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BASIC ECGBASIC ECG
INTERPRETATIONINTERPRETATION
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ECGECG
electrocardiogramelectrocardiogram ((ECGECG ororEKGEKG,,abbreviated from the Germanabbreviated from the German
ElektrokardiogrammElektrokardiogramm)) electroelectro, becauseitis relatedtoelectrical, becauseitis relatedtoelectrical
activityactivity
cardiocardio,, GreekGreek for heart,for heart, gramgram, a Greek root meaning"to write"., a Greek root meaning"to write".
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IndicationsIndications
Todetermine cardiac rateTodetermine cardiac rate
To accuratelydefine cardiac rhythmTo accuratelydefine cardiac rhythm
Todiagnoseoldor new MITodiagnoseoldor new MI Toidentifyintracardiac conductionToidentifyintracardiac conduction
disturbancesdisturbances
To aidin thediagnosis ofischemic heartTo aidin thediagnosis ofischemic heartdiseaseelectrolytes abnormalities anddiseaseelectrolytes abnormalities andpacemakermalfunctionpacemakermalfunction
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PROPER LEADS PLACEMENTPROPER LEADS PLACEMENT
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PROPER LEADS PLACEMENTPROPER LEADS PLACEMENT
Lead V1 is placedin the fourth intercostal space to therightof the sternum
Lead V2 is placedin the fourth intercostal space to theleftof the sternum
Lead V3 is placeddirectly between leads V2 and V4 Lead V4 is placedin the fifth intercostal spacein the
midclavicularline(even if theapex beatis displaced) Lead V5 is placed horizontally with V4 in the anterior
axillaryline
Lead V6 is placed horizontally with V4 and V5 in themidaxillaryline
.
.
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PROPER LEADS PLACEMENTPROPER LEADS PLACEMENT
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MeasurementMeasurement
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Six components of ECGSix components of ECG
InterpretationInterpretation RateRate
RhythmRhythm
AxisAxis HypertrophyHypertrophy
Ischemia andinfarctionIschemia andinfarction
Miscellaneous findings (including normalMiscellaneous findings (including normalvariants)variants)
Mnemonic: RRAHIMMnemonic: RRAHIM
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RateRate
Formula:Formula:
HRHR == 15001500# of small square# of small square
== 300300
# of big boxes# of big boxes
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RateRate
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RateRate
ShortcutShortcut
If R to R intervalis > 5 big squares:If R to R intervalis > 5 big squares:
BradycardiaBradycardiaIf R to R interval between 3If R to R interval between 35 big5 bigsquares:squares:
NormalrateNormalrateif R to R intervalis < 3 big squares:if R to R intervalis < 3 big squares:
TachycardiaTachycardia
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AxisAxis
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AxisAxis
Lead ILead I Lead AVFLead AVF
NormalNormal ++ ++
Left axisLeft axis
deviationdeviation++ --
Right axisRight axis
deviationdeviation
-- ++
IndeterminateIndeterminate
axisaxis-- --
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Differential Diagnosis of Right andDifferential Diagnosis of Right andLeft Axis DeviationLeft Axis Deviation
LADLAD RADRAD
Normalvariant( short &Normalvariant( short &
fatindividualsfatindividuals
LVHLVH
Inferior wallinfarctionInferior wallinfarction
LBBBLBBB
LAHBLAHB
WPWSWPWS
Normalvariant( thin, tallNormalvariant( thin, tall
individuals)individuals)
RVHRVH
Lateral wallinfarctionLateral wallinfarction
Pulmonary EmbolismPulmonary Embolism
LPHBLPHB
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AxisAxis
causes of a Northwest axis (no man'scauses of a Northwest axis (no man'sland)land)
emphysemaemphysema hyperkalaemiahyperkalaemia
lead transpositionlead transposition
artificial cardiac pacingartificial cardiac pacing ventricular tachycardiaventricular tachycardia
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RhythmRhythm
Commom Rhythm Interpretations:Commom Rhythm Interpretations:1.1. Sinus rhythmSinus rhythm2.2. Arrhythmias ( AF, AtrialFlutter, SVT)Arrhythmias ( AF, AtrialFlutter, SVT)
3.3. Heart BlocksHeart Blocks-- firstdegree AV Blockfirstdegree AV Block-- Seconddegree AV Block ( Mobits Type 1 andSeconddegree AV Block ( Mobits Type 1 and22
-- Thirddegree AV BlockThirddegree AV Block-- LBBB and RBBBLBBB and RBBB
4. Ventricular arrhythmias ( PVC, VT , VF)4. Ventricular arrhythmias ( PVC, VT , VF)
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Sinus rhythmSinus rhythm P waveis presentP waveis present Each QRS is preceded by a P waveEach QRS is preceded by a P wave HR 60HR 60 -- 100100
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Sinus arrhythmiaSinus arrhythmia
PP--P intervalvary bymore than 10%P intervalvary bymore than 10%
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AtrialFibrillationAtrialFibrillation P waves are absentP waves are absent Irregular RIrregular R--R intervalR interval
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AtrialFlutterAtrialFlutter sawtooth patternsawtooth pattern absenceof P waveabsenceof P wave
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Premature Atrial contractionPremature Atrial contraction
P wave thatdiffers in morphologyP wave thatdiffers in morphology
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Premature Ventricular ContractionPremature Ventricular Contraction
bizzarelooking QRS complexbizzarelooking QRS complex
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HypertrophyHypertrophy
1.1. Atrial HypertropyAtrial Hypertropy
-- P wavemore than 3 small square wideP wavemore than 3 small square wide
A.A. RAHRAH-- largediphasic P wave with tallinitiallargediphasic P wave with tallinitialcomponent.component.
B. LAHB. LAH-- largediphasic P wave with widelargediphasic P wave with wideterminal component.terminal component.
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HypertrophyHypertrophy
Left ventricular hypertrophy (LVH)Left ventricular hypertrophy (LVH)There are many different criteria for LVH.There are many different criteria for LVH.
Sokolow + LyonSokolow + Lyon (Am Heart J, 1949;37:161)(Am Heart J, 1949;37:161) SV1+ R V5 or V6 > 35 mmSV1+ R V5 or V6 > 35 mm
Cornell criteriaCornell criteria (Circulation, 1987;3: 565(Circulation, 1987;3: 565--72)72) SV3 + R avl > 28 mm in menSV3 + R avl > 28 mm in men SV3 + R avl > 20 mm in womenSV3 + R avl > 20 mm in women
Framingham criteriaFramingham criteria (Circulation,1990; 81:815(Circulation,1990; 81:815--820)820)
R avl > 11mm, R V4R avl > 11mm, R V4--6 > 25mm6 > 25mm SV1SV1--3 > 25mm, SV1 or V2 +3 > 25mm, SV1 or V2 + R V5 or V6 > 35mm, R I + S III > 25mmR V5 or V6 > 35mm, R I + S III > 25mm
Romhilt + EstesRomhilt + Estes (Am Heart J, 1986:75:752(Am Heart J, 1986:75:752--58)58) Point score systemPoint score system
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Ischemia/InfarctIschemia/Infarct
IschemiaIschemia
-- T waveinversionT waveinversion
-- ST depressionST depression
InfarctionInfarction
-- ST elevationST elevation
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TREADMILL STRESS TESTTREADMILL STRESS TEST
FordiagnosisFordiagnosis
Atypical symptoms or symptoms suggestiveofAtypical symptoms or symptoms suggestiveofIHDIHD
Prognostic assessment and functional capacityPrognostic assessment and functional capacityevaluationevaluation
Blood pressureevaluationBlood pressureevaluation
Evaluation of therapy for arrhytmiasEvaluation of therapy for arrhytmias
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CONTRAINDICATION FOR TETCONTRAINDICATION FOR TET
PhysicaldisabilityPhysicaldisability
Acute non cardiac illnessAcute non cardiac illness
Acute MI ( within 2 days)Acute MI ( within 2 days) Suspected Leftmain coronary arterySuspected Leftmain coronary artery
stenosisstenosis
Uncompensated CHF( Class IIIUncompensated CHF( Class III--IV)IV)
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Uninterpretable ResultUninterpretable Result
Resting ST segmentdepression >1 mmResting ST segmentdepression >1 mm
Digitalis therapyDigitalis therapy
LVH with repolarization changesLVH with repolarization changes CLBBBCLBBB
PrePre-- excitation syndromeexcitation syndrome
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High risk parametersHigh risk parameters
Duration of symptomDuration of symptom--limitinglimitingexercise 120mmHg,or a sustaines dercrease >10 mmHgor a sustaines dercrease >10 mmHgduring progressiveexerciseduring progressiveexercise
ST segmentdepression of >2mmST segmentdepression of >2mm(downsloping type)(downsloping type)
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High risk parametersHigh risk parameters
ST segmentelevation ( AVR excluded)inST segmentelevation ( AVR excluded)ina non Q waveleada non Q wavelead
Reproducible sustaines ( >30 sec)orReproducible sustaines ( >30 sec)orsymptomatic VTsymptomatic VT
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INDICATIONS FORINDICATIONS FOR
TERMINATING A STRESS TESTTERMINATING A STRESS TESTModerate to severe anginaModerate to severe angina
Increasing nervous system symptomsIncreasing nervous system symptoms
Patient unable to continuedue toPatient unable to continuedue toexcessive fatigue, claudication, wheezing,excessive fatigue, claudication, wheezing,ordyspneaordyspnea
Achievemntof predictedmaximal heartAchievemntof predictedmaximal heartrate for agerate for age
Decreasing heartrateDecreasing heartrate
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INDICATIONS FORINDICATIONS FORTERMINATING A STRESS TESTTERMINATING A STRESS TEST
BP systolic >220 mmHg ordiastolic >115BP systolic >220 mmHg ordiastolic >115mmHgmmHg
BP drops by 10mmHg from baselineBP drops by 10mmHg from baselineindicativeofleftventriculardysfunctionindicativeofleftventriculardysfunction
When high risk exercise parameters areWhen high risk exercise parameters arealready present:already present:
--Ischemic ST segmentdepressionIschemic ST segmentdepression >> 3mmin3mminseveralleadsseveralleads
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INDICATIONS FORINDICATIONS FORTERMINATING A STRESS TESTTERMINATING A STRESS TEST
--Ischemic ST segmentelevationIschemic ST segmentelevation >> 1 mmin1 mmina nona non--Q wavw leadQ wavw lead
Unsustainedventricular tachycardiaUnsustainedventricular tachycardia Onsetof supraventricular tachycardia,Onsetof supraventricular tachycardia,
advanced AV block or bradyarrhythmiasadvanced AV block or bradyarrhythmias
Technical problems interfering with ECGTechnical problems interfering with ECGand BP interpretationand BP interpretation
Patient's desire to stop the testPatient's desire to stop the test
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THANKYOU!THANKYOU!