkalemia
 Morphologic analysis of
components of the ECG: Step 8
QT interval
1. QT prolonged
• ‘Long QT syndromes’
• Hypocalcemia
2. QT shortened : hypercalcemia
3. Fusion of T and U : hypokalemia
Gene-Specific ECG Patterns of LQTS

Adapted from Moss, et al, LQTS Registry, 1998

Hypokalemia
 Right Ventricular
Hypertrophy (RVH)

Dominant R in V1
Right Axis Deviation
(Ddx : Posterior MI
RBBB
WPW)
Possible ECG Signs in Acute
Pulmonary Embolism
ECG in Acute Pulmonary Embolism
ECG Quiz
Case 1. F/18 C/O Palpitation and syncope
 Q 1. What is the ECG diagnosis ?

A. AF
B. VT
C. VF
D. Atrial tachycardia
 Case 2
45 year old policeman admitted with syncope
 Q 2. What is the ECG diagnosis ?

A. Sinus rhythm
B. Atrial premature beat
C. Second degree AV block
D. Sinus arrhythmia
Q 3. What is the causes of his syncope ?

A. Vasovagal syncope
B. Ventricular tachycardia
C. Second degree AV block
D. None of the above
Case 2-Tilt Table Test
 Case 3
50 year old man presented with pre-syncope
 Case 3
50 year old man presented with pre-syncope
 Q 4. What is the ECG diagnosis ?

A. Sinus rhythm
B. Atrial flutter
C. Ventricular tachycardia
D. Supraventricular tachycardia
 Case 4
30 year old man presented with palpitation
 Case 4
After ATP injection
 Q 5. What is the ECG diagnosis ?

A. Atrial tachycardia
B. Atrial flutter
C. Ventricular tachycardia
D. Supraventricular tachycardia
 Case 5
30 year old lady admitted with syncope
 Q 6. What is the ECG diagnosis ?

A. Sinus rhythm
B. Atrial flutter
C. Ventricular tachycardia
D. Atrial tachycardia
 Case 5
12 Lead ECG
 Clinical Consequences of
Electrocardiographic Artifact Mimicking
Ventricular Tachycardia
Knight et al. N Engl J Med 1999; 341:1270-1274.

• 12 patients received at least one unnecessary

intervention solely because of the misdiagnosis of
artifact as ventricular tachycardia.
• The unnecessary intervention include
antiarrhythmic therapy to as drastic as the
implantation of a permanent pacemaker or an
implantable cardioverter–defibrillator.
• These findings indicate the importance of improved
training in the recognition of artifact and the need for
a heightened index of suspicion among physicians
who treat patients with arrhythmias.
The "Notches Sign" of Wide-Complex Artifact
Littmann L. Engl J Med 2000; 342:590
 Case 6
50 year old man presented with acute chest
pain
 Q 7. What is the ECG diagnosis ?

A. Acute myocardial infarction

B. Acute pericarditis
C. Acute pulmonary embolism
D. Hypertrophic cardiomyopathy
 Q 8. Which of the following ECG feature is
useful to make the diagnosis myocardial
infarction in the presence of LBBB?
A. ST-segment depression > 5 mm that was
discordant with the QRS complex
B. ST segment elevation > 2 mm over V1-V3
C. ST segment depression > 1 mm over the
inferior lead
D. ST-segment elevation > 5 mm that was
discordant with the QRS complex
Electrocardiographic diagnosis of evolving
acute myocardial infarction in the presence
of left bundle-branch block.
Sgarbossa et al. N Engl J Med 1996;334:481-487.

• ST-segment elevation equal to or greater than 1

mm in the presence of a positive QRS complex;
• ST-segment depression equal to or greater than 1
mm in lead V1, V2, or V3;
• ST-segment elevation equal to or greater than 5
mm in the presence of a negative QRS complex.
 Case 7
70 year old lady presented with chest
discomfort
 Q 9. What is the ECG diagnosis ?

A. Acute myocardial infarction

B. Acute pericarditis
C. Acute pulmonary embolism
D. None of the above
 Q 10. Which of the following ECG feature
indicates a proximal LAD stenosis as the cause
of myocardial infarction?

A. RBBB
B. ST segment elevation > 5 mm over V4-V6
C. ST segment elevation > 1 mm over the
inferior lead
D. ST-segment elevation > 1 mm over V5
 Value of the electrocardiogram in
localizing the occlusion site in the LAD in
anterior AMI
Engelen et al. JACC;343:89-95.

ST # V1 > 2.5 mm Proximal to S1

RBBB Proximal to S1
ST # aVR Proximal to S1
ST $ V5 Proximal to S1
Q aVL Proximal to D1
Inferior ST $ > 1mm Proximal to S1/D1
Case 8. 75 year old man presented with
syncope
 Q 11. What is the ECG diagnosis ?

A. Acute Inferior MI + prolonged PR

interval
B. Acute inferior MI + second degree
AV block
C. Acute inferior MI + CHB
D. Acute inferior MI + accelerated
junctional rhythm
 Q 12. Which of the following ECG feature
indicates a poor prognosis during inferior
myocardial infarction?
A. Prolonged PR interval
B. ST segment elevation in V4 or V5 in right
sided ECG
C. ST segment elevation > 1 mm over the
inferior lead
D. ST-segment depression > 1 mm over V4-V6
Q 13. Which of the following ECG feature
in V4R indicates a proximal RCA
occlusion during inferior myocardial
infarction?
A. ST segment depression
B. ST segment elevation
C. ST segment isoelectric
D. None of the above
 Case 9
25 year old lady presented with palpitation
 Q 14. What is the ECG diagnosis ?

A. Sinus tachycardia
B. Atrial tachycardia
C. Junctional rhythm
D. Sinus arrhythmia
 Case 10
35 year old man presented with palpitation
 Q 15. What is the ECG diagnosis ?

A. Sinus tachycardia
B. Atrial tachycardia
C. Junctional tachycardia
D. Atrial flutter
 Case 11
65 year old man with COPD
 Q 16. What is the appropriate treatment
for this patient ?

A. Pacemaker implantation
B. Electrophysiology study
C. Beta-blocker
D. None of the above
 Case 12
75 year old man with palpitation
 Q 17. What is the ECG diagnosis ?

A. Ventricular tachycardia
B. Atrial tachycardia
C. Junctional tachycardia
D. PSVT with aberrant conduction
 Case 13
55 year old man with palpitation
 Q 18. What is the ECG diagnosis ?

A. AF + Ventricular ectopy
B. AF + aberrant conduction
C. AF + AV block
D. Atrial flutter with variable block
 Case 14
65 year old man with no symptom
 Q 19. What is the ECG diagnosis ?

A. Idioventricular rhythm
B. Junctional rhythm
C. Second degree AV block
D. Atrial flutter with variable block
 Case 15
35 year old man with severe dyspnea
Q 20. What is the likely cause of his
symptom ?
A. Pulmonary embolism
B. Pericardial effusion
C. Asthma
D. Myocardial infarction
 Case 16
45 year old man with severe dyspnea and
echocardiogram showed LVH
Q 21. What is the likely cause of his symptom ?

A. Hypertrophic cardiomyopathy
B. Restrictive cardiomyopathy
C. Sacroidosis
D. Amyloidosis