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This summary of ECG abnormalities is part of the almostadoctor ECG series. For a more in
depth explanation of ECG abnormalities, see ECG abnormalities. To learn about the basic
principle of an ECG, see Understanding ECGs
Sinus Tachycardia Same as above, except All leads Does not represent cardiac
>100bpm (best to look patholoy. May be a sign of
at the anxiety, dehydration, recent
rhythm strip) exercise, or general illness
(e.g. sepsis, pneumonia,
respiratory pathology, other
illness)
Sinus bradycardia Same as above except <60bpm All leads This is normal in young fit
(best to look people
at the
rhythm strip)
Right ventricular hypertrophy Negative QRS Lead I Because the cardiac axis has
shifted from 11-5 o’clock to 1-
7 o’clock, thus lead I which
measures laterally from right
to left now gets a negative
signal because the signal is
going from left to right. This
axis shift is called right axis
deviation.
Right ventricular hypertrophy Taller QRS Lead III – Because lead III measures
becomes vertically but also slightly left
taller than to right, and this is pretty
lead II much the exact direction of
the new shifted axis. Lead II,
measuring from right arm to
left leg is no longer lined up
as well. This axis shift is
called right axis deviation.
Left Ventricular Hypertrophy Small lead I QRS, negative Leads I-III Left axis deviation – this is
leads II and lead III QRS often the results of a
conduction defect, and not an
increased bulk of left
ventricular tissue.
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Atrial fibrillation Absent P waves – just an some? As well as no p waves, the
irregular baseline. rhythm will be irregularly
irregular. There will be a
Irregularly Irregular, irregular Rhythm strip fibrillating baseline due to
QRS (but QRS is normal uncoordinated activity.
shape) The causes of atrial
fibrillation are:
Might look messy! E.g. Generally 1. Ischaemic heart
disease
2. Thyrotoxicosis
(hyperthyroidism)
3. Sepsis
4. Valvular heart
disease
5. Alcohol excess
6. PE
Atrial tachycardia >150bpm, p waves Any where p Caused by a foci of the atria
superimposed over t waves of waves are (outside of the SA node)
preceding beat, normal QRS best seen depolarising quickly
Junctional tachycardia P waves very close to QRS, or Anywhere Due to a ‘re-entry’ loop; there
no QRS visible. QRS is is an area of depolarisation
normal near the AV node; this not
only transmits a signal
throughout the rest of the
ventricles to depolarise them
1st degree heart block PR interval >0.2s (one big Allover – This is an AV node block
square) best in I or Can be caused by CAD,
V1 acute rheumatic carditis,
digoxin toxicity, or
electrolyte disturbance
1st Degree Heart Block It is NOT an medical
emergency
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2nd degree heart block Progressive lengthening of Anywhere This can be an AV node
Mobitz type 1 – the PR interval followed by block (nearly always), or an
Wencebach absent QRS, then cycle SA node block. usually
repeats. Cycles are variable in benign and generally doesn’t
length. R-R interval shortens require specific treatment.
with lengthening of PR can be caused by CHD or
interval acute MI.
It is usually symptomless, but
can present with:
–Dizziness / light-
Mobitz type 2 headedness / syncope
Complete (third degree) 90 P waves/min, only about 38 Best in II This is an AV node block.
heart block QRS/min, and not relationship and V1 Atrial activity will be
between the P waves and the completely normal, but this
QRS complexes. QRS will conductivity does not pass
often have an abnormal into the ventricles.
shape, and be broad This always indicates
(>120ms). However, the P-P underlying disease – the
intervals will be regular, as will disease is often fibrosis
the R-R intervals – they are rather than ischaemia, but it
just not in time with each can occur in MI.
other. The rhythm of the
ventricles is the escape
rhythm.
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RBBB – right bundle branch ECG may appear normal. In These are infra-Hisian
block some people there may be 2 R blocks. In bundle branch
waves. This creates a blockages, the wave of
distinctive pattern: depolarisation can still
V1 – there is an M shaped reach the IV septum, then
QRS – this is sometimes called the PR interval will be
an RSR pattern normal – and it is. However,
V6 – there is a W shaped QRS the time taken for the
Wide QRS (120ms) depolarisation to spread
throughout the ventricles is
LBBB – left bundle branch V1 – there is an W shaped longer – thus QRS complex
block QRS duration is lengthened.
V6 – there is a M shaped QRS In the acute setting it may be
Wide QRS (>120ms) caused by MI
The axis can be deviated either RBBB – may indicate right
way in BBB’s, but it is most sided disease. The two R
commonly normal waves indicate the
depolarisation of the right and
left sides of the heart at
different times (the right
depolarises after the left).
You can remember the
pattern with the word
MarroW – there is M in V1,
and W in v6, and the ‘rr’ tells
you it is on the right!
There is NOT specific
treatment, and it is often
caused by an atrial septal
defect.
In the acute setting it may be
caused by MI
LBBB – often indicates left
sided heart disease.
Remember the pattern with
WillaM.
Causes:
Aortic stenosis, dilated
cardiomyopathy, acute MI,
CAD
Symptoms:
Syncope, and in more severe
cases; heart failure. Those
with syncope and / or heart
failure will usually be
treated with a pacemaker.
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Ventricular rhythms Wide QRS complexes Anywhere
(aka escape rhythms)
Atrial escape Abnormal p wave (e.g. Anywhere This occurs when the SA
Junctional escape inverted) node fails to depolarise.
Ventricular escape Normal QRS Instead, some other part of
Accelerated idioventricular Some normal beats after the the atrium depolarises and
rhythm abnormal one sends the signal to the
ventricles.
Extrasystoles These are easy – they are the same as ventricular escapes, except that where
(aka ectopics) in escapes the escape beat comes after a pause in the rhythm, in
extrasystole, there is an abnormal beat earlier than expected.
The QRS complexes are the same as those of sinus rhythm, but there are
usually abnormal p waves that tend to come immediately before or immediately
after the QRS.
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Posterior MI ST depression, tall R waves V1-V3 Posterior MI is unusual!
The changes that occur are
opposite to the changes of
other type of MI. thus the tall
R waves are the opposite of
Q waves (remember Q waves
are negative), and ST
depression occurs in place of
ST elevation
The digoxin effect Depression of ST, inverted T widespread This causes a sloping ST
waves segment that has a ‘reversed
tick’ look. This occurs
because digoxin blocks the
na/K pump, which increases
intracellular Ca2+
concentrations. (similarly,
ischaemia causes reduced
production of ATP, and thus
reduced pump activity)
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Pericarditis T wave inversion (rare: also ST Widespread If ST elevation does occur,
elevation) then the ST waves will
appear ‘saddle shaped’ thus
helping you to differentiate it
from MI. also, the elevation in
MI tends to be confined to a
certain area, but in
pericarditis, it is widespread
Bifid P waves (‘P-Mitrale’) P waves with two peaks, broad ? Left ventricular
– looks like an ‘M’; hence the hypertrophy
name ‘Mitrale’
Axis deviation
+ + Normal
+ – LAD
– Either RAD
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By applying pressure to the carotid sinus you can stimulate the AV and SA nodes via
vagal stimulation. This will reduce the frequency of discharge of the SA node, and
increase the time of conduction across the AV node.
Thus, by applying pressure to the carotid sinus you can:
Reduce the rate of some arrhythmias
Completely stop some arrhythmias
It will have NO EFFECT ON VENTRICULAR TACHYCARDIAS – thus is can help you
differentiate these from supraventricular tachycardias (SVT)
Applying the pressure reduces the frequency of QRS complexes, and allows the
underlying atrial arrhythmia to become more visible.
Related Articles
ECG Abnormalities
Understanding ECGs
Angiotensin II Receptor Blockers (ARBs)
Amiodarone
Cardiac Tamponade
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