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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
>100bpm (best to look cardiac patholoy. May be
at the a sign of anxiety,
rhythm dehydration, recent
strip) exercise, or general illness
(e.g. sepsis, pneumonia,
respiratory pathology,
other illness)
Sinus bradycardia Same as above except All leads This is normal in young fit
<60bpm (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
taller than left to right, and this is
lead II pretty 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
leads II and lead III QRS is 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,
irregular baseline. the rhythm will be
irregularly irregular. There
Irregularly Irregular, irregular Rhythm will be a fibrillating
QRS (but QRS is normal strip baseline due to
shape) uncoordinated activity.
The causes of atrial
Might look messy! E.g. Generally
fibrillation are:
1. Ischaemic heart
disease
2. Thyrotoxicosis
(hyperthyroidism)
3. Sepsis
4. Valvular heart
disease
5. Alcohol excess
6. PE
Junctional tachycardia P waves very close to QRS, Anywhere Due to a ‘re-entry’ loop;
or no QRS visible. QRS is there is an area of
normal depolarisation 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
It is NOT an medical
emergency
1st Degree Heart Block
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2nd degree heart block Progressive lengthening of Anywhere This can be an AV node
Mobitz type 1 – Wencebach the PR interval followed by block (nearly always), or
absent QRS, then cycle an SA node block. usually
repeats. Cycles are variable benign and generally
in length. R-R interval doesn’t require specific
Mobitz type 2 shortens with lengthening of treatment. can be caused
PR interval by CHD or acute MI.
It is usually symptomless,
but can present with:
–Dizziness / light-
2:1 and 3:1 conduction headedness / syncope
Complete (third degree) heart block 90 P waves/min, only about Best in II This is an AV node block.
38 QRS/min, and not and V1 Atrial activity will be
relationship between the P completely normal, but
waves and the QRS this conductivity does not
complexes. QRS will often pass into the ventricles.
have an abnormal shape, This always indicates
and be broad (>120ms). underlying disease – the
However, the P-P intervals disease is often fibrosis
will be regular, as will the R-R rather than ischaemia, but
intervals – they are just not it can occur in MI.
in time with each other. The
rhythm of the ventricles is the
escape rhythm.
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RBBB – right bundle branch block ECG may appear normal. In These are infra-Hisian
some people there may be 2 blocks. In bundle branch
R 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 the PR interval will be
called an RSR pattern normal – and it is.
V6 – there is a W shaped However, the time taken
QRS for the depolarisation to
Wide QRS (120ms) spread throughout the
ventricles is longer –
LBBB – left bundle branch block V1 – there is an W shaped thus QRS complex
QRS duration is lengthened.
V6 – there is a M shaped In the acute setting it may
QRS be caused by MI
Wide QRS (>120ms) RBBB – may indicate right
The axis can be deviated sided disease. The two R
either way in BBB’s, but it is waves indicate the
most commonly normal 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
Accelerated idioventricular rhythm Some normal beats after the of the atrium depolarises
abnormal one and sends the signal to
the ventricles.
Extrasystoles These are easy – they are the same as ventricular escapes, except that
(aka ectopics) where 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
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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)
Axis deviation
7/8
Lead I Lead II Axis
+ + Normal
+ – LAD
– Either RAD
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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