1

Basic Interpretation of Electrocardiography 2012

Joe M. Moody, Jr., MD
Introduction
1. ECG is only a test like any other test. It is always subservient to the clinical context created
by the history and physical.
2. Text is Dubin (6
th
ed, $35.50) only because students like it best, but Marriotts text (eleventh
ed) by Wagner may be a little better, and is more complete. Probably the best book is
Chous, 6
th
edition by Surawicz, but it is expensive, and probably not worth the difference in
cost to many non-Cardiologists. There are several other choices as well, generally all are
fairly reliable.
3. This handout has more information than the test will cover. The testable material is
underlined.
4. I need feedback to make the course better. Im learning too. Send suggestions to me by
email: [email protected]
To do well in this course:
1. Start working on the practice ECG strips early; you are expected to have analyzed the first
practice set before the first small group session. After the first two hours of lecture, you
should be able to determine rate and intervals. After the second two hours of lecture, you
should be able to determine the diagnosis of the axis.
2. The test is open book, open notes, but there is not enough time to look up every little detail,
so you must have a strong working knowledge of the material. There will be about 30 to 35
questions, single best answer out of five choices.

Objectives: Given an ECG or rhythm strip, correctly identify the following
features:
1. Normal ECG, atrial rate, ventricular rate, PR interval, QRS duration,
QT interval
2. Identify whether the QRS axis is normal, left axis deviation or right axis
deviation
3. Sinus rhythm, sinus bradycardia, sinus tachycardia, sinus arrhythmia
4. Ventricular subendocardial ischemia pattern
5. Ventricular transmural (subepicardial) ischemia pattern (inferior,
anterior, lateral, or combination); and pericarditis
6. Acute or recent myocardial infarction pattern (inferior, anterior, lateral,
posterior, or combination), old myocardial infarction pattern (inferior,
anterior, lateral, posterior, or combination)
7. LV hypertrophy, RV hypertrophy, LA enlargement, RA enlargement
8. LBBB, RBBB, ventricular pre-excitation of the WPW type
9. Prolonged QT interval, hypokalemia pattern, hyperkalemia pattern
10. Premature atrial complexes (normally conducted, aberrantly
conducted, and nonconducted), supraventricular tachycardia, atrial
flutter (2:1 conduction, variable conduction), atrial fibrillation (slow,
moderate or rapid ventricular response), multifocal atrial tachycardia,
junctional rhythm
11. Premature ventricular complexes (uniform, multiform, couplets),
ventricular tachycardia, ventricular fibrillation
2
12. First degree AV block, second degree AV block (Mobitz Type I or
Wenckebach, and Mobitz Type II), third degree AV block (Complete
AV block, or complete heart block)
13. Ventricular pacemaker


Section I: Basic Principles in ECG interpretation

Part A: Electrophysiology and Foundational Considerations
Action Potential, (this is an oversimplified generalization typical of a Purkinje cell,
specific cardiac cell types vary in electrical properties; good ref is Braunwalds
textbook of heart disease, 8
th
ed., 2008, pp 737-744)
Phase 0: rapid depolarization to about +30mV
Conductance is dominated by Sodium (opening of Na channels)
Inward Sodium current channels open only for 1-2 msec
Faster rate of rise of Phase 0 means faster conduction velocity
Phase 1: brief rapid repolarization to about 0 mV
Due to inactivation of Sodium current and transient outward
Potassium current
Phase 2: plateau of depolarization due to inward Calcium current
Phase 3: final repolarization due to outward Potassium current (required
for any subsequent depolarization to occur)
Phase 4: Polarized state - resting potential, -90 mV (inside negative) due
to conductance dominated by Potassium (leaking out) - this is the
state of readiness of the membrane

Depolarization results in Contraction! No contraction without
depolarization!
Phase 4
Phase 3
Phase 2
Phase 0
Phase 1
Na
+
in Ca
++
in K
+
out
0 mV
-90 mV
250-300 msec
3

Important electrical characteristics:
Automaticity - the characteristic of a tissue with spontaneous generation of an
action potential (due to phase 4 depolarization)
Conductivity - the characteristic of a tissue with transmission of an action
potential through a tissue (related mainly to the steepness of phase 0
depolarization)
Conduction of the Cardiac Impulse - Cardiac Conduction System
Sinus Node (SA node, sinoatrial node):
Normal location of pacemaker of heart
High in the right atrium near the junction of the superior vena cava
On the ECG sinus node depolarization is not seen
Atrium - cell-to-cell conduction from the SA node, velocity of 1 m/sec
By atrial contractile muscle and/or specialized atrial conduction
pathways
Results in depolarization and therefore contraction of the atria
On the ECG, atrial depolarization is the P wave
Presents the action potential to the AV node
AV node - slowest conducting tissue in the heart, as slow as 0.05 m/sec
Long refractory period protects ventricle from too many impulses
22mm long, 10mm wide, 3mm thick, near ostium of coronary sinus
Normally the only electrical connection between the atria and
ventricles
Delay allows for time for blood to flow out of atrium into ventricles
Retrograde and reentrant conduction patterns can occur here
On the ECG: straight line between P wave and QRS ("PR
segment")
Bundle of His (common bundle) - Purkinje fibers, conduct at 1-4 m/sec
Beginning of the His-Purkinje system, length about 10mm
On the ECG, depolarization of the bundle of His is not seen
Bundle branches - the rest of the His-Purkinje system, fibers are
subendocardial
Right bundle branch
Left bundle branch (Anterior and posterior hemifascicles)
On the ECG, depolarization of the bundle branches is not seen
Ventricular myocardium - conducts at 0.3-0.4 m/sec, endocardium to
epicardium
Ventricular depolarization causes ventricular contraction (arterial
pulse)
On the ECG, ventricular depolarization is seen as the QRS
complex

4
Repolarization: All these tissues must repolarize after each depolarization. The
most important repolarization for ECG interpretation is repolarization of the
ventricles.
On the ECG, repolarization of the ventricles is seen in the ST segment and the
T wave






During depolarization and repolarization, the heart creates a detectable electric
potential on the body surface, and the ECG machine simply records that voltage.

ECG machine definition: a device that creates graph of voltage versus time.
Time always moves from left to right (horizontal), and voltage is displayed up and
down (vertical). Voltage is the electrical potential difference between 2 points
(measured in millivolts (mV) on the ECG. All modern ECG machines
automatically include on the tracing a standard mark. A standard mark is a
square wave pulse of 1.0mV amplitude and 0.2 sec duration. A standard mark is
usually 10 mm high and 5 mm wide, indicating:
As the electrical impulse travels through the heart depolarizing first the
atria then the ventricles, it creates an electrical dipole (voltage), which
changes in magnitude and direction (in 3-D space) during
depolarization and repolarization. This is recordable on the surface of
the body. In this recording, the depolarization of the atria is called the
P wave, the depolarization of the ventricles is called the QRS complex,
and the repolarization of the ventricles is called the T wave. The ECG
we study looks at the 3-D activity in 12 different standard 1-D
projections, or from 12 different vantage points.

5
Normal sensitivity of 10 mm/mV
Normal paper speed of 25 mm/sec
Machines may adjust automatically to half sensitivity, can be manually
adjusted
Other choices include quarter sensitivity (quarter standard) or double sensitivity
(double standard), or double speed (50 mm/sec) or other speeds
ECG machine prints on graph paper with marks 1 mm apart
Heavier marks every 5 mm both horizontally and vertically
Standard horizontally (time): 1 mm=0.04 sec, 5 mm=0.20 sec, 25
mm=1 sec
Standard vertically (voltage): 1 mm=0.1 mV, 10 mm=1.0 mV



Waves of the ECG
P wave - wave indicating atrial depolarization, not very spiky
QRS complex - the group of waves indicating ventricular depolarization,
usually very spiky
Q wave - an initial downward (below
the baseline level) deflection of the QRS
complex (may be absent)
R wave - the first upward (above the
baseline level) deflection of the QRS complex
(may be absent)
S wave - the first downward deflection
of the QRS complex after an R wave
QS complex - a QRS complex which
has an initial downward deflection (usually
called a Q wave) and then NO deflection
which goes above the baseline, (that is, no R
wave), so that the QRS complex is all below
the baseline.
6
qR complex - a QRS complex with a small Q wave followed by a large R wave
rS complex - a QRS complex with a small R wave followed by a deep S
wave
R prime wave - the first upward deflection of the QRS complex after an S
wave
J point - the point marking the end of the QRS complex
T wave - the wave after the QRS complex indicating ventricular
repolarization, even less spiky than the P wave
U wave - the wave after the T wave indicating further repolarization (may
be absent, due to slow repolarization of a special type of cell called the M cell)


Intervals of the ECG (measured as the longest duration in any limb lead; normal
range in parenthesis)
P wave duration - from the beginning of the P wave to its end (0.06-
0.10sec, or 1.5-2.5mm)
PR interval from the onset of the P wave to the onset of the QRS
complex (0.12-0.20sec, or 3-5mm), includes the P wave duration plus the PR
segment
PR segment - from the end of the P wave to the beginning of the QRS
complex
QRS duration - from the beginning of the QRS complex to its end
(0.06-0.10 sec or 1.5-2.5mm)
ST segment - from the end of the QRS to the beginning of the T wave
QT interval - from the beginning of the QRS to the end of the T wave
(Varies with rate. If regular rhythm, should be 0.41sec corrected for rate)
T-P segment - from the end of the T wave to the beginning of the next P
wave
P-P interval - from the beginning of one P wave to the beginning of the
next P wave
7
R-R interval - from the beginning of one QRS to the beginning of the next
QRS


Additional intervals sometimes helpful in arrhythmia analysis:
R-R-prime interval - from the beginning of a normal QRS to the beginning
of an abnormal QRS, also called coupling interval
R-P interval - from the beginning of the QRS to the beginning of the next P
wave
R-prime-R-prime interval - from one abnormal QRS (usually a PVC) to the
next abnormal QRS, also called interectopic interval


Calculating the Rate - 3 methods, require normal paper speed of 25
mm/sec. If nonstandard speed, adjust calculations

Method 1: 6 second rule
Requires 6 seconds of recording
Does not require regular rhythm NOTE: this is the ONLY method useful in
irregular rhythm
--Count total number of complexes in 6 seconds and multiply by 10, result in
rate/min (counting all the P waves gives the atrial rate; counting all the
QRS complexes gives the ventricular rate; normally the atrial and
ventricular rates are the same)
--Helpful hint: there are little vertical lines every 3 seconds on some ECG paper.
--Helpful hint: on the new ECG tracings, there are exactly 10 seconds of rhythm,
so count all the QRS complexes and multiply by 6, a variation of the 6
second rule (call it the "10 second rule"?)
8

Method 2: Calculation by interval measurement
Does not require 6 seconds of recording
Requires regular rhythm
--Measure distance in mm between 2 adjacent complexes
--Divide 1,500 by the distance in mm, and result is rate in beats/min

Method 3: Estimating by nearest of the darker 5 mm markers
Fastest method, but not most accurate
Does not require 6 seconds of recording
Requires regular rhythm
--Find a wave beginning on or near a dark 5-mm marker
--Count subsequent 5-mm markers until the next wave of interest
--As counting markers, say, "300, 150, 100, 75, 60, 50 (, 42, 38, 33, 30)"
--When you get to the marker, you have the rate bracketed between 2
numbers
--Interpolate between the 2 bracketed numbers

The 12 leads, 12 standard pairs, 2 points each of electrical potential difference
Each of the 12 leads records from a different 2-D projection
The first 6 leads are frontal plane (Limb leads - 3 standard and 3
augmented),
The other 6 are transverse plane (Chest leads)

Three standard limb leads (4 electrodes, right leg is electrical
ground)
I - Right arm negative, left arm positive
II - Right arm negative, left leg positive
III - Left arm negative, left leg positive

+
+
+
0 degrees
Lead I
60 degrees
Lead II
120 degrees
Lead III
-
- -
Standard frontal plane leads
9
Three augmented limb leads (between one lead and a "central
terminal" from the other 2)
aV
R
- Right arm positive, other 2 negative
aV
L
- Left arm positive, other 2 negative
aV
F
- Left leg positive, other 2 negative



Six chest leads (precordial leads, transverse plane leads)
(between one lead and a central terminal from all 3 limb
electrodes)
V
1
- electrode in 4
th
Right intercostal space (ics) at sternal
edge
V
2
- electrode in 4
th
Left ics at sternal edge
V
3
- electrode halfway between V
2
and V
4
V
4
- electrode in 5
th
Left ics in the midclavicular line
V
5
- electrode in anterior axillary line, same plane as V
4

V
6
- electrode in mid-axillary line, same plane as V
4
Augmented frontal plane leads
-30 degrees
aVL
+90 degrees
aVF
-150 or +210 degrees
aVR +
+
+
10
Determining the Axis

What is an Axis? When the heart depolarizes and repolarizes, the
depolarization generally has a predominant direction in space. That predominant
direction is the axis of the depolarization or repolarization. We generally focus
our attention on the depolarization of the ventricle as represented in the QRS
complex. The predominant direction of the ventricular depolarization is called the
QRS axis. (The predominant direction of atrial depolarization is the P wave axis,
and the predominant direction of ventricular repolarization is the T wave axis)
Background 1, once again, recall that the electrical activity is occurring as
an electrical dipole (a voltage) which varies in amplitude and direction in 3-D
space over time.
However, an
ECG lead is looking at only one-dimensional voltage. But the ECG has 12 leads
which look at the one-dimensional voltage from 12 different fixed vantage points,
6 in the frontal plane (limb leads), and 6 in the transverse plane (chest leads).
We generally analyze the axis only in the frontal plane. We most commonly
analyze the axis of the QRS complex, but any wave or portion of a wave (such as
the P wave or the T wave or even the initial forces of the QRS or the terminal
forces of the QRS) may be analyzed using the same principles. We will focus on
the axis of the QRS complex. By common agreement for many years, the frontal
plane is divided into a circle of 360 degrees, and by definition, 0 degrees is
directed to the left, and the number of degrees increases as the direction
progresses clockwise. Therefore, directly inferior is 90 degrees, directly
rightward is 180 degrees, and directly superior is either 270 degrees or -90
11
degrees. Similarly, a direction to the left and inferior will be between 0 and 90
degrees, a direction to the right and inferior will be between 90 and 180 degrees,
a direction to the right and superior will be between 180 and 270 degrees, and a
direction to the left and superior will be between -90 and 0 degrees.
Background 2; realize that each of the 6 limb leads has a consistent
vantage point, which is mapped to a constant direction in polar coordinates. You
must memorize each lead's vantage point (see diagrams above of standard and
augmented limb leads). Lead I is defined as 0 degrees and is directly leftward.
Lead II is defined as +60 degrees and is directed clockwise 60 degrees from lead
I, or leftward and inferiorly.
Lead III is defined as +120 degrees and is directed another 60 degrees clockwise
from lead II, and so is directed rightward and inferiorly.
Lead aV
R
is defined as toward the right shoulder, at +210 degrees or -150
degrees, and so is rightward and is 30 degrees superior to the horizontal.
Lead aV
L
is defined as toward the left shoulder, at 30 degrees above the
horizontal, or minus 30 degrees, that is, 30 degrees counterclockwise from lead I.
Lead aV
F
is defined as directed inferiorly, 90 degrees clockwise from lead I, or at
+90 degrees.
Background 3, Understand that determining an axis in the frontal plane
requires determining for each limb lead whether the wave (for example the QRS
complex) is positive, negative, or isoelectric.
The QRS complex is positive in a lead if the upward deflection is larger than the
downward deflection in that lead.
The QRS complex is negative if the downward deflection is larger than the
upward deflection.
The QRS complex is isoelectric if the upward deflection is the same size as the
downward deflection.
If the QRS complex is positive in a lead, then the
QRS axis is not too different from the axis of that lead;
specifically, the difference between the axis of the wave
and the axis of the lead is less than 90 degrees (less
than perpendicular). As a matter of fact, the more
positive the QRS complex is in a lead, the closer the
QRS axis will be to the axis of that lead (the angle
between the QRS axis and the axis of the lead may be
nearly 0 degrees). Conversely, if the QRS complex is
negative in a lead, then the difference between the axis
of the wave and the axis of the lead is more than 90
degrees (more than perpendicular). Again, the more negative the QRS complex
is in a given lead, the farther away the QRS axis will be from the axis of that lead
(the angle between the QRS axis and the axis of the lead may be nearly 0
degrees). Similarly, if a wave is isoelectric in a lead, then the difference between
the axis of the QRS complex and the axis of the lead is 90 degrees
(perpendicular). Given the three background points, the axis can be determined
using the steps below.

Positive
in I is
shaded
area

aVF
I
12
Step 1, look at the two perpendicular leads I
and aV
F
. Determine for each of these leads, whether
the wave is positive (mainly above the baseline,
upgoing), negative (mainly below the baseline,
downgoing), or isoelectric (that the upgoing forces are
balanced by equal downgoing forces) in that lead.
If the wave is positive in lead I (at 0 degrees),
then the axis is to the left side of the patient (less than
90 degrees from lead I, which is directly leftward, i.e.,
between about -75 and +75 degrees). But if the wave
is negative in lead I, then the axis is to the right side of
the patient. If the wave is isoelectric in lead I, then the axis is perpendicular to
lead I, or at either +90 degrees or -90 degrees.
If the wave is positive in lead aV
F
(at +90
degrees), then the axis is below the horizontal (less
than 90 degrees from lead aV
F
, or between about +15
and +165 degrees). But if the wave is negative in aV
F
,
then the axis is above the horizontal. If the wave is
isoelectric in lead aV
F
, the axis will be perpendicular to
lead aV
F
, or at either 0 or +180 degrees.
Most normal axes are below the horizontal and
to the left side of the patient, so are positive in both
lead I and lead aV
F
. The results of this analysis then
tell you in which quadrant the axis lies. If the wave is
positive in leads I and aV
F
, the axis is in the left lower quadrant. If the wave is
positive in lead I but negative in aV
F
, the axis is in the left superior quadrant. If
the wave is negative in lead I, but positive in aV
F
, the axis is in the right lower
quadrant, and if the wave is negative in both leads I and aV
F
, the axis is in the
right upper quadrant.
If either lead I or lead aV
F
is isoelectric, then you can complete the
determination of the axis with this step. If the wave is isoelectric in I and positive
in aV
F
, then the axis is +90 degrees. If the wave is isoelectric in I and negative in
aV
F
, then the axis is -90 degrees. If the wave is positive in I and isoelectric in
aV
F
, then the axis is 0 degrees, and if the wave is negative in I and isoelectric in
aV
F
, then the axis is +180 degrees. In this case, you have succeeded in
determining the axis.
Step 2, If neither leads I or aV
F
is isoelectric, then look for a lead in which
the wave is isoelectric (equal magnitude of upward and downward deflections). If
you find an isoelectric lead, the axis will be perpendicular from that lead, and so
will be either 90 degrees greater than or 90 degrees less than the axis defined by
that lead. Whether the 90 degrees should be added or subtracted depends on
which quadrant contains the axis as found in step three above. Just select the
direction that results in the correct quadrant.
Example 1: The wave is positive in leads I and aV
F
, and it is isoelectric in lead
aV
L.
So the axis will be perpendicular to aV
L
, which is defined as -30 degrees, so
it will be either -120 degrees or +60 degrees. Since +60 degrees falls in the
aVF
I
Pos in I
Pos in
aVF
Pos in I
Neg in
aVF
Neg in I
Pos in
aVF
Neg in I
Neg in
aVF
Pos in I
Iso in aVF
Iso in I
Pos in
aVF
aVF
I
13
correct quadrant (left lower quadrant since both leads I and aV
F
are positive), the
axis is +60 degrees.
Example 2: The wave is positive in leads I and aV
F
, and it is isoelectric in lead III.
Lead III is defined as +120 degrees, so the perpendicular is either +30 or +210,
and since +30 is in the correct quadrant, it is the correct axis. So if there is an
isoelectric lead, you are finished! So, if there is an isoelectric lead, the axis will
be a multiple of 30.
Step 3, if there is no isoelectric lead, look for the two leads with the
smallest net deflections (closest to isoelectric). Similar to step two, the axis will
be between the perpendiculars of those two leads, (nearly perpendicular to the
nearly isoelectric leads). If the lead is slightly negative, the axis will be slightly
more than 90 degrees from the lead, and if the lead is slightly positive, the axis
will be slightly less than 90 degrees from the lead.
Example 1: If the QRS is positive in leads I and aV
F
and is also slightly positive
in leads III and aV
L
, the axis is slightly greater than +30 degrees (slightly less
than perpendicular to III) and slightly less than +60 degrees (slightly less than
perpendicular to aV
L
), so call it +45 degrees, and you're finished!
Example 2: If the QRS is positive in leads I and aV
F
, and is only slightly positive
in lead I and slightly negative in lead aVL, then the axis is slightly less than +90
degrees (slightly less than perpendicular to I) and slightly more than +60 degrees
(slightly more than perpendicular to aV
L
), call it +75 degrees, and you're finished
again! So, when there is no isoelectric lead, the axis will be a multiple of 15, but
not 30.
Step 4, additionally, for confirmation of your work, of the six limb leads,
find the lead with the tallest wave. The axis of this lead is close to the axis of the
wave you are assessing. So, if the tallest QRS complex is in lead I, the axis of
the QRS complex is close to 0 degrees, or if the tallest QRS complex is in lead
aV
L
, the axis of the QRS complex is near -30 degrees. If the tallest P wave is in
lead II, the P wave axis is close to +60 degrees. This gives you a way to confirm
the axis you calculated by the three steps above.

Note 1: The reason we measure the axis of a wave is to assist in
interpretation of the wave. There are normal limits to axis of a wave, so
determining the axis helps determine whether a wave is normal. The normal axis
of the QRS complex ranges from -30 degrees to +90 degrees. If the QRS axis is
less than -30 degrees, then the QRS has left axis deviation, and that raises
specific diagnostic possibilities, such as inferior wall MI or left anterior fascicular
block. If the axis is more than +90 degrees, then the QRS has right axis
deviation, and that raises the possibility of RVH or lateral wall MI or left posterior
fascicular block. These aren't the only possibilities, but the first that should be
considered. Likewise, if the P wave axis is -75 degrees, the P wave is likely a
retrograde P wave, beginning from the AV node.
Note 2: The rate and intervals and axis form the "Vital Signs" of the ECG.
The first step in evaluating an ECG is determining these numbers. If any of the
numbers is abnormal, they are clues to abnormalities on the ECG, and lead to
the appropriate diagnoses.
14
Note 3 = Key Note: If the QRS complex is positive in both leads I and
aVF, the QRS axis is in the left lower quadrant (between 0 and 90) and is normal.
If the QRS complex is positive in both leads I and II, the QRS axis is between -30
and +90 degrees and is normal. If the QRS complex is positive in lead I and
negative in lead II, there is left axis deviation. If the QRS complex is negative in
lead I and positive in lead aVF, it is right axis deviation. If the QRS complex is
negative in both I and aVF, the QRS complex is right superior axis (or northwest
axis, very abnormal).

Diagnosis Axis (degrees) Lead projections
Normal -30 to 90 Up in I, up in II
Left Axis Deviation -90 to -30 Up in I, down in II
Right Axis Deviation 90 to 180 Down in I, up in aVF
Northwest Axis 180 to 270 Down in I, down in aVF

Part B: Steps to interpreting the ECG
1. Check the Standardization, then obtain the Vital Signs

a) The standardization marker height and width should be 10 mm high and 5
mm wide
b) The atrial and ventricular rates should be the same and should be
between 60 and 100 per minute (15-25mm between successive waves)
c) The PR, QRS, and QT intervals should be within the ranges listed above.
d) Determine whether the QRS axis is normal, left axis deviation or right axis
deviation
e) Circle all abnormal vital signs, because they require a diagnostic
explanation

Normal rate is between 60 and 100 /min, and
The rhythm should be generally regular
Rate below 60 is bradycardia by definition (or below 50, according to some)
Bradycardia may be normal in well-conditioned individuals or during sleep,
or may be caused by medications such as beta-blockers or heart rate-lowering
calcium blockers like verapamil or diltiazem
Rate above 100 is tachycardia by definition
Tachycardia usually indicates heart disease or excess sympathetic tone or
both

2. P wave: ("cherchez le P", look for the P wave! from Marriott)

Normal P is uniform in configuration from beat to beat
15
Normal P wave is upright in leads I, II and aV
F

Normal P duration 0.06-0.10 sec
Normal P height usually less than 2.5mm (usually tallest in lead II)
In V
1
, the P wave is usually biphasic (the initial part of the P goes up, and the
terminal part goes down)

3. PR interval

From the beginning of the P wave to the beginning of the QRS, contains both the
P wave and the PR segment (the short straight line between the P wave and the
QRS complex)
Normally is constant from one beat to the next, and from 0.12-0.20 sec in adults
(twice the normal P wave duration)
Normally the PR segment is at the same baseline level as the segment before
the P wave (T-P segment)
4. QRS complex

Axis is normally between -30 and +90 degrees
Duration normally from 0.06-0.10 sec (same as P wave duration)
Q waves
Normally less than 0.03 sec (3/4 mm) wide in leads I, II, III, aV
L
, aV
F
, V
5

and V
6
and depth less than 25% of the height of the R wave
Normally less than 0.02 sec (1/2 mm) in lead V
4
and not deep
Normally absent in V
1
to V
3
, definitely absent in V2-V3
R waves
Normally increase in size from V
1
to V
4
, called R wave progression,
Deflection usually positive by V
4
(R greater than S),
usually negative in V
1
(S greater than R)
Normally none is greater than 20mm in limb leads
Normally none is greater than 30mm in chest leads
Normally at least one limb lead is over 5 mm in R+S voltage
Normally at least one chest lead is over 10 mm in R+S voltage
S waves
Normally increase from V
1
, to V
2
, then decrease from V
3
to V
6
5. ST segment

(during the plateau phase of the ventricular action potential)
Generally begins horizontally then curves gently into the T wave
Generally begins at the level of both the PR segment and the TP segment
May be displaced 1 mm in the direction of the following T wave (early
repolarization)
6. T wave

16
Smooth, rounded, monophasic or diphasic, more gradual onset and more sudden
offset.
Amplitude diminishes with age, larger in men, should be larger than U wave if
present
Amplitude usually less than 5 mm in limb leads, and less than 10 mm in chest
leads
Amplitude usually less than 3 mm in III and aV
L
and less than 5 mm in V
1
and V
6

Direction similar to QRS, so if the QRS is upright, the T wave should usually be
upright, and vice versa
Direction in transverse plane: variable in V
1
, upright T in V
2
to V
6

Tall and peaked in hyperkalemia, small and flattened in hypokalemia
7. U wave

May be absent
Larger or more prominent in bradycardia, (if larger than T wave, indicates
hypokalemia)
Same direction as T wave, but only about 10% of amplitude of T wave, less than
1 mm tall
8. QTc interval

A measure of duration of activation and recovery of ventricular myocardium
Normal QT interval varies inversely with heart rate, generally less than half the
RR interval
QT interval corrected for heart rate is called QTc
QTc = QT/(square root of the R-R interval), called Bazetts formula.
Normal QTc is 0.41 seconds
Slightly longer in women and older people
Should be measured after a series of regular cycles
9. Analyzing the Rhythm
A) Rate and Regularity
1) The normal rhythm is normal sinus rhythm, with normal
findings as noted above for P wave uniformity and rate and
PR interval
2) Due to continual variation in autonomic tone the sinus node
may normally vary its rate slightly, synchronous with
respiration (inspiration gives increase in rate, called
respiratory phasic sinus arrhythmia)
B) P wave morphology:
1) P wave axis in the left lower quadrant (between 0 and 90
degrees) indicates that the rhythm is originating in the sinus
node (SA or sinoatrial node), the normal pacemaker of the
heart (normal sinus rhythm, or NSR, or sinus rhythm).
2) When a P wave is slightly upright in lead I but is inverted in
II, III, and aV
F
, the P wave is likely originating in the area of
17
the AV node and is conducting retrograde through the
atrium, indicating abnormal rhythm.
C) Finding the P wave:
1) In normal sinus rhythm, there is usually no problem finding
the P wave displayed prominently in front of the QRS
complex, but in other circumstances, the P may be hard to
find
2) Hard P waves to find (this section is for future reference):
(a) Sometimes the rhythm is sinus, and the P wave is in
front of the QRS, but the P wave may be very small.
Other times, the rhythm is sinus, but the rate is fast,
and the P wave in front of the QRS is riding on the
downslope of the T wave of the preceding beat.
(b) In complete heart block, some P waves may be
buried inside a QRS complex. To find these, note the
usual distance between two successive P waves and
"march" forward and backward from definite P waves
to see if a P wave occurring at the usual distance
would fall inside a QRS. All the P waves must be
found so that the proper atrial rate may be
determined.
(c) In second degree AV block, some P waves may occur
during an ST segment or during a T wave, creating a
distortion of the usual shape, like a "wart" on the ST
segment or the T wave.
(d) Premature atrial complexes (PAC's) frequently occur
during ventricular depolarization, also showing a
distortion of the ST segment or the T wave. If the
PAC is nonconducted, it will be only a distortion of the
ventricular repolarization (again, a "wart" on the T
wave or in the ST segment) without any QRS to
provide a clue to its presence, but often a pause in
the rhythm because the PAC resets the sinus node.
(e) In some instances of junctional rhythm, the P wave
may be buried in the QRS for every beat, giving no
definite atrial activity, so no P waves are seen at all.
In such a situation, it is unsure whether the atrium is
contracting. In other instances of junctional rhythm,
the P wave may be after the QRS early in the ST
segment or right at the end of the QRS (again, a
"wart" on the T wave or in the ST segment), and will
be inverted in II, III, and aVF.
(f) In patients with electronic pacemaker of the atrium
("electronic atrial pacemaker"), the P wave after the
atrial pacing spike may be hard to see. The presence
of such a P wave may be inferred with confidence if
18
there is a constant and relatively normal PR interval
between the spike of the atrial pacemaker and the
beginning of the QRS complex.
(g) Difficulty also arises when trying to decide among the
rapid atrial rhythms, such as multifocal atrial
tachycardia and atrial fibrillation and atrial flutter, and
the distinctions between these are explained
elsewhere in this document.
D) PR interval 0.12-0.20 sec
1) Short PR interval: <0.12 sec, causes include non-sinus atrial
or junctional rhythm, and ventricular pre-excitation (WPW)
2) Long PR interval: >0.20 sec, AV node is slow in conduction
3) Variable PR interval: definitely abnormal, always indicating
an interesting dysrhythmia
(a) Wenckebach-type second-degree AV block
(b) Complete heart block (third degree)
(c) AV dissociation with ventricular rate faster than atrial
rate
E) QRS complex: morphology which may predispose to dysrhythmia
1) Slurred onset of QRS complex with short PR interval
suggests pre-excitation (WPW)
2) Normal QRS complex with short PR interval suggests pre-
excitation (not WPW)
3) Wide QRS (> 0.10 sec duration) indicates one of many
abnormalities (LBBB, RBBB, IVCD, WPW, electronically
paced QRS or QRS originating from the ventricle itself), may
predispose to dysrhythmia
F) Repolarization morphology which may predispose to dysrhythmia
1) ST segment elevation (indicating acute transmural ischemia,
probably myocardial infarction, also can indicate
hyperkalemia) or depression (indicating possible acute
subendocardial ischemia or possibly infarction or secondary
change from a depolarization abnormality such as ventricular
hypertrophy or bundle branch block)
2) Increase in T amplitude - may indicate hyperkalemia or
hyperacute phase of myocardial infarction
3) Decrease in T amplitude - may indicate electrolyte
imbalance such as hypokalemia or ischemia
4) Prolonged QTc - risk for ventricular arrhythmias, most likely
due to pharmaceutical or ischemia, electrolyte imbalance,
congenital problem, or wide QRS
5) Increase in U wave amplitude - electrolyte imbalance,
specifically hypokalemia
19
Section II: Abnormalities of the ECG
Part A: Chamber Hypertrophy or Enlargement
Atrial abnormalities
Usually accompanied by LVH or RVH or both

RAE (Right atrial enlargement or right atrial abnormality, also "P
pulmonale")
Peaked P wave in lead II, over 2.5mm tall, P duration <0.12 sec
P axis often >70 degrees
Also in lead V1, the P initial force is often tall and peaked
LAE (Left atrial enlargement or left atrial abnormality, also "P mitrale")
Wide notched P in lead II, over 3 mm wide
Best criterion: P terminal force (end of the P wave)
At least 1 mm (0.10mV) deep and 1 mm (0.04sec) wide in
lead V1
Also, 0.04 sec distance between the peaks of the notch in lead II
LAE can come and go day by day, depending on LA pressure
Therefore the appearance of LAE might signal worsening CHF


LVH -
.
I) When the left ventricular mass increases in response to a stimulus
(usually pressure or volume overload), the electrical forces of the left
ventricle also increase. This increase is seen on the ECG by larger QRS
complexes. Since the left ventricle is located on the left and inferior and
somewhat posterior portion of the heart, the larger voltage in the QRS is
directed posteriorly and leftward and inferiorly. That means that the QRS
complex will be deeper in V1-2, taller in 2, 3, and F, and taller in V5-6.
When the ventricle becomes thicker, the depolarization takes longer to be
conducted, so the QRS duration prolongs slightly. Repolarization is
frequently disturbed by the LVH, with the T wave often directed away from
the main QRS direction (called "discordant"). So, if the QRS is tall, the T
20
will often be inverted, and if the QRS is deeply negative, the T will often be
tall and positive. Likewise, the ST segment may be displaced in a
direction similar to the discordant T wave. Additionally, the left atrium is
frequently stressed by LVH, so left atrial abnormality is often present, with
criteria as described above. These findings in LVH are formalized in an
assessment algorithm that follows:
II) Criteria: Use a point score system and add up the points. A total of 5
points is LVH and 4 points is probable LVH. The most important of the
criteria is voltage. Second is left atrial enlargement. Here are the
Romhilt-Estes Criteria:
A) Voltage criteria (any one of these)- 3 points
1) R or S in any limb lead at least 20mm (2.0mV) OR
2) [S in V1 or V2] or [R in V5 or V6] at least 30 mm (3.0mV)
3) Other criteria you may see:
(a) Cornell criteria, described in III. below
(b) [S in V1 or V2] plus [R in V5 or V6] at least 35 mm
(0.35mV)
(c) R in aVL at least 11 mm or 13 mm
(d) Sokolow-Lyon criterion, R in I plus S in III over 25 mm
B) Repolarization abnormality - (if on digitalis, only 1 point) 3 points
ST segment and T wave discordant from QRS complex,
especially ST depression and T wave inversion in V5-V6
C) Left atrial enlargement in V1 (criteria above) - 3 points
D) QRS duration 0.09 to 0.10 sec - 2 points
(if longer, consider another diagnosis, like LBBB)
E) Left axis deviation superior to -30 degrees (dont use) 2 points
F) Intrinsicoid deflection in V5 or V6 longer than 0.05 sec 1 point
1) Measure from onset of QRS to the peak of the R wave
2) Also called "R peak time"
III) Cornell voltage Criteria
A) Women: R wave in aVL + S wave in lead V3 >2.0mV
B) Men: R wave in aVL + S wave in lead V3 >2.8mV
IV) The voltage criteria do not apply to young people, since they were studied
in patients over 40 years old, and if applied to young athletic people, can
erroneously diagnose LVH

RVH -
I) ECG diagnosis is tougher than LVH, because the normal ECG is
dominated by the LV, so the RV has to hypertrophy dramatically to
overcome LV forces and manifest on the ECG. RV forces are normally
anteriorly and rightward. So, at its best, the sensitivity of the ECG for RVH
is probably only about 20%, and specificity is maybe 80%, depending on
which criteria and patient populations are involved. Since the right
ventricle is the anterior and rightward portion of the heart, hypertrophy of
the right ventricle is seen in amplification of rightward and anterior forces,
and diagnosis is made using the criteria below.
21
II) Criteria often used (there is not a generally accepted point score system)
A) Right axis deviation >110 degrees
Note: Other causes of right axis deviation besides RVH in
patients without prolonged QRS duration: normal variant in
young adults, COPD without cor pulmonale, lateral
myocardial infarction, and left posterior hemiblock. Also, a
technician error with reversal of the left and right arm leads,
which can be recognized by the inverted P wave seen in
lead I in arm lead reversal.
B) Prominent anterior forces: R/S in V1 >1 (R wave larger than S wave
in V1), also abnormal is R/S is greater than 1 in V3R, a lead that is
in the position of V3, but on the right side of the sternum.
Note: Other causes of prominent anterior forces besides
RVH in patients without prolonged QRS duration: normal
variant in young adults, true posterior myocardial infarction,
pulmonary disease, WPW pattern (the latter with QRS
widening)
C) Prominent anterior forces: R in V1 > 7 mm
D) S in V1 < 2 mm
E) qR pattern in V1 (little Q wave then big R wave)
F) r-S-R-prime in V1 with R-prime > 10 mm
G) Supporting: ST depression and T inversion in V1-V2


Part B: Intraventricular Conduction Abnormalities

LBBB - Left Bundle Branch Block, the delay is a leftward posterior mid-
QRS conduction delay
I) QRS duration >= 0.12 sec AND
II) Broad R in I, V5, and V6, usually notched or slurred, no good sharp peak,
because there is a mid-QRS delay
III) Absent Q waves in I, V5, and V6, because the normal septal activation
from the left septal surface to the right septal surface from the left bundle
is absent, so the septum is activated from right to left.
A) Therefore the initial forces are directed leftward.
B) Since the initial forces are distorted by LBBB, old myocardial
infarctions cannot be diagnosed in the presence of LBBB
IV) Delay of onset of the intrinsicoid deflection (R peak time) in V5 and V6 to
0.06 sec
V) ST segment and T wave are directed opposite to the main QRS deflection.
A) Generally, any depolarization abnormality will have a characteristic
consequent repolarization abnormality.
22
B) Since the ST segment and the T wave are distorted by the
depolarization abnormality, the ST segment is not interpretable for
treadmill tests in LBBB
VI) Although not a criterion, it is helpful to note that there is a broad deep S
wave in V1 a big one
VII) INCOMPLETE LBBB - as for complete LBBB except QRS duration only
0.10-0.11


RBBB - Right Bundle Branch Block, the delay is a rightward anterior
terminal conduction delay (contrast with LBBB above)
I) QRS duration >= 0.12 sec AND
II) rsR-prime wave in V1 or V2 (the R-prime is the terminal delay) with R-
prime larger than initial R wave (so the second rabbit ear is taller than the
first). The width of the R prime in V1 is often 0.06 sec. NOTE: if the
patient has lost the initial small R wave in V1, and the QRS in V1 begins
with a Q wave, then the terminal delay in V1 will be a qR pattern instead of
a rsR-prime. The important thing is that the terminal forces (the final
forces at the end of the QRS) are positive in V1, and slurred, with a width
of 0.06 sec or so
III) Intrinsicoid deflection in V1 or V2 later then 0.05 sec (remember that
intrinsicoid deflection is also called "R peak time", and is duration from the
onset of the QRS forces to the peak of the R wave)
IV) Wide (slurred) S wave in I, V5, and V6, often with a very distinct onset
V) Since the initial forces are not disturbed in RBBB, old myocardial
infarctions may be diagnosed in the presence of RBBB
VI) Repolarization:
A) the ST segment is generally normal (except maybe depressed in
V1 or v2), and
B) The T wave is directed opposite the terminal delay (down in V1-V2,
up in I, V5, and V6).
C) Since the ST segment is normal, the treadmill test can be used for
diagnosis of ischemia using ST depression in leads V5 and V6 (but
not V1 and V2)
VII) INCOMPLETE RBBB - as for complete RBBB except QRS duration only
0.09-0.11, and terminal delay is shorter, so width of R prime is less
VIII) Distinguish from Normal Variant R-S-R-prime in V1-V2, where the QRS
duration is normal and the R prime is less than 6 mm tall, and the R prime
is brief, without real delay, and there are no criteria for RVH


Fascicular Blocks (Hemiblocks)
I) Left anterior fascicular block (left anterior hemiblock, LAFB): all of the first
three criteria must be present
23
A) Left axis deviation -45 to -90 degrees (-30 to -45 degrees is
probable or possible, not definite)
Other causes of left axis deviation:
B) A qR complex or an R wave in leads I and aVL; and an rS complex
in leads II, III, and aVF
C) Normal or slightly prolonged QRS duration
D) Usually poor precordial R wave progression and often persistent S
waves in V5 and V6
E) Repolarization: T usually upright in II, III, and aVF and precordial
leads, resulting in a wide angle between the QRS axis and the T
axis, with the QRS axis about -45 degrees and the T wave axis
about +75 degrees
II) Left posterior fascicular block (left posterior hemiblock, LPFB, these are
rare): all of the first three criteria must be present
A) Right axis deviation + 90 to + 180 degrees, better if +110 or greater
B) S in I and Q in III
C) Normal or slightly prolonged QRS duration
D) Repolarization: T usually more superiorly displaced, often inverted
in II, III, and aVF
III) Combinations of Conduction abnormalities
A) Bifascicular blocks
1) RBBB plus LAFB, the criteria are additive; usual criteria of
RBBB, and the first half or first 0.06 sec of the QRS complex
have an axis of -30 to -90 degrees in the frontal plane, with
an initial r in II, III, and aVF
2) RBBB plus LPFB, the criteria are additive
B) Trifascicular block - bifascicular block plus first or second degree
AV block


IVCD, Peri-infarction blocks -
I) IVCD (intraventricular conduction delay or defect)
A) QRS duration 0.11 sec or more without LBBB or RBBB criteria
B) Also called nonspecific or diffuse IVCD
C) A small notch in the QRS with normal QRS duration is insignificant
and is best not called an IVCD but rather ignored (for
completeness, the diagnosis of minor IVCD may be added)
II) Peri-infarction block - after a transmural myocardial infarction, especially
an inferior or lateral infarction, there may be a mild terminal delay directed
toward the infarcted area. This will be seen as a slurred downstroke of the
R wave in a lead with a pathologic Q wave


WPW - (Wolff-Parkinson-White Syndrome, also called Pre-excitation)
I) Original description was 1930 and included
24
A) Short PR interval
B) Wide QRS complex with slurred initial forces (initial force is "delta
wave")
C) Paroxysmal tachycardia (usually supraventricular)
II) Every beat is a fusion beat
A) DEFINITION: A fusion beat is a beat caused by simultaneous
transmission of impulses from more than one focus resulting in a
hybrid complex, some of the ventricular cells depolarized from one
focus and the rest of the cells from the other focus, so the QRS
form is intermediate in morphology between the morphology of
either of the single focus complexes
B) Part of the QRS is caused by conduction through the AV node and
His-Purkinje system
C) Part of the QRS is caused by conduction through the accessory AV
connection (called "Bundle of Kent") from atrial muscle to
ventricular muscle
D) The relative contribution of each conduction pathway determines
how wide the QRS is and how large and prominent the delta wave
is, and how short the PR interval is. The more abnormal the QRS,
the more "pre-excited" the ventricle.
III) Tachycardias are often due to electrical activity traveling in a circular
pathway that includes the atrium, the ventricle, and the AV node and the
accessory pathway. This circular electrical activity is called circus
movement tachycardia, and it is specifically called atrioventricular
reciprocating (or reentrant) tachycardia (AVRT) when the pathway
includes all 4 of these structures.
IV) Criteria for WPW pattern (for the "WPW syndrome", must have
paroxysmal supraventricular tachycardias)
A) PR interval less than 0.12 sec
B) QRS duration at least 0.11 sec
C) Initial slurring of QRS, delta wave - the most important criterion
D) Secondary ST segment and T wave abnormality
E) Frequent association of paroxysmal tachycardia
F) The manifestations of pre-excitation may be intermittent

Part C: Ischemia and Infarction, and Repolarization Abnormalities

I) Review of physiology of infarction: Coronary blood supply must meet the demands
of the myocardium (supply-demand balance)
A) Oxygen extraction of coronary flow is maximal at rest, so any increase in oxygen
delivery must come from reserve in coronary flow volume, which normally can
increase about four-fold
B) Oxygen demand of myocardium is increased by mainly by increases in heart
rate, contractility, chamber diameter, and systolic pressure
25
C) Oxygen supply to myocardium is impaired by obstruction to coronary flow, but
also potentially by problems in oxygen carrying capacity of the blood from
anemia, hypoxia, or hemoglobin abnormalities
D) Infarction generally requires total absence of blood supply for at least 45 min or
so, and infarction is first seen in the more vulnerable subendocardium and
spreads toward the epicardium as the absence of blood supply persists

II) Ischemia and Infarction definition and ECG findings
A) Ischemia
1) T wave abnormalities are not generally specific, so are often
called nonspecific T wave abnormality. They could be from
ischemia, hypertrophy, electrolyte abnormality or a host of
other things
2) ST segment deviation - Generally a clinically more significant
imbalance in supply/demand than ischemia, is seen on ECG
as ST segment abnormalities
3) ECG: ST elevation points toward the area of transmural
("subepicardial") ischemia, that is, ST elevation in the leads
representing the involved wall - so ST elevation localizes the
problem area
(a) Usually elevation is at least a full 1 mm or more,
sometimes 10-15 mm, often is concave downward,
called "coving"
(b) A mere 1 or 2 mm elevation seen in V2, also possibly
V1 and V3, in the setting of normal deep S waves is
usually normal, and especially will be normal in the
setting of LBBB or LVH
(c) Transmural ischemic pattern is very important in
management: in an appropriate clinical setting of
chest pain or other symptoms suspicious for
myocardial infarction, this pattern constitutes an
indication for either thrombolytic therapy or emergent
cardiac catheterization for locating and opening an
occluded coronary artery (STEMI)
4) ECG: ST depression means subendocardial, and does not
localize to any particular segment of the LV, only indicates
ischemia somewhere (may have ST depression in
NSTEMI)
B) Infarction - Irreversible loss of myocardial cells, replaced by
electrically silent scar tissue
1) ECG: initial forces of QRS complex are directed away from
the area of the infarction, that is, loss of R wave or abnormal
Q wave in the affected leads
2) Pathologic Q wave is usually 0.04 sec wide and 25% (some
say 33%) of the height of the R wave
3) The diagnosis of a Non-Q MI cannot be made on a single
ECG, whereas the diagnosis of a Q wave MI can. The ECG
criterion for diagnosis of a non-Q MI (NQMI) is an
26
abnormality which is limited to repolarization change which
persists and evolves over a period of at least 24-72 hours

III) Localization of Ischemia or Infarction by affected leads - This mainly
applies to Q waves of infarction and transmural ischemia (ST segment
elevation). Generally Q waves are the most localized, and ST segment
elevation is somewhat more widespread.
A) Inferior - II, III, aVF
B) Inferolateral - II, III, and aVF and abnormal in V4 - V6
C) Anteroseptal - V1 - V3, sometimes V4 too
D) Anterior - one or more of leads V2 - V4 (an anterior infarction can
also be diagnosed without a Q wave in these leads if there is a
reversal of the normal R wave progression such that the R wave
gets smaller and/or the R/S ratio gets smaller from V2 to V3 or V3
to V4, and so on)
E) Anterolateral - V5 - V6 and sometimes V4 too, with I and aVL
F) Extensive anterior - nearly all of V1 - V6, also maybe I and aVL
G) High lateral, or just "lateral" - I, aVL
H) True posterior - TRICKY - there are no leads directed posteriorly,
so you must look at the anterior leads upside down to see the
analogous QRS and ST and T abnormalities. When looking at the
leads upside down, be careful not to reverse the time sequence.
1) Wide tall R wave in V1 or V2 (>0.04 sec and taller than S
wave) is the pathologic "Q" wave
2) ST depression in V1 or V2 is the transmural ischemia pattern
3) Tall peaked T waves in V1 or V2 are the ischemic "T wave
inversion"
4) To determine whether a wide tall R wave in V1 or V2 is due
to a true posterior MI or to RVH, look for the company it
keeps
(a) If the limb leads show right axis deviation with an rS in
lead I or RAE with peaked P in lead II, then the large
R in V1 is probably RVH
(b) If the limb leads show no right axis deviation or RAE,
but show pathologic Q's in II, III, and aVF, then the
large R in V1 is probably a true posterior MI
(c) If neither of these is present, but there are deep S
waves in V5-6, the large R in V1 is probably RVH
(d) If none of these is present, including (c), then the
large R in V1 is probably a true posterior MI
I) Inferoposterior - criteria for inferior and posterior
J) Posterolateral - criteria for posterior and for anterolateral

IV) Time course of infarction in the absence of reperfusion (The time course of
ECG changes may be altered drastically when early intervention is
successful in reperfusing the myocardium)
27
A) Hyperacute T wave is a peaked T wave pointing toward the area of
infarction, only the first few minutes of infarction, infrequently seen
B) ST depression, doesn't localize, generally means "Non-Q MI",
usually normalizes in 24-72 hours in NQMI
C) ST elevation does localize, KEY FEATURE, begins in minutes and
is maximal for the first 7-12 hr, and is the best ECG criterion for
quick intervention in an acute MI, with either thrombolysis or direct
angioplasty of the culprit vessel
D) Q wave formation - Begins at 6-12 hrs, may be permanent, a
minority will shrink over months to years
E) T wave inversion - Begins after a day or a few days, normalizes in
months to years, variable
F) ST segment normalizes in 2 to 8 weeks, unless LV aneurysm has
developed which has persistent elevation
G) Criteria for infarction age:
1) Acute MI - ST elevation, with upright T wave and pathologic
Q wave
2) Recent MI - pathologic Q wave with ST elevation and T
wave inversion
3) Old MI - pathologic Q wave without ST elevation or T
inversion
4) MI, age indeterminate - pathologic Q wave without ST
elevation, with T inversion
V) Examples of Readings from Abnormalities
A) ECG that has ST elevation and no Q wave and upright T wave in II,
III, and aV
F
is acute inferior wall transmural ischemia and needs
immediate attention (fibrinolysis or PCI).
B) ECG that has abnormal Q waves in V5-V6 with no ST deviation and
upright T wave is old lateral MI.
C) ECG that has very large and wide R waves in V1-V2 and abnormal
Q waves in II, III, and aV
F
and upright T waves and no ST deviation
is old inferoposterior MI. If this ECG had T inversion in the inferior
leads it would be inferoposterior MI, age indeterminate.
D) ECG that has ST depression in II, III, and aV
F
and V5-V6 is
Subendocardial ischemia (cannot localize).
VI) Other Repolarization abnormalities -
A) Pericarditis Interesting fact: the pericardium is electrically silent,
so the ECG changes actually reflect subepicardial ischemia from
the adjacent epicardium
1) PR segment discordant displacement (PR segment
depressed in leads with tallest P waves or elevated in aVR)
2) HALLMARK: Diffuse ST segment elevation in almost all
leads, usually not much more than 4 to 5 mm, often only 1 to
2 mm, often associated with lowish voltage T waves, and
generally the shape of the ST segment is concave upward.
To distinguish this ST elevation from transmural ischemia is
28
usually not difficult. The ST elevation in transmural ischemia
usually is much more localized, and there is usually
associated "reciprocal ST depression" in transmural
ischemia. To distinguish this ST elevation from normal
variant, early repolarization may be very difficult or
impossible. If there is PR segment depression, then likely
the diagnosis is pericarditis. If there is a little positive
terminal delay (notch) in the QRS complex in V5-6, then
likely the diagnosis is early repolarization. If the T wave is
tall, then likely the diagnosis is early repolarization.
3) T wave inversion, usually generalized and discordant from
the QRS, happens usually later, after a couple of weeks or
so, and represents a phase in evolution of the process.
These inversions are generally less deep than in evolving
MI. In pericarditis, often the ECG returns to normal over a
month or so.
4) Generally the ST segment returns to baseline before the T
wave starts to invert, in contrast to MI
5) Generally there is no change in the QRS complex, in
contrast to MI
B) Electrolyte abnormalities
1) Hypokalemia - T wave becomes low amplitude and U wave
enlarges, so U may be as large as T wave, also
predisposition to atrial and ventricular arrhythmias
2) Hyperkalemia - first, T wave becomes tall and with sharp
peak (peaked T waves), then first degree AV block and
smaller voltage P wave, then QRS complex widens
progressively till it looks like a sine wave. Hyperkalemia can
also look like acute MI with ST elevation, so it can mimic
both MI and Pericarditis.
3) Hypercalcemia - decrease in QTc interval is proportional to
ionized Calcium level, due to shortening of the ST segment,
with generally preserved T wave shape and duration
4) Hypocalcemia - increase in the QTc interval is proportional
to ionized Calcium level, due to lengthening the ST segment
5) Hypermagnesemia or hypomagnesemia - changes are
subtle. Hypomagnesemia may look like hypokalemia
C) QT prolongation
1) Congenital long-QT syndrome is a series of congenital
abnormalities of action potential currents, which result in
repolarization abnormalities and QTc of >460 msec. Several
gene defects have been discovered affecting currents of
Potassium and Sodium. Different gene defects produce
different ECG abnormalities, and the specifics of these
differences are just recently being clarified. The T wave may
be broad or low amplitude or cleft, or show T wave
29
alternans, and sudden cardiac death or family history of
sudden cardiac death are the hallmarks of this syndrome
2) Metabolic abnormalities producing QT prolongation,
especially medication-induced changes, such as by
antiarrhythmic agents as well as other medications such as
some antihistamine-antibiotic combinations, and these may
also produce sudden cardiac death
3) Ischemia and hypertrophy produce QT interval prolongation
as a secondary repolarization abnormality
D) CNS abnormalities may give diffuse T wave inversion and striking
QT prolongation
E) Normal variant, Early Repolarization
1) Often seen in healthy asymptomatic young persons
2) ST elevation similar to pericarditis, but stable over time, and
usually with tall T waves rather than lowish voltage T waves,
so the T wave height is at least 4 times the ST elevation
height
3) Often a little terminal notch in the QRS (sometimes called a
J wave, since it is at the J point)
4) No PR segment depression
F) Normal variant, persistent juvenile pattern - T wave inversion in V1-
V3 in normal young adult, will be stable for months to years
G) Nonspecific ST-T wave abnormality
1) Indicates that ST segment and T wave are not normal, but
the cause is not apparent
2) Example: flat T waves or slightly inverted T waves or mild ST
depression of less than a millimeter
3) Causes include ischemic heart disease, hypertrophy,
pericardial abnormalities, drug effects or electrolyte or
metabolic abnormalities, myocarditis, as well as even
abdominal problems
H) Secondary repolarization abnormalities - every depolarization
abnormality has a consequent repolarization abnormality these
are discussed in the sections describing the depolarization
abnormalities
1) Hypertrophy: LVH, RVH
2) Conduction abnormality: LBBB, RBBB, LAFB, LPFB, WPW

Section III: Normal and Abnormal Rhythms

I) Sinus Rhythms
A) NSR (normal sinus rhythm) - Needs all of the following:
1) Rate 60-100 (some say 50-100)
2) P wave axis 0-70 degrees (upright in I and II)
3) PR interval 0.12-0.20 sec.
4) P wave uniformity
30
5) P-P interval regularity
B) Sinus arrhythmia - NSR (that is, all P waves are uniform with
normal P wave axis) but with P-P interval irregular (PP interval
varies by 0.16 sec) with gradual changes in PP interval
1) Respiratory-phasic sinus arrhythmia
(i) normal in youth and healthy due to vagal tone
fluctuation
(ii) increase in rate with inspiration due to increase
right heart filling
2) Non-respiratory phasic sinus arrhythmia - in older patients
3) Ventriculophasic sinus arrhythmia - in AV block only (the P-P
interval after an intervening QRS complex is longer than the
P-P interval not after a QRS) - interesting to speculate on
mechanism, possibly due to brief vagal discharge provoked
by the arterial pulse caused by the QRS
C) Sinus tachycardia - same as NSR but rate >100
D) Sinus bradycardia - same as NSR but rate <60
E) Sinus or SA arrest or pause - failure of SA node to initiate impulse,
so pause occurs with no P wave, with pause not a multiple of the
basic P-P interval
F) Sinus or SA exit block - looks like sinus pause, but pause IS a
multiple of the basic P-P interval, caused by on-time firing of the
sinus node, but the impulse dies without depolarizing the atrium
II) Atrial Rhythms
A) Wandering atrial pacemaker - gradually and progressively varying
P wave morphology and P-P interval, and also to a lesser extent
PR interval, which remains >=0.12 sec
B) Ectopic atrial rhythm - like sinus rhythm, but P wave axis and
morphology not normal
C) Ectopic atrial tachycardia (also called atrial tachycardia)- like
ectopic atrial rhythm, but rate over 100
1) Can be automatic or reentrant in mechanism
2) Can conduct 1:1 (one QRS for every P wave), or can show
some level of AV block, usually when atrial rate is fast (150-
250 beat/min)
D) PAC (Premature atrial complex) - early different P wave, usually
with normal PR interval
1) Look carefully for these P waves! "Cherchez le P" - they may
look like a wart on a T wave
2) PAC with normal conduction - normal QRS - the most
common, the atrial impulse is early, but ventricle is ready
3) PAC with aberrant conduction - aberrant (wide) QRS - atrial
impulse comes so early that the ventricle is partially
refractory, most often in a RBBB pattern
31
4) Nonconducted PAC P wave not followed by QRS - atrial
impulse comes so early that the ventricle is completely
refractory
(a) Can be tricky - must distinguish from second degree
heart block or sinus pause (but in neither of these
does the P wave come early and different like occurs
in PAC)
(b) The commonest cause of a pause
E) Atrial flutter
1) organized atrial rhythm at rate 250-350 waves per minute,
will be consistent throughout the entire rhythm strip
2) atrial flutter waves usually best seen in II, III, and aVF, look
like sawtooth
3) ventricular response (QRS complexes)
(a) May be half of atrial rate and regular - watch out for
regular rate of 150!
(b) may alternate 2:1 with 4:1
(c) may be irregular
F) Atrial fibrillation
1) Disorganized (chaotic) atrial rhythm, with average rate of
fibrillation waves faster than 350-360 - IMPORTANT: even if
the waves start to look organized for a few seconds, they will
look disorganized in a later portion of the strip, and this
variability distinguishes it from atrial flutter which is always
organized
2) Atrial fibrillatory waves are usually best seen in lead V1
3) Ventricular rate - Moderate is 70-110, slow is slower and
rapid is faster.
4) Ventricular regularity (R-R interval)
(a) Irregularly irregular (chaotic, no clear pattern) when
conducted through AV Node, the usual expected
pattern
(b) If regular, means no conduction through the AV Node,
but QRS comes from a lower escape or usurping
rhythm
G) MAT (Multifocal atrial tachycardia) - rate over 100 beats/min
1) With variable P morphology and P-P interval and PR interval
2) Not gradually and progressively variable distinguishing from
wandering atrial pacemaker
3) Variable in a jerky unpredictable fashion, requires 3 different
P wave shapes and PR intervals and rate over 100
4) Often indicates severe end-stage cardiac or pulmonary
decompensation
III) AV Junctional Rhythms
A) Junctional beat
32
1) P wave if seen has a left axis deviation, inverted in II, III,
and aVF, called "retrograde P wave"
2) PR interval is short, or there is no P wave preceding the
QRS, in fact the P wave may occur immediately or shortly
after the QRS (with R-P interval of <0.20 sec)
3) QRS is generally the same as a normal sinus beat, usually
narrow
B) Junctional rhythm - also called junctional escape rhythm, all
junctional beats, very regular, usually 40-50 or up to 59 beats/min
1) Happens because of default of the normal sinus mechanism
or impairment of AV conduction
2) Criteria
(a) P waves either not visible (hidden inside the QRS) or
very close before the QRS with short PR interval, or
very close after the QRS
(b) P waves inverted in II, III, and aVF, called "retrograde
P wave"
(c) Rate 40-59/min
C) Accelerated junctional rhythm - junctional rhythm but with rate
usually 70-130 beats/min
D) Junctional escape complexes - junctional beat which occurs after a
pause
E) Junctional premature complexes - junctional beat which occurs
early, before the next expected sinus beat
F) Supraventricular tachycardia (SVT, or PSVT with P indicating
paroxysmal)
1) Rate about 140 to 220
2) Regular tachycardia with narrow or normal QRS pattern (in a
patient with pre-existing bundle branch block, the QRS will
be wide and will be identical to the pre-existing QRS)
3) No sinus P waves present (excludes sinus tachycardia),
possibly no P waves present
4) Unable to determine specific mechanism of supraventricular
tachycardia by the ECG tracing
5) May include AVNRT and AVRT as well as other atrial
tachyarrhythmias
G) AVNRT (A-V Nodal reentrant tachycardia), reentrant circuit in the
AV node
1) The most common form of paroxysmal supraventricular
tachycardia
2) Onset and termination are abrupt, may last seconds,
minutes, hours, or days
3) Initiation is usually by a PAC with a long PR interval, but this
may have happened earlier and not be on the ECG you see
4) Rate usually 140-220 beats/min
33
5) P waves have retrograde character, inverted in II, III, and
aVF
6) QRS usually normal or same as baseline sinus conducted
QRS, but also may be aberrantly conducted due to high rate
7) The AV node has 2 functionally distinct conduction
pathways, slow and fast
(a) Common type of AVNRT is antegrade conduction
down the slow pathway and retrograde conduction up
the fast pathway, giving a P wave that is usually
buried in the QRS or is immediately at the end of the
QRS (R-P interval less than the P-R interval). So in
half of these, no P is found, and in half, the P is right
at the end of the QRS, giving a pseudo S wave
(b) Uncommon type of AVNRT is antegrade conduction
down the fast pathway and retrograde conduction up
the slow pathway, giving a P wave that is very late
after the QRS, and closer to the following QRS (R-P
interval greater than the P-R interval)
H) AVRT (Atrio-ventricular re-entrant tachycardia), always with
accessory AV (atrioventricular) pathway (bundle of Kent,
discussed in section on ventricular pre-excitation), comes in 2 types
1) Orthodromic - the impulse is conducted down the AV node
and normal His-Purkinje system and retrogradely through
the bypass tract, so the QRS is normal in duration and
appearance - this is the most common occurrence with heart
rates in the range of 140-250 beats/min. In this situation, the
ECG will look very similar to the common type of AVNRT,
but the retrograde P wave will be AFTER the QRS, not in it
or at the end of it.
2) Antidromic - the impulse is conducted retrogradely up the AV
node and antegradely down the bypass tract, so the QRS is
wide and abnormal, looks just like ventricular tachycardia
IV) Ventricular rhythms
A) Ventricular beat
1) No preceding premature P wave (but if the PVC is not very
premature, there could be a preceding normal sinus P wave)
2) QRS wide and different from native QRS, often >0.12 sec,
even >0.14 sec
3) May have a following P wave (retrograde conduction or V-A
conduction), or may not interrupt the normal atrial rhythm
B) PVC (Premature ventricular complex)
1) Early different QRS complex (not preceded by early different
P wave)
2) QRS usually wide >0.12 sec, with discordant ST segment
and T wave
34
3) Often has a compensatory pause, because the conduction of
the impulse from the ventricle retrogradely through the AV
node may not occur at all or fast enough to reset the SA
node, so the SA node fires on time, giving a pause which
precisely compensates for the prematurity of the PVC
4) Specifics
(a) If each fourth beat is a PVC, this is "ventricular
quadrigeminy"
(b) If each third beat is a PVC, this is "ventricular
trigeminy"
(c) If every other beat is a PVC, this is "ventricular
bigeminy"
(d) If all the PVC's look alike, they are called unifocal
(e) If all the PVC's don't look alike, they are called
multifocal
(f) If a PVC occurs very early after the preceding beat,
so that it begins near the peak of the preceding T
wave, it is called "R-on-T phenomenon", and is
considered by some to pose increased risk for sudden
death. This definitely occurs in cases of prolonged
QT interval, especially in bradycardic situations
(g) If 2 PVC's occur together without an intervening
normal beat, they are called a couplet or a ventricular
couplet
(h) If 3 PVC's occur together without an intervening
normal beat, they are called a triplet or a ventricular
triplet, or a short burst of ventricular tachycardia
C) VT (Ventricular tachycardia)
1) Succession of 3 or more PVC's without intervening sinus
beats
2) Shorter than 30 seconds - nonsustained, longer than 30
seconds - sustained
3) Rate usually 140-200
4) Regular or slightly irregular
5) Abrupt onset and termination (some say "paroxysmal VT")
6) AV dissociation, capture beats, fusion beats (Dressler beats)
7) If rate less than 110, called accelerated idioventricular
rhythm
8) If all the QRS complexes are alike, called monomorphic VT
9) If the QRS complexes are not alike and are jerkily variable,
called polymorphic VT (usually in setting of acute ongoing
ischemia)
10) Torsades de pointes (turning of the points) - special type of
polymorphic ventricular tachycardia where there is a gradual
change from beat to beat of the morphology of the QRS
35
complexes, from having sharp points upward to having sharp
points downward
(a) Always in setting of long QT interval - medication-
induced, electrolyte disturbances, intrinsic heart
disease, CNS disease, congenital QT prolongation,
liquid protein diet
(b) Rate often 200-250 beats/min
D) Ventricular flutter - regular rhythm, like ventricular tachycardia, but
QRS complexes are no longer identifiable - this diagnosis is rarely
made, usually choose between VT and VF
E) Ventricular fibrillation - irregular rhythm, chaotic, with deflections
varying in amplitude and contour, rate of deflections 150 to 500. No
P wave, QRS complex, or T wave visible
F) Ventricular escape rhythm
1) Series of ventricular beats
2) Requires default of sinus rhythm and AV junctional escape
rhythms
3) Usually rate is 30-40 beats/min
4) Usually requires prompt attention since these rhythms may
not be reliable to persist, and since the rate is so slow that
there are usually symptoms
G) Asystole - no P wave or QRS - also no pulse!
H) Wide complex tachycardia (WCT): DIFFERENTIATING
VENTRICULAR TACHYCARDIA FROM SUPRAVENTRICULAR
TACHYCARDIA WITH ABERRANT CONDUCTION
1) Both are relatively regular, wide-QRS tachycardias
2) CLINICAL CONTEXT: if the patient has a history of organic
heart disease, such as coronary artery disease, myocardial
infarction, or cardiomyopathy, the dysrhythmia is more likely
ventricular tachycardia, but this is uncertain
3) Try to obtain a 12-lead ECG during tachycardia
(a) Look hard for a P wave. If there is a sinus P wave
before every QRS and a constant PR interval, then it
is sinus tachycardia with a wide QRS. If there is AV
dissociation, then it is probably VT. For further
distinctions, see below under "AV dissociation" and
"QRS morphology"
4) Find a previous ECG
(a) If QRS is wide and the same on a previous ECG in
sinus rhythm, it is probably supraventricular
(b) If the prior tracing has aberrantly conducted
supraventricular beats with the same morphology as
the wide QRS tachycardia, it is probably
supraventricular
36
(c) If the prior tracing has PVC's with the same
morphology as the wide QRS tachycardia, it is
probably ventricular
(d) If there is a prior tracing with narrow complex
tachycardia, and the rate is identical to the wide QRS
tachycardia, it is probably supraventricular
5) Onset
(a) If onset is with PAC, probably supraventricular
(b) If onset is with PVC, probably ventricular
6) AV dissociation
(a) Presence of AV dissociation favors ventricular, but not
conclusive
(i) If there is an interruption in the regularity of the
tachycardia with one beat occurring early, and
being more normal or narrower QRS complex,
the beat is a fusion (Dressler) beat or a capture
beat, and means that the tachycardia is
ventricular. Reason: if an aberrant beat is
conducted earlier, it should be more aberrant
rather than more normal.
(b) Presence of 1:1 AV relationship favors
supraventricular, but not conclusive
(i) If the R-P interval is 0.10 sec or less, then the
tachycardia is likely junctional tachycardia with
aberrancy and 1:1 retrograde conduction the
P wave will be retrograde in morphology
7) Morphology of the QRS complex - this is uncertain
(a) All QRS concordant in V1-V6, either all positive or all
negative, favors ventricular
(b) QRS duration 0.14 sec or greater in RBBB pattern or
0.16 sec or greater in LBBB pattern favor ventricular
(c) Left axis deviation, and right superior axis, favor
ventricular
(d) Monophasic or biphasic RBBB type of QRS in V1
favors ventricular (VT)
(e) LBBB pattern with rightward axis favors ventricular
(VT)

Summary of characteristics of types of beats:

TYPE OF BEAT P WAVE PR INTERVAL QRS COMPLEX
Sinus Normal Normal Usually Normal
Atrial Abnormal Normal Usually Normal
Junctional Retrograde Short or absent Usually Normal
Ventricular None None Abnormal


37
Atrioventricular Blocks, Pacemakers

I) Atrioventricular Blocks - failure of a P wave to be followed appropriately by
a QRS
A) HINT: To diagnose AV blocks, first the regularity of the P-P interval
should be established. If the P-P interval is irregular, that must be
explained separately, and the pauses may not be AV block, but
something else, like non-conducted PAC's
B) First degree AV block - all beats conduct (i.e. every P wave is
followed by a QRS complex), but PR interval is too long (>0.20 sec)
C) Second degree AV block - some beats conduct but some don't, so
there are more P waves than QRS's
1) Mobitz I (also called Wenckebach) AV Block
(a) Progressive prolongation of the PR till the dropped
beat
(b) Shortest PR interval is after the dropped beat
(c) Usually subtle progressive shortening of the RR
interval till the dropped beat
(d) The RR interval of the dropped beat is less than twice
the unblocked RR interval
(e) Usually block is at the AV node or junction because
that is the tissue with the property of decremental
conduction
(f) So, usually the QRS is narrow, unless the prior ECG
showed wide QRS in unblocked sinus rhythm
2) Mobitz II AV Block
(a) PR interval is constant (normal or slightly long) for the
conducted beats
(b) Usually block below the AV node in the His-Purkinje
system, where there is no decremental conduction
(c) So the QRS is usually wide
3) 2:1 AV block
(a) Half the P waves don't conduct
(b) Could be from either Mobitz I or Mobitz II AV block
mechanism
(c) Can't tell whether Mobitz I or Mobitz II absolutely, but
if QRS is wide, more likely Mobitz II and if QRS is
narrow, more likely Mobitz I
D) High grade AV block - AV block more than 2:1, maybe 3:1, with
some evidence of AV conduction, but not third degree AV block
(one definition of high grade AV block is more than 2 sequential
nonconducted P waves)
1) The PR interval may be constant at 3:1 block
2) The RR interval may be irregular, because the ventricular
escape rhythm may be interrupted by early and conducted
QRS complexes
38
E) Third degree AV block (also called complete heart block or
complete AV block)- no beats conduct, more P waves than QRS's
1) The P-R interval is variable and random
2) The P-P interval is constant (atrial rate is regular)
3) The R-R interval is constant (ventricular rate is regular)
(a) The ventricular rhythm may be wide QRS (ventricular
escape rhythm rate 30-40) or narrow QRS (junctional
escape rhythm, rate 40-50)
(b) Some mild irregularity of the RR interval is possible,
but no irregularity due to the presence of conducted P
waves


Type of Block PR interval RR
interval
QRS complex Which P waves
cause QRS
complexes
First degree Constant and
long
Regular Usually
narrow
All
Second
degree,
Mobitz I
(Wenckebach)
Variable,
progressive
prolongation
Grouped
beating
Usually
narrow
Some
Second
degree,
Mobitz II
Constant for
conducted
beats
Irregular Usually wide Some
Second
degree, 2:1
Constant Regular Wide or
narrow
Some
Third degree Variable,
random
Regular Wide or
narrow
None

II) Atrioventricular Dissociation (AV dissociation)
A) Loss of the normal relationship between P and QRS
1) Different from AV block (not AV block), because in AV
dissociation there are not more P waves than QRS's. There
are at least as many QRS's as P's, and often more QRS's
than P's
2) AV dissociation is always a secondary problem, meaning
that there is a more fundamental primary problem, one of the
following:
(a) Abnormally slow atrial activity (Default)
(b) Abnormally fast ventricular activity (Usurpation)
3) Default
(a) Upper rhythm is too slow
(b) Lower rhythm is normal escape rhythm (junctional
escape or ventricular escape rhythm)
4) Usurpation
(a) Upper rhythm is normal
39
(b) Lower rhythm is too fast (such as junctional or
ventricular tachycardia)
B) Special cases
1) Isorhythmic AV dissociation - there is one P for each QRS,
but the PR interval is variable, due to the fact that the atrial
and ventricular rates are effectively equal. All other AV
dissociations have more QRS's than P waves
(a) If the isorhythmic dissociation is stable, it is called
synchronization
(b) If the isorhythmic dissociation is transient, it is called
accrochage
2) Complete AV dissociation - the atrial and ventricular rates
are quite constant, and no effect of a P causing a QRS or a
QRS causing a P can be seen
3) Incomplete AV dissociation (also "interference dissociation")
- although there are more QRS's than P's, evidence can be
found of occasional conduction of a P to make a QRS early,
or a QRS to make a P early

III) Pacemaker Hints
A) Pacemaker spikes are unnaturally short, actually only about 1 msec
or less, and about 1 volt or more (not millivolt) in strength, so they
appear as very narrow spikes on the ECG, and their height is
variable from very low to very large
B) Pacemaker terminology - CODE, usually 3 or 4 letters
1) First letter is chamber paced
(a) V-Ventricle
(b) A-Atrium
(c) D-Dual chamber, a lead in both atrium and ventricle
2) Second letter is chamber sensed
(a) Same letter code as first letter
(b) O- no chamber sensed
3) Third letter is mode of interaction
(a) O-no mode of interaction
(b) I-pacer inhibited by interaction
(c) D- dual mode of interaction, inhibited or triggered
(d) T-triggered
4) Fourth letter is special function
(a) R-rate-responsive
5) Rarely a fifth letter is seen
(a) Anti-tachycardic
(b) Shocking (like implantable defibrillator)
6) Examples
(a) VVI paces the ventricle, senses the ventricle and is
inhibited by sensing
40
(b) VOO paces the ventricle, and doesn't sense - the
original pacemaker, no longer used except in magnet
mode for testing
(c) DDD paces both atrium and ventricle, senses both
atrium and ventricle, and both is triggered or inhibited,
depending on what is appropriately programmed
(d) VVIR - a VVI with rate modulation based on a
physiologic sensor, such as activity
(e) DDD-R does everything a DDD does, and also has
rate modulation based on a physiologic sensor, such
as activity
C) Pacemaker firing
1) See a pacemaker spike on the ECG - a pacemaker spike is
very spiky. It is a deflection that lasts only 1/4 mm on the
ECG. It is so sharp and quick that it couldn't possibly be a
physiologic wave of the heart itself. The truth is that the
spike delivered to the heart by the pacemaker is on the order
of 2 volts (not millivolts) and only 1 millisecond.
2) Should occur after a pause that is appropriate for the
settings of the particular pacemaker
3) Failure to fire would be a pause with no spike showing up
even after the programmed time (usually no more than 1
second or 1.2 seconds)
D) Pacemaker sensing
1) Normally there is no pacemaker spike occurring shortly after
the heart chamber depolarizes because the pacemaker is
supposed to notice (sense) a depolarization, and reset to
wait a while before firing
2) Failure to sense would be a pacer spike shortly after the
chamber depolarization
E) Pacemaker capture
1) See that a pacemaker spike is immediately followed by the
depolarization of the paced chamber
2) Failure to capture would be a pacer spike followed by no P
or QRS