ELECTROCARDIOGRAPHY 2014 -2015

Dr. O. Payawal Jr. CARDIOLOGY

ELECTROCARDIOGRAPHY ECG MACHINE
Electro- means electricity noninvasive, inexpensive and readily available
Cardio- means heart
Just to interest you, if you have seen how ECG is done and how it
looks like. You see lines: some are straight, some are upright,
some are going down. But then by just looking at those lines, the
physician can say to the patient ohhh you have a heart attack;
ohhh you a blockage in your coronary artery or right ventricle
is peaked or your right atrium is peaked and yet when you
look at the paper, you just see lines. The physician can tell a lot by
just looking at the ECG of the patient, what is wrong to the
patient, what is the diagnosis of the patient. This is the purpose of
our lecture today so you can appreciate ECG.
Remember before the heart can even move or contract, it has to
be stimulated electrically otherwise the heart will not moved.
Okay? And this electrical activity comes from specialized cells
within the heart, known as pacemaker cells
And the real pacemaker of the heart is real structure located in
superior fossa of the right atrium, known as SA node- Sinoatrial
node
graphic recording of electric potentials produced by the heart-
you do not see electricity by your eyes, you need a machine to
record, right? And the ECG machine is a recorder, transmit it to
the lines that we see
you can tell to your patients especially to those who are first
times that is painless
We put electrodes in all extremities and likewise we put it on the
chestwall.
signals detected by metal electrodes attached to
extremities and chest wall and recorded by the
study of electrical activity of the heart (review the cardiac
cycle)
This is during 1920s- wherein the patient soaked their extremity in
electrical events preceding the contraction of the heart
electrical solution and mix the electrical impulses and recorded.
electrical events seen on ECG
(parang footspa lang lols )
Electrical activity
Originates from the pacemaker cells
st
ECG (1 slide)
can see enlargement of heart cavities
non invasive, inexpensive and readily available
warning: interpretation of machine is not reliable
R-leg is used only as a ground
ST
*REMINDER OF DOC- 1 TWO LECTURE IS THE MOST IMPORTANT:
ECG & CARDIAC DYSRTHYMIA--NEED TO FOCUS IN STUDYING THIS Now it is compact, small, portable and can be battery operated.
TOPIC (MORE THAN 30% OF EXAM WILL BE INCLUDED HERE ) You can bring it in the car, ambulance, train. In the rural settings
*Cardiomyopathy and infective Pericarditisread in your Harrison na when there is no electricity, you can do ECG because it is battery
lang daw operated. You dont need to be a cardiologist in order to read
ECG, even General Practitioner can read ECG.

There are some models now that can do interpretation but is not
accurate. Because the machine cannot distinguish artifacts for
the real ones. It is still need human mind, and thats the purpose
of our lecture today.

Magno Opere Somnia Dura Page 1 of 10 SHIELA & MITCHIE

ELECTROCARDIOGRAPHY 2014 -2015

Dr. O. Payawal Jr. CARDIOLOGY

Phase 3: Rapid Repolarization
Large amounts of K diffuse out as all K channels open
Resting or Polarized State (Phase 4) Inactvation of Ca channels
Charge = continuous to go down

Phase 4: Resting Phase

Na-K pump restores Na out
Cell membrane impermeable to Na ions
-
Charge = -90

The electrical events are produced by the influx and efflux of ions
of myocardial cells.

Cardiac cycle electrical events represented in the ECG

Since we will be talking about cardiac electrical activity here, there
is also corresponding electrical cardiac cycle because we are talking
about electrical events, thats the one being measured by
electrocardiography
There are stages/ phases in this electrical eventsit is one of the
basis which is measured by ECG machine
Remember electrical events precede cardiac contractile events.
In this phase, we called it phase 4 or resting phase or polarized
phase. If this is the plasma membrane of your cell membrane, it
does not only protect the cell, it has several functions: there are
several receptors there, wherein it receive signals from the outside
There are ionic channels, and the ones that are important in
cardiology are the sodium, potassium and calcium channel, as far
as this lecture is concern
In this particular phase, for example we label this as sodium
channel, it is closed, it is outside the cell and it carries positive
charge, so that the interior of the cell if we put in a microelectrode
is more negative than that of outside the cell because the protein If you put it in a graph, and you put a microelectrode inside the
inside the cell like the ribosome, endoplasmic reticulumthey are cell. You can see the normal concentration of the electrolytes or
predominantly negatively charged. the ions in the blood, then we check this to our patients. When
there is abnormality in the conduction of the heart, we request
DEPOLARIZATION-REPOLARIZATION CYCLE this routinely. For example: Cardiac arrhythmia (refer picture on
(Action Potential) left side)
Phase 0 : Rapid depolarization Resting phase or Phase 4- where the sodium channel ions
Sodium channels were initially closed, they now open up are closed, the interior of the cell is around negative 90 mv,
along the cell membrane so we are talking here of millivolts which is 1000 or 1 volt,
So there is now a surge of sodium ions inside the cell thats why when your sinus nodes fires, you dont get
carrying its positive charge, so that interior of the cell now electric circuit when your heart pumps. We have 220 volts
becomes positive in other cavity. That is why you need to have a machine to
Na moves rapidly into the cell measure it.
Ca moves slowly into the cell Phase 0- it is where the sodium channel opens, the interior
Charge = (+) of the cell becomes positive 30 mv
Phase 1- closure of sodium channel ions
Phase 1: Early Repolarization Plateau phase- equal influx and efflux of calcium and
Na channels close potassium respectively
Transient efflux of K Phase 3- Rapid Repolarization; efflux of potassium ions and
Charge = slight dip in charge then we go back again to Phase 4
You can see the measurement of the movements of ions that
Phase 2: Plateau phase produces the electrical depth.
Plateau means flat because there is no net change inside Blue- measurement of tension produced by the heart and it is
the cell overtime. As you can see before any contractions even occurs
Ca continues to flow in produced by the heart, that will be stimulated electrically. The
K continues to flow out electrical events precedes contractile events (inulit niya ulit )
Charge = 0 So before it can generate any tension, the tension is produced

Magno Opere Somnia Dura Page 2 of 10 SHIELA & MITCHIE

ELECTROCARDIOGRAPHY
Dr. O. Payawal Jr.
before the muscle contract, it needs to be stimulated electrically.
(paulit ulit lols)
QRS complex upward deflection
seen in all ECG (unless dead)
occurs in phase 0/ represents phase 0 of both ventricles-
rapid depolarization of the ventricle
occurs first before any contractile movement of the heart
ST segment
used to diagnose heart attack or ischemia
represents phase 2 of ventricles
T wave
upward wave
represents phase 3 of ventricles
P wave
upward deflection
What precedes ventricular contraction. It is the atrial
contraction.
represents atrial depolarization (atrial repolarization is
buried in the QRS complex)
remember the primary pacemaker of the heart is SA node which
is in between the atrium. So the atrium is depolarized first
before the ventricle that is why it gives you contractions
Absolute Refractory period
from phase 0 to peak of T wave (middle of phase 3)
heart cannot be re stimulated
Relative refractory period
When you stimulate, the response is weak
needs a strong stimulus for heart to produce a response
there is a boundary in the heart that divides it to absolute
and relative refractory period
from peak T wave or until the end of phase 3
vulnerable period during the cardiac cycle that can cause
malignant dysrrhytmiawhich may produce sudden cardiac
death
Place the electrodes in the extremities of the patient and on the
chest wall, many of those are positive electrodes, some are
bipolar (meaning they hold a positive and negative electrodes)
Just to illustrate, for example we have positive electrode over
here, it deflected this way of depolarization, that electrode it
translate and produce into positive wave deflection until we
hold ventricle, for example in the foreright, it goes back to
baseline (pakicheck part na to, medyo hindi ko madinig) then
PQRST develops
Magno Opere Somnia Dura Page 3 of 10
2014 -2015
CARDIOLOGY
ECG STANDARD LIMB LEADS (BIPOLAR)- ORIENTATION OF LEADS
Einthoven in the year 1890, he was the first to revised the
lead system which up to now in the year 2014, we still used
it
Lead I - from R arm to L arm-- negative electrode on the
right arm and a positive electrode on the left arm
Lead II from R arm to L leg- negative electrode on the right
arm and a positive electrode on the left leg
Lead III From L arm to L leg- a positive electrode on the
left arm and a positive electrode on the left leg
Right leg is for ground electron
Limb leads:
R arm negative electrode
L arm positive electrode
L leg - positive electrode
R leg used for grounding only
*we cannot see electricity , we can only measure it
There are standard 12 limb lead (bipolar) to be used, what
is important is the orientation of the lead
EINTHOVEN TRIANGLE HYPOTHESIS
Assumptions:
Roots of the LA, RA, LL form apices of a triangle.
Electrical forces produced by the heart are
represented by an equivalent dipole at the center of
the triangle.
Body tissues and fluids in which triangle is located act
as homogenous conductor because it contain
sodium, potassium, calcium and chloride
Bipolar limb leads record potential variations of the
heart in the frontal plane.
Einthovens Law: Lead I + Lead III = Lead II
When you look at the ECG, if the QRS complex in Lead I
is predominantly upright or positive and Lead III is
predominantly positive, then Lead II should be taller
than the two
If Lead I is predominantly positive and Lead III is
negative, then Lead II should be very small
If Lead I is negative and Lead III is positive, Lead II
should be smaller
3 Bipolar Leads
I, II, III
SHIELA & MITCHIE
ELECTROCARDIOGRAPHY 2014 -2015

Dr. O. Payawal Jr. CARDIOLOGY

ECG AUGMENTED LIMB LEADS (UNIPOLAR)
Dr. Emanuel Goldberger added more leads, but this time you only
used a unipolar electrode.
Used positive electrode on the left foot and the negative is
assumed to be in zero potential which is measured assumed by the
machine
AVF- it is up and down ,has a positive electrode, located on
the left leg
AVR- has a positive electrode, located on the right arm, the
negative is assumed by the machine
AVL- has a positive electrode, located on the left arm, the
negative is assumed by the machine
during a heart attack? It will block your artery, wherein it is
supplied by your coronary artery. And what is infarct? It is
lack of oxygen and after several hours it becomes necrotic
(dead tissue) and that dead tissue will not have electrical
activity anymore. If its dead already, the deviation will be
on the left
Example 3: big right ventricle = axis deviated to the right
Total electrical axis of heart Take note of Lead I and AVF
The normal axis is between 0 to 90 degrees but some books will say
up to -30 is still normal
Normal . direction is going to the left between (+) 30 degrees and
(+) 60 degrees
Lead I and AVF: they should have a QRS that is predominantly
positive which means axis is between 0-90 degrees which is normal
IF Lead I is (+) and AVF is (-) = L axis deviation
IF Lead I is (-) and AVF is (+) = R axis deviation
IF Lead I is (-) and AVF is (-) = R axis deviation

tweety ETO NA PART MO

Unipolar Precordial Leads
th
V1 - 4 ICS right sternal margin
th
V2 - 4 ICS left sternal margin
V3 - midway between V2 and V4
th
V4 - 5 ICS MCL
V5 - AAL same level as V4
V6 - MAL same level as V4

For male patients V4 is usually under the L nipple

You have to stimulate your imagination, remember the orientation

is very important. If you transpose this unipolar lead into bipolar, it
will now appear this way. This is the hexaxial reference system
known as Cabrera System. This is used to compute for the total
electrical activity of the heart.
Why do we need to know this electrical activity of the heart? How
does it helps us to know the electrical axis of the heart? For the
patients having hypertension, valvular heart disease,etc.
Example 1: Big left ventricle, you can expect electrical axis
of the heart leftward
Example 2: Inferior wall Myocardial infarction that affected
the inferior wall of left ventricle. What happens when you

Magno Opere Somnia Dura Page 4 of 10 SHIELA & MITCHIE

ELECTROCARDIOGRAPHY 2014 -2015

Dr. O. Payawal Jr. CARDIOLOGY

Chest leads measure the horizontal plane

Limb leads measure the frontal plane
Know the pathway of electrical conduction system of the heart

SA node to atrium to AV node (has the longest refractory period)HIS

bundle to purkinje fibers to ventricles

ECG
gives you an idea where the pathology is.
if it is ischemia, you know which coronary artery is involved
depending on the wall affected. This is important specially
when doing angioplasty (need to canulate the artery first)
youll have an idea about the extent of the
pathology/prognosis. If there are multiple leads affected X axis horizontal , Measurement of time

Normal standard ECG machine paper speed is 25 mm/sec

1 small square = 0.04 seconds
1 big square = 0.20 seconds (5 small squares)

Leads View of Heart Y axis = measurement of voltage

LI Lateral wall 1 millivolt of electricity = 10 mm amplitude on ECG paper
LII Inferior wall 10 mm = 10 squares
LIII Inferior wall Bigger heart gives a bigger voltage = bigger QRS
AVR No specific view If heart is too big ECG graph has QRS larger than the paper. - Label
AVL Lateral wall ECG paper as half sensitivity
AVF Interior wall
V1 Anteroseptal wall 1 small square = 0.1 mv
V2 Anteroseptal wall
V3 Anterior wall P wave
V4 Anterior wall represents atrial depolarization
V5 Lateral wall atrial conduction time
V6 Lateral wall normal amplitude is 0.5 to 2.5 mm (increased in RA
enlargement)
normal duration is up to 0.10s (2 small squares) in adults
(increased in LA enlargement or dilatation)
usually biphasic (with upward and downward deflection) in
st
V1 (1 prox. half RA phenomenon; later - LA
phenomenon)

P-R Interval (or PQ interval)

represents time interval for impulse to reach ventricles
from SA node

Magno Opere Somnia Dura Page 5 of 10 SHIELA & MITCHIE

ELECTROCARDIOGRAPHY 2014 -2015

Dr. O. Payawal Jr. CARDIOLOGY

measured in limb lead with longest PR interval
normal is 0.12-0.20s in adults (HR = 70-90/min) (increased
in AV block)
Start of P to start of QRS
0.20 s = 5 small squares or 1 big square

One figure of impulse:

Normal duration = 0.5 sec
It is very important when you put the electrodes on the Chest leads measure the horizontal plane
chest. It has been accepted globally. Limb leads measure the frontal plane
ECG are frequently requested for the same
patient,sometimes we request 5 ECG in the day for 1
patient because we want to see if there are changes and
that will tell us if there is something going on or not .
I am expecting that an ECG done in Standford Univ Hosp
will be similar in the ECG done on emergency room at
FUMC done by an INTERN!!The standard, quality should be
the same..

ICS stands for Intercostal Space. You know how to count

and locate your ICS?How.Now, you appreciate the
landmark( Sternal Angle of Louis) and then below that is
nd rd th
what? Its below the 2 ,3 ,4
Chest leads measure these electrical potential in
horizontal plane.
Unipolar Precordial Leads
L,L2,L3,AVR, AVL,AVF and chest leads
th
V1 - 4 ICS right sternal margin represent a particular area of the heart
th
V2 - 4 ICS left sternal margin especially of the left ventricle.
V3 - midway between V2 and V4 So, the inferior wall of the left ventricle is
th
V4 - 5 ICS MCL(MCL-Midclavicular line) represented in ECG by lead II,III, AVL.
V5 - AAL same level as V4 (AAL-Anterior Axillary line) It will tell us where the pathology is
V6 - MAL same level as V4(MAL-Midaxillary line) Example is inferior wall ischemia ,inferior
myocardial infarction.
For male patients Lead V4 is usually around or below the We know that the inferior wall of the left
L nipple without gynecomastia ventricle gets its blood supply from the right
coronary artery. and if you plan to do
.Because there are some male pts taking
primary angioplasty to remove the thrombus
medications to produce gynecomasria
or plaque (chelate?? Di ko maintindihan yung
intentionallyand that is the exception to the rule.
word..right coronary)
For female patients, it depends. I know you
If the left anterior descending artery has thrombus or
already know the reason. Right?
totally occluded,
we expect changes to be from V1,V2,V3 V4,
and its a proximal lesion in Left anterior
descending

Magno Opere Somnia Dura Page 6 of 10 SHIELA & MITCHIE

ELECTROCARDIOGRAPHY 2014 -2015

Dr. O. Payawal Jr. CARDIOLOGY

It also involving V5,V6, V1,AVF because most
regions of the heart gets its blood supply
from the left anterior descending
artery,which is the biggest artery (Coronaty
Artery)
The left circumflex artery supplies part of
inferior wall and part lateral wall.
The more leads that are involved like for an example we see
an elevation in more leads, the bigger the infarct, the bigger
ischemic burden of the heart by just looking at the ECG.
When we diagnose the heart attack, it should be rapid
because 20% of the heart attack will kill the patient and
what makes the survived is the early recognition and, early
intervention.
We can more likely determine the extent as well as what
coronary artery is involved when we are presented with the
patient with chest pain especially at the ER
ECG gives you an idea where the pathology is.
- if it is ischemia, you know which coronary artery is involved
depending on the wall affected. This is important specially
when doing angioplasty (need to canulate the artery first)
- youll have an idea about the extent of the
pathology/prognosis. If there are multiple leads affected
And from there,it goes to AV node(Atrioventricular
node).
Again, its a real structure located in the
inferomedian portion of right atrium,
just behind the septal leaflet of the
tricuspid valve.
And from AV node, it goes under the cardiac skeleton up to
bundle of HIS or common AV bundle
And from HIS bundle, it bifurcates into two,
1. a big left bundle (it goes first on the left
venrtricle and its the biggest chamber of the
heart)and
2. smaller right bundle and innervates the cardiac
muscle as tiny purkinje fibers.
If you look at the cardiac cycle the last part of the heart to
contract is the posterobasal portion of both ventricle. Why?
Because its the last one to depolarize.
Atrium contracts first, because its the first one to
depolarize and the sinus node is in the atrium
The AV node in the whole cardiac cycle has the longest
refractory period.

Leads View of Heart

LI Lateral wall
LII Inferior wall
LIII Inferior wall
AVR No specific view
AVL Lateral wall
AVF Interior wall
V1 Anteroseptal wall
V2 Anteroseptal wall
V3 Anterior wall
V4 Anterior wall
V5 Lateral wall
V6 Lateral wall
X axis represent time, horizontal ,

Normal standard ECG machine paper speed is 25 mm/sec

1 small square = 0.04 seconds
1 big square = 0.20 seconds (4 small squares)
0.04 x 5 =0.2 sec 1/5 of the second

Y axis = measurement of voltage

1 millivolt of electricity = 10 mm amplitude on ECG paper
10 mm = 10 squares.
Its important! Why? Because if you have a patient with
big huge heart,it carries more voltage in the heart and
then you see the ECG that the voltages will be bigger.
Patient with big huge, so big heart,the deflection dont fit
anymore. Dina na kasya, lumalagpas na..
Know the pathway of electrical conduction system of the heart . In automated ECG the machine will automatically reduce
The primary pacemaker of the heart is located in SA the sensitivity, meaning 1millivolt will produce 5 mm para
node(Sinoatrial node). magkasya sa paper. You have to label it as 5 mm sensitivity
Its a real structure in the superior portion of In manual ECG (which is cheaper and half the price,)you
the right atrium as the superiorvenacava have to label it.
enters the right atrium Otherwise, if you do not label it and give it t me. I will read
it is the one that initiates the wave of The ECg as normal,or in fact the patient has big heart.
depolarization. It is important for the criteria for bigger heart
And from the SA node, it travels internodal pathways Bigger heart gives a bigger voltage = bigger QRS
that goes to the right atrium and left atrium

Magno Opere Somnia Dura Page 7 of 10 SHIELA & MITCHIE

ELECTROCARDIOGRAPHY
Dr. O. Payawal Jr.
If heart is too big ECG graph has QRS larger than the paper. - Label
ECG paper as half sensitivity
1 small square = 0.1 mv
P wave
represents atrial depolarization
atrial conduction time
normal amplitude is 0.5 to 2.5 mm (if Height of P wave
is more than 2.5 or more in RA enlargementor
hypertrophy)
normal duration is up to 0.10s (2 small squares) in
adults (increased in LA enlargement or dilatation)
usually biphasic (with upward and downward or
st
(positive and negative deflection) in V1 (1 prox. half
Right Atrial phenomenon; distal - L Atrial
phenomenon)
P-R Interval (or PQ interval)
Measurement from the start of P wave to start of QRS
and by counting small square.
represents time interval for impulse to reach ventricles
from SA node
measured in limb lead with longest PR interval
normal is 0.12-0.20s or 5 small square or 1 big square)
in adults (HR = 70-90/min) (more than 0.20s is called
st
1 degree AV block)
st
1 degree AV block is prolong PR interval
Start of P to start of QRS
0.20 s = 5 small squares or 1 big square
One figure of impulse:
Normal duration = 0.5 sec
PR interval is measured from p wave to start ofQRS
4 small square or 0.04 x 4=0.16 is less than 2O, (NORMAL)
QRS Complex
1890, designated by DrWHY QRS? HE knows that abcde
will be use often for some other things..
Q wave first downward deflection that comprises QRS.
(if seen in many leads or as prominent 1/3 of QRS = old infarct,); not
seen very often
Significant is usually one small square and 1/3 of QRS.It
signifies OLD INFARCT or heart attack.
Magno Opere Somnia Dura Page 8 of 10
2014 -2015
CARDIOLOGY
Example: when you see a patient, just a
NEGATIVE DEFLECTION, QS, significant q wave
and its II,III AVF-PREVIOUS THROMBOSIS of
Right Coronary Artery.
If you see QS ,no R wave, (QS from V1-V6 an OLD
MASSIVE anterior wall MI ,with shortness of breath.
If he has previous MI, it means that a big part of
his heart are no longer contracting, you produce
Shortness of breath.
R wave -first upward deflection whether preceded by a Qwave or not
(smallest in V1 and V2 and becomes taller as you go to V6.
Highest in V4)
First Upright positive deflection that comprises the QRS.
S wave downward or negative deflection following the R wave
(deepest in V1 and V2 and becomes shallower as you go to
V6)
QS wave - single negative deflection representing entire QRS
(prominent in SOB with LV infarct. If prominent from V1 to
V6 may indicate a big part of the heart has an infarct)
With previous MI, and it depends where the MI is and what
coronary is involved.
R wave - second upward deflection after S wave and S wave,
(bundle branch block); Will be absent in patients with heart
attack. (You will only have a QS wave)
\
st
Q wave: 1 downward deflection
st
R wave-1 positive deflection
S wave-the next negative deflection afer R wave.
If there is no R wave- previous heart attack;only QS
or may be there is R wave but there is significant Q
wave.
If there are more deflections like in Right Bundle
brach Block,R wave is the next upward deflection
after S wave
Swave- another deflection after R wave.
R wave which is upright and positive deflection
It is smallest in V1 or V2 and becomes tallest at
V1to V6
S wave which is downward deflection
It is deepest from V1 to V2 and becomes
shallowest at V1to V6
ST Segment
SHIELA & MITCHIE
ELECTROCARDIOGRAPHY
Dr. O. Payawal Jr.
Where we find Hear attack and coronary disease
without Heart attack
Phase 2 and plateau pahse
represents period from end of ventricular
depolarization to start of ventricular repolarization
between end of QRS and start of T wave
clinically important if elevated or depressed as it may
represent infarction or ischemia
usually isoelectric (same level as PR INTERVAL) but may
be depressed 0.5 mm (half of small square) or
elevated by 1mm(1 small square)
Used to diagnose acute MI > Elevated in acute infarct
(higher risk if seen in more leads)
Elevated >1mm in acute MI (heart attack)
Elevated >0.5mm in ischemia
Elevation should be convex upward (MI unless proven
st
otherwise) (drawing is kamukha ng 1 2 figures ng part A sa
next pic)
If elevated but concave upward, could be a normal variant,
electrolyte imbalance or pericarditis (not specific for
infarcts but suspicious for a coronary event). (seen on next
tracings)
Ex. ST elevation in Lead II. III and aVF acute Inferior Wall
infarct -> Thrombosed Right Coronary Artery (Blood Supply
of inferior wall)
MI: heaviness, feeling of impending death b/c of pain, cold
clammy perspiration, SOB
The more elevated the ST segment is, the bigger the infarct
(massive MI) which, if not treated, can cause CARDIOGENIC
SHOCK (80% mortality)
Philippines CVD #1 mortality (9 pinoys die/hour)
50% of deaths of CVD is 2 Sudden Cardiac Death (death
within 1 hour after onset of S/Sx.
Prevention: #1 factor is early recognition (utmost
importance) - ECG
Depression of more than 0.5mm is an ischemia.
suspicious
Part A figures high specificity especially if with clinical correlation
with the pts dse.
Magno Opere Somnia Dura
2014 -2015
CARDIOLOGY
ER: Patient with chest pain,cold sweat, ST segment is
convex,upward- Heart attack(
Patients complains of parang dinadagang adobe
sa dibdib and not pain) or
sometimes jaw pain or left arm pain(atypical
Heart attack)
Risk Factors: DM,Male,smoker, family history
st
1 48 hrs will kill the patient with arrhymia
ECG may be suspicious,it is isoelctric and Normal
because it may be depressed by 4-5 square or elevated
by 1 square.
Lead 2,3 AVF- Acute Inferior Wall Myocardial
Infarction, thrombosis is at a Coronary artery
V1-V6 Left anterior descending artery has
thrombosis.
ECG should be correlated with patient because not all
ST elevation is Heart Attack.
Examples of St elevation w/o Heart attack:
Percarditis and LV Aneurysm and si doc with
pleuritic chestpain
When in doubt, we request for cardiac
enzymes but sometimes we need to know
immediately bec if we delayed the treatment
,then the infarct will proceed,so success rate
will be lower.
Q wave without ST ehlevation OLD INFARCT
Q wave wit ST elevation RECENT INFARCT
ST elevation without Q Wave ACUte
In pericarditis with ST elevation and No Q wave
So when in doubt, keep repeating the ECG to know the
evolution
12-Lead ECG is more Expensive
Page 9 of 10 SHIELA & MITCHIE
ELECTROCARDIOGRAPHY 2014 -2015

Dr. O. Payawal Jr. CARDIOLOGY

60 y/o woman,with cold clammy sweat and SOB

ADMIT
There is ST segment elevation
Extensive V2,V3 anterolateral wall MI
Cardiogenic shock
Immediate tx is needed

WHAT IS THE AXIS OF THIS LEAD?

Look at lead I is predominantly positive, QRS is
positive Normal( ganito yung exam plus cases
)
50 year old man with atypical slight chest pain , with SOB after playing
tennis.

ADMIT IN ICU
With 2,3 AVF ST segment elevation
Acute Inferior wall MI
Supplied by Right coronary artery

ST elevation in Lead II, III, aVR, aVF, V4-V6 (eto lang ata)
Q wave at lead II (old infarct)
Long lead II shows the Concave upward variant of ST elevation, but
since ST elevations are also seen in other leads, it is more probable
that it is MI than normal (tinanong ko kay doc)
ADMIT = MASSIVE MI

**Giving MI tx to a non-MI pt can cause death 2 hemorrhagic

bleeding

Magno Opere Somnia Dura Page 10 of 10 SHIELA & MITCHIE