ECG Dr.

Shaf3y

ECG

4
2013 12

ECG

ECG
exam oriented

mentality

Anyway

ECG
limbs electrodes Limb leads
Limbs
6 leads
AVF AVL AVR Lead 3 lead 2 lead 1

chest leads
V1, V2, V3, V4, V5 and V6

AVR

Page | 1
ECG Dr. Shaf3y

ECG

second << 0.04

0.08 second 2 X 0.04 P wave

0.1

ECG

ECG

lead lead lead

aVF aVL aVR
V3 V2 V1
V6 V5 V4

Page | 2
ECG Dr. Shaf3y

P QRS R wave P QRS T wave lead

P QRS T wave P QRS T wave lead
lead

Lead

Long strip

Long strip
lead lead
aVF

ECG

rhythm
rhythm
Long strip

rhythm
Long strip
irregular regular << rhythm
Rs

Regular

Rs RRR
Irregular

long strip ECG

3 Lead
3 lead

Page | 3
ECG Dr. Shaf3y

rhythm
Long strip

Long strip
3 lead
irregular regular << rhythm

3
irregular regular
rhythm
3

rhythm

rhythm
rate
rate

regular rhythm
300 rate

QRS QRS
rate
150 300 / 2

3
100 300 / 3

1500 rate

<< <<

Page | 4
ECG Dr. Shaf3y

13
rate
115.38 13 1500
115

regular rhythm heart rate

regular rhythm
irregular << rhythm
heart rate irregular << rhythm
30

30

5
heart rate
50 10 X 5

30

30 15
15
30
30 30

Page | 5
ECG Dr. Shaf3y

rhythm heart rate

Axis
Axis

P vector << English school

vector

SA node
SA node
SA node

ventricles AV node
both ventricles

Axis

SA node
Axis

Axis

Axis

aVF lead lead

Page | 6
ECG Dr. Shaf3y

aVF

QRS

QRS

QRS
Positive << QRS Lead
Positive

lead
positive QRS
normal

lead
positive << QRS
aVF lead
Positive << QRS
Axis is normal
Axis is normal

left ventricle << heart

left axis
Left

right ventricle

right axis deviation axis

Page | 7
ECG Dr. Shaf3y

Left ventricle
left axis deviation

right axis deviation Left

Lead
negative << QRS

aVF lead
positive << QRS

QRS

QRS

right axis deviation

QRS
positive lead
negative lead

left axis deviation

right axis deviation

Right ventricular enlargement

Page | 8
ECG Dr. Shaf3y

Right bundle branch block

Left axis deviation

Left ventricular enlargement
Left bundle branch block
axis

rhythm
Long strip
long strip

3 lead
rate
regular
300
1500

Irregular
30
rhythm

axis
aVF lead lead
Normal Positive

Negative aVF lead positive Lead

left axis deviation

positive aVF lead negative Lead

right axis deviation

axis rate rhythm

lead
lead
PR P

lead
Lead

Page | 9
ECG Dr. Shaf3y

PR P

P wave
P wave
2.5 X 2.5

2.5

2.5

lead
Lead
2.5 X 2.5

P wave

3 2.5 P wave
P mitral
Left atrial enlargement

P mitral

2.5 P wave
P pulmonale

Right atrial enlargement

Mitral Normal

Page | 10
ECG Dr. Shaf3y

V1
Normal P mitral P pulmonale

V1

V1
biphasic P wave

V1
biphasic P wave

right atrium
left atrium

activate SA node
right atrium
Left ventricle activate
right SA node

wave
right atrium
wave
Left atrium

Negative positive

right atrial enlargement wave

P wave
negative Positive biphasic
right atrial enlargement Positive
left atrial enlargement negative
Lead

Page | 11
ECG Dr. Shaf3y

absent << P wave

is absent << P wave

AF

irregular << rhythm

AF

regular << rhythm

regular << rhythm
P wave
QRS

QRS

wide << QRS

wide
3 QRS
3

3
Wide QRS
Ventricular tachycardia
Ventricular fibrillation

narrow << QRS

supra ventricular tachycardia

Nodal rhythm

rate
<< supra ventricular tachycardia

Page | 12
ECG Dr. Shaf3y

Nodal rhythm

Sawtooth appearance
atrial flutter

Lead

PR P

P wave
2.5 X 2.5

left atrial enlargement P mitral

right atrial enlargement P pulmonale

V1 P wave

Atrial flutter << Sawtooth << P wave

<< P wave
AF << irregular << rhythm

regular << rhythm

QRS
Wide
Ventricular fibrillation
ventricular tachycardia
Narrow
supra ventricular tachycardia
Nodal rhythm

supra ventricular tachycardia

nodal rhythm Nodal rhythm

Page | 13
ECG Dr. Shaf3y

P wave

PR interval
PR
Lead

PR
QRS P
5 3 << Normally

second << 0.2 0.1

0.4

0.12 0.04 X 3

0.20 0.04 X 5

PR

normal l PR

prolonged << PR
5
st
1 degree heart block

First degree heart block

3 PR
Wolff-Parkinson-White WPW

variable << PR

Page | 14
ECG Dr. Shaf3y

variable

PR variable
Lead

P QRS P QRS P QRS

variable << PR
ECG

Variable QRS
QRS
<< wide << QRS
complete heart block
Complete heart block

wide << QRS

complete heart block

wide QRS
3 << QRS
complete heart block

<< narrow << QRS

second degree heart block
Mobitz two Mobitz one
Wenckebach
PR

wide QRS
Complete heart block

Page | 15
 ECG Dr. Shaf3y

Narrow QRS
second degree heart block
PR

QRS
QRS

rhythm

long strip

irregular regular

long strip
lead

rate
regular << rhythm
300
1500

Irregular << rhythm

10 30

Axis
lead axis
aVF Lead Lead
Normal axis deviation << positive aVF lead Positive Lead
left axis deviation << negative aVF lead positive lead
right axis deviation << positive aVF lead negative lead

Lead

P wave

Page | 16
ECG Dr. Shaf3y

PR interval

Normally << P wave

2.5 X 2.5

P mitral <<
left atrial enlargement

P pulmonale <<
right atrial enlargement

Lead
V1 P wave
Negative positive << biphasic << P wave
right atrium
left atrium

right atrial enlargement

left atrial enlargement

Sawtooth
atrial flutter

rhythm absent << P wave

Regular
irregular

irregular
AF

regular
QRS

Wide QRS
Ventricular tachycardia
ventricular fibrillation
Narrow << QRS
supra ventricular tachycardia
Nodal rhythm

Page | 17
ECG Dr. Shaf3y

rate
<< supra ventricular tachycardia

Nodal rhythm

PR
lead
Lead

Normally << PR
5 3

5
first degree heart block

3
Wolff-Parkinson-White WPW

variable PR interval
QRS
complete heart block << wide QRS
Second degree heart block << narrow QRS

Preexcitation syndrome Wolff-Parkinson-White WPW

Nodal

QRS

QRS

QRS comment
V1

Page | 18
ECG Dr. Shaf3y

V1

<< V1
RSR
right bundle branch block

RSR
right bundle branch block V1

V6

V
V1

V6

V6
left bundle branch block

V1 RSR
right bundle branch block

V6
left bundle branch block

V1

V1

normally << V1
biphasic P wave

Page | 19
 ECG Dr. Shaf3y

RS
Normal

QRS ECG

heart ECG

Heart heart electrodes

QRS ECG

P wave negative wave Q wave
P wave Positive R wave
P wave
Q wave <<
R wave <<

S wave
R wave negative

S wave

RS << normally V1

ECG
positive << electrode

electrode
Positive

Page | 20
ECG Dr. Shaf3y

electrode
Negative

electrode
Positive
negative

heart
Inter ventricular septum

bundle of His AV node

left bundle right bundle

V4 V3 V2 V1
V6 V5
chest leads

bundle of His AV node

septum
septum activate
left bundle branch
from left to right
activation Left

V1
Positive

left ventricle right ventricle

At the same time

V1
right
right

Page | 21
ECG Dr. Shaf3y

Positive right
Negative left left

Positive Negative
Left ventricle
rS
r << V1
right ventricle septum r

S
Left ventricle

septum right ventricle

r

left ventricle
S

V6

bundle of His
septum
negative
Q <<

ventricle

left ventricle

Positive

right

Negative
s wave
QRS V6

Page | 22
ECG Dr. Shaf3y

septum
R
Left ventricle
s
right ventricle

right ventricular enlargement

V1
r
R

left ventricular enlargement

V6
septum Q
left ventricle R
right ventricle S

right ventricular enlargement

S V6

left ventricular enlargement

R V6

septal hypertrophy
V1
R

V6
Q

V
V1

Page | 23
ECG Dr. Shaf3y

V1
right bundle branch block <<

V6
left bundle branch block <<

right bundle branch
block
right

right bundle
V1

septum
septum activation
Left
r
Left ventricle

right ventricle activation wall

right bundle branch

septum

activation
From left to right
Positive r
V1

left bundle branch left ventricle

V1
negative S

Page | 24
ECG Dr. Shaf3y

right ventricle
wall

activated right ventricle

activated
V1
V1
R
R

left bundle branch block

V6

left bundle branch

Left bundle branch
right bundle branch

septum
left bundle
septum activation
right bundle branch
left right

septum activation
Positive
right ventricle

negative
left ventricle activation wall
positive
RSR

Page | 25
 ECG Dr. Shaf3y

R RS

V1
right bundle branch block

V6
left bundle branch block

V1

V1

V1
S R V1
right ventricular enlargement

r
right ventricle septum
s R
S r V1

V6 V1 S
V6 V1 R wave

capital << R small letter r ECG

capital R letter

Small r
small s capital S S wave

r
right ventricle septum
s R
r
right ventricular enlargement << S R

Page | 26
ECG Dr. Shaf3y

V6
V6 V1

V6
P QRS T ECG
septum Q
left ventricle R
right ventricle S

5 R
left ventricular enlargement
Left ventricle R

septum Q
right ventricle S

V1
Right bundle branch block

V6

Left bundle branch block

V1
right ventricular enlargement S R
septal hypertrophy septal hypertrophy

V6
5 R
left ventricular enlargement

V1

Page | 27
ECG Dr. Shaf3y

V2 V1
V6 V5

V1
V6
S R V1
5 R V6

leads QRS
leads QRS

Leads QRS

Pathological Q

Pathological Q

Pathological Q
Pathological Q

Q
Q complex PQT

R 1/3 Q
pathological Q R Q

Pathological Q

pathological Q
Old myocardial infarction

Old

pathological Q
Old inferior MI aVF

Page | 28
 ECG Dr. Shaf3y

Pathological Q
V4 V3 V2 V1
old anterior MI

pathological Q
V6 V5
old lateral MI

High lateral
Low lateral
extensive anterior antero-septal
right bundle left anterior hemi-block left posterior hemiblock left anterior hemiblock

Spot diagnosis
ECG
left ventricular enlargement left anterior hemi-block
left anterior
Spot diagnosis

ECG

Over

Page | 29
ECG Dr. Shaf3y

12 ECG

ECG
ECG
12 << ECG

ECG

pathological Q

pathological Q
leads
aVF
old inferior MI

V4 V3 V2 V1
old anterior MI

V6 V5
old lateral MI

aVL
High lateral

Page | 30
 ECG Dr. Shaf3y

topographism

leads of ECG Wall of the heart

topographism

topographism
topographism
wall artery Leads

Lateral Inferior anterior

Leads Wall

II - III - aVF Inferior

I - aVL High lateral wall

V1 - V2 Septal ( antro-septal)

V3 - V4 Strict anterior

V5 - V6 Low lateral

V1 - V3R V6R RV free wall

Louis Leads Atrial Activity

N.B. posterior wall potentials are recorded in the anterior leads as a mirror
image for waves provided to be drawn in the posterior leads because posterior
leads are technically difficult to be made.

pathological Q
width of the QRS
3
wide QRS

already
P
wide QRS
Ventricular tachycardia
Ventricular fibrillation

Page | 31
ECG Dr. Shaf3y

QRS
P wave wide QRS

QRS
leads ST segment

leads ST segment

ST segment
PR

ST segement
elevation << ST segment

PR ST segment elevation

Pericarditis
Myocardial infarction
Prinzmetals angina

Pericarditis
Leads ST segement elevation

Myocardial infarction Angina

some leads

myocardial infarction angina

Cardiac enzymes
infarction

timing
elevated ECG ECG
myocardial infarction

Page | 32
 ECG Dr. Shaf3y

angina

ST segment depression

ST segment depression

ST segment depression
Digitalis
Hypokalemia
angina
Myocardial infarction
Pericarditis
cardiac hypertrophy
bundle branch block

myocardial infarction angina hypokalemia pericarditis digitalis ST segement depression
bundle branch block Hypertrophy

Digitalis
hypokalemia
pericarditis
diffuse ST segment depression
Leads

Leads ST segment depression

digitalis
sagging ST segment depression

pericarditis Hypokalemia

hypokalemia

Page | 33
ECG Dr. Shaf3y

serum potassium

Pericarditis
stitchy << pain clinically

Leads ST segment depression

digitalis

some leads
angina
myocardial infarction
hypertrophy
bundle branch block

ST segment depression
V3 V2 V1
right ventricle Leads

right ventricle
V3 V2 V1

ST segment depression
V3 V2 V1
right ventricular hypertrophy
strain pattern

right ventricular hypertrophy

With strain pattern

secondary changes

left ventricular enlargement

V6 V5 V4 ST segment depression

Page | 34
 ECG Dr. Shaf3y

right bundle branch block

V3 V2 V1 ST segment depression

V6 V5 V4 ST segment depression left bundle branch block

V1

Right bundle branch block

ST segment
depressed
right bundle

right bundle branch block

anterior wall angina ST segment depression
anterior wall ischemia

ST segment depression
right ventricular hypertrophy right bundle branch block

left ventricular enlargement

left ventricular enlargement V6
V6 V5 V4
ST segment depression
left ventricular hypertrophy secondary

ventricular hypertrophy
bundle branch block
angina

ST segment depression
angina
hypertrophy leads
bundle branch block angina angina
exercise ECHO ST segment depression already Hypertrophy

Page | 35
 ECG Dr. Shaf3y

ST segment depression already Exercise ECG

T wave

ST segment elevation
Hyper acute T

ST segment depression
T wave ineversion

ECG ECG

Exam oriented

ECG

rhythm

rhythm strip
rhyhm
irregular Regular

long strip
3 lead

rate
rhythm regular
300
1500

irregular rhythm
30

Axis
aVF lead lead
Normal axis deviation << positive aVF lead Positive Lead

Page | 36
 ECG Dr. Shaf3y

left axis deviation << negative aVF lead positive lead

right axis deviation << positive aVF lead negative lead

lead

P wave
PR interval

Normally << P wave

2.5 X 2.5

P wave
right atrial enlargement P pulmonale

P wave
left atrial enlargement P mitral

P wave
V1

sawtooth << P wave

atrial flutter

absent P wave
irregular regular << rhythm
AF << irregular << rhythm

<< regular << rhythm

QRS
wide QRS
Ventricular tachycardia
ventricular fibrillation

narrow QRS
Supra ventricular tachycardia
nodal rhythm

Page | 37
ECG Dr. Shaf3y

PR interval

normally << PR
5 3

first degree heart block

WPW

Variable PR interval
QRS
complete heart block << wide QRS
second degree heart block << narrow QRS

QRS
V1
right bundle branch block

V6
Left bundle branch block

ST segment
right bundle branch block
V3 V2 V1 T wave inversion ST segment depression

left bundle branch block

V6 V5 V4 T wave inversion ST segment depression
secondary changes

Page | 38
ECG Dr. Shaf3y

Secondary changes

V1
V6

V1

S R
right ventricular enlargement

V6
left ventricular enlargement R

Leads QRS complex

pathological Q

old myocardial infarction

Inferior aVF lead lead
high lateral aVL Lead

ST segment
ST segment elevation
pericarditis leads

Myocardial infarction Leads

Prinzmetals angina
Myocardial infarction

ST segment depression
Leads
Digitalis
hypokalemia
pericarditis

Page | 39
 ECG Dr. Shaf3y

Digitalis
sagging

ST segment depression
leads
Angina
cardiac hypertrophy bundle branch block exclusion

ST segment elevation
hyper acute T

ST segment depression
inversion of T wave

rhythm strip
rhythm strip
ECG
lead

rhythm strip
rhythm strip

Rhythm Strip

rhythm strip
P rhythm strip

rhythm strip

P wave
P wave

present P wave

Page | 40
ECG Dr. Shaf3y

regular long strip

tachycardia rate

QRS

deformed

Narrow normal

deformed

ventricular tachycardia

Narrow normal
P
P wave

single

multiple

sinus tachycardia single

QRS T P wave

multiple P

Atrial flutter

Supra ventricular tachycardia

Page | 41
ECG Dr. Shaf3y

deformed QRS

ventricular tachycarida

sinus tachycardia

multiple P

Atrial flutter

P wave
Supra ventricular tachy cardia

Regular bradycardia

Sinus bradycardia

first degree heart block

Mobitz two

third degree heart block

Nodal rhythm

regular bradycardia
sinus bradycardia

first degree heart block

Just prolonged PR interval

Page | 42
ECG Dr. Shaf3y

Mobitz two
regular drop of QRS complex

third degree heart block

deformed QRS
AV dissociation

nodal rhythm
peace maker A.V. node
peace maker A.V. node
P
inverted
absent QRS

regular bradycardia

QRS

deformed

Narrow normal

deformed
third degree heart block

Narrow normal

P wave

P wave

single

Multiple

first degree heart block sinus bradycardia single

Page | 43
 ECG Dr. Shaf3y

first degree heart block

just prolonged PR interval

multiple P wave
Mobitz two
Atrial flutter Mobitz two
bradycardia Mobitz two
tachycardia atrial flutter

Noda rhythm

long strip diagnostic approach

QRS rate rhythm
P

segmented
P
QRS
ST segment

Long strip

ECG

8
2013 13

Page | 44
 ECG Dr. Shaf3y

www.facebook.com/dr.tafreegh

Page | 45