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Transcript 
INTERPRETATION of
ELECTROCARDIOGRAMS
BRIAN D. LE, MD
Presbyterian Hospital
CIVA
Outline
I.
II.
III.
Approach to interpretation of ECGs
Cases illustrating approach principles
Unusual Cases
Seven Step Approach
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Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system
Seven Step Approach







Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system
Seven Step Approach







Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system
Seven Step Approach







Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system
Seven Step Approach







Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system
INTERVALS
PR < 200 ms
QRS < 120 ms
QTc: Men < 440 ms, Women < 460 ms
Seven Step Approach


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Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system

Left Ventricular Hypertrophy
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Cornell +R (aVL)+Sw(V3)>24mm (male)
>20mm (female)
Sokolow S(V1) + R(V5)=32mm
Rw (aVL)>11mm
Rw (I)>14mm

Right Ventricular Hypertrophy
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1. RAD>100*
2. IRBBB
3. R>S V1
4. R<S V6
5. R in V1>=7mm
6. R V1 + S V5 or V6 >=10mm
7. RAE
8. strain pattern in rt precordial leads
Seven Step Approach



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

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Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system
ANATOMICAL LOCALIZATION
ANTERIOR: V1-V4, SEPTAL V1-V2
LATERAL: V5-V6, I, Avl
INFERIOR: II, III, aVF
Seven Step Approach
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Rate
Rhythm
Axis
Intervals
Hypertrophy
ST/Tw changes, Q waves
Conduction system

LBBB
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Left Anterior Fascicular Block
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LAD > -30', + I, aVR, -II/III/aVF
qR in I and L
rS in II, III and aVF
Left Posterior Fascicular Block
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QRS > 0.12 sec
wide monophasic R in I, V5 and V6
(usually notched or slurred)
no Q in I, V5 and V6
RAD > 100'
small R in I and aVL, Q in II, III, aVF
S1 Q3 pattern
RBBB
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QRS>0.12 sec
R' > r in right precordium
wide S in I, V5 and V6
Normal Variants- Juvenile Tw
inversions
Nuts and Bolts
Electrode Misplacement
Amplitude Artifact
Parkinson’s Tremor
CASES
Case 1: 21 yo presents for routine
physical exam
DEXTROCARDIA
Case 2: 38 yo with one week of URI
presents with chest pain
Acute Pericarditis

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Stage I--ST elevation, Tw upright,
PR depression
Stage II--ST baseline, flattened Tw
Stage III--inv Tw
Stage IV--Tw baseline, days to wks
Case 3: 48 yo homeless man found
unresponsive
Hypothermia
Case 4: 34 yo ESRD missed three
days of dialysis
Hyperkalemia
Case 5: 28 yo woman s/p neck
surgery
Hypocalcemia
Case 6: 32 yo female on antidepressants
had syncope
Acquired Long QT Syndrome
Case 7: 60 yo man with chest pain
Inferior MI with RV infarction and 2:1
and complete heart block
2:1 Heart block with
ventriculophasic effect
Case 8: 80 yo man with syncope
Aflutter with complete heart block
Aflutter with complete heart block
Aflutter with normal conduction
Aflutter with 1:1 conduction
Aflutter with carotid sinus massage
Counter-clockwise Aflutter
Clockwise Aflutter
Case 9: 50 yo man with DCM
Biventricular pacing
Case 10: 25 yo man with palpitations
Pre-excited Atrial Fibrillation- right
sided postero-septal pathway
Wolf-Parkinson-White: Left
anterolateral pathway
Postero-septal pathway
pre-ablation
Post-ablation with repolarization
abn due to memory effect
Case 11: 25 yo female with
lightheadedness
AV Node Re-entrant Tachycardia
(AVNRT)
Case 12: 75 yo man with ischemic
DCM and syncope
Ventricular Tachycardia
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BRUGADA'S CRITERIA- Circulation '91
1. Absence of all RS complex in all
precordial leads S 21%, SP 100%
2. R to S interval > 100ms in one
precordial lead S 65%, SP 98%
3 A-V Dissociation, fusion, capture beats
S 82%, SP 98%
4. Morphologic criteria in V1+2, 6
Ventricular Tachycardia
Ventricular Tachycardia: AV
dissociation, RS >100ms
Case 13: 18 yo Asian man with family
history of SCD presents with syncope
Brugada Syndrome

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Genetic mutation in SCNA5
Predominantly in Asian males
Syncope and sudden cardiac death
Three types
Brugada’s Type II- Saddle back
Case 14: 28 yo man with syncope
Arrythmogenic Right Ventricular
Dysplasia (ARVD)
Case 15: 28 yo man with syncope
Short-coupled Torsades
Case 16: 34 yo woman with fatigue,
weight gain, and abn menstrual period
Myxedema
Case 17: 84 yo man with skipped
beats
Sino-atrial exit block Type I
Case 18: 64 yo woman presents for
routine exam
Retrograde concealed conduction
into the AV node
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