1. P wave before every QRS 2. P wave with sinus morphology 3. Positive in I, II, aVF, negative in aVR 4. HR 60-100 bpm

1. I + aVF + - > 0-90 degrees (normal axis) ``` 2. I+ aVF - II + -> 0-(-30) degrees (normal axis) II - -> -30-(-90) degrees (LAD -> left-axis deviation) ``` 3. I - aVF + - > 90-180 degrees (RAD -> right-axis deviation) 4. I- aVF - - > -90-(-180) degrees (EAD -> extreme-axis deviation)

1. Always should be positive in: 1) I, II 2) aVL 3) V4, V5, V6 2. Should be negative in 1) aVR 2) V1 3) V2 3. In other (III, aVF, V3) can be either

- > all 1. QRS ≥ 0.12 s (incomplete ≥ 0.11 s) 2. V1 or V2: M-shaped QRS (RSR’) and 3. I and V6: S wave wider than R wave or ≥ 0.04 s) 4. Possible changes of ST (oblique decrease) and T (negative) -> V1, V2, V3 - > (if not -> consider myocardial infarction) 5. Late intrinsicoid in V1 R’ peak or late R peak, >0.05 s

1. Left axis deviation (-45 to -90 degrees) 2. Small Q (qR) in aVL and I 3. Small R (rS) in III and aVF 4. QRS 0.045 s (qR)

1. Right axis deviation (90 to 180 degrees) 2. Small Q (qR) in III and aVF and 3. Small R (rS) in I and aVL 4. QRS 0.045 s) 6. No evidence of RVH

ECG quick Flashcards by Birwe Leon

sinus rhythm

P wave before every QRS
P wave with sinus morphology
Positive in I, II, aVF, negative in aVR
HR 60-100 bpm

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Heart axis

I + aVF +
- > 0-90 degrees (normal axis)

2. I+ aVF -
II +
-> 0-(-30) degrees (normal axis)
II -
-> -30-(-90) degrees (LAD -> left-axis deviation)

I - aVF +
- > 90-180 degrees (RAD -> right-axis deviation)
I- aVF -
- > -90-(-180) degrees (EAD -> extreme-axis deviation)

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P wave duration + amplitude

≤ 0.12 s

amplitude -> normally no more than:
1. 0.25mV in frontal plane leads
2. 0.3 mV in precordial leads
3. V1: positive ≤0.15 mV
negative ≤0.1 mV

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PR duration

adult: 0.12 to 0.20 s

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QRS duration

0.07-0.11 s

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Direction of QRS

Always should be positive in:
1) I, II
2) aVL
3) V4, V5, V6
Should be negative in
1) aVR
2) V1
3) V2
In other (III, aVF, V3) can be either

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Significant elevation of ST -> norms

1) in V2 and V3
1. Women ≥0.15 mV
2. Men <40 years: ≥0.25 mV
3. Men ≥40: ≥0.2 mV
2) in other leads: ≥0.1 mV

3) Measured in point J

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Significant decrease of ST -> norms

V1, V2, V3 ≥0.05 mV
Other leads ≥0.1 mV
Measured in point J

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T wave amplitude

1) shouldn’t exceed 0.6 mV in limb leads

2) shouldn’t exceed 1.0 mV in precordial leads

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QTc duration

≤ 0.46 s

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right atrial enlargement

peaked proximal part of P wave (A-like appearance)
- > it’s called P PULMONALE
Amplitudes of P wave: >0.25 mV in II or > 0.15 mV in positive phase of V1

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left atrial enlargement

Duration of P wave > 0.12s in II or

Increase in duration (>0.04s) and amplitude (0.1 ms) of negative phase of P wave in V1

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Left ventricular enlargement suggestion

V1 -> increase in S (QS) wave amplitude
V6 -> increase in R amplitude
I and aVL-> increase in R wave amplitude

Cornell criteria: R wave in aVL + S wave in V3:
⩾ 2.8 mV in males
⩾ 2.0 mV in females

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Right ventricular enlargement suggestion

V1 -> increase in R amplitude
V6 -> increase in S amplitude
R>S in V1
S>R in V5 or V6

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RBBB

> all
1. QRS ≥ 0.12 s (incomplete ≥ 0.11 s)
2. V1 or V2: M-shaped QRS (RSR’) and
3. I and V6: S wave wider than R wave or ≥ 0.04 s)
4. Possible changes of ST (oblique decrease) and T (negative) -> V1, V2, V3
> (if not -> consider myocardial infarction)
5. Late intrinsicoid in V1 R’ peak or late R peak, >0.05 s

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LAFB

Left axis deviation (-45 to -90 degrees)
Small Q (qR) in aVL and I
Small R (rS) in III and aVF
QRS <0.12 s
Late intrinsicoid deflection in aVL >0.045 s (qR)

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LPFB

Right axis deviation (90 to 180 degrees)
Small Q (qR) in III and aVF and
Small R (rS) in I and aVL
QRS <0.12 s
Late intrinsicoid deflection in aVF (>0.045 s)
No evidence of RVH

LBBB

QRS ≥ 0.12s (incomplete ≥ 0.11 s)
Mid QRS notching/ slurring in two of the left-leaning leads (I, aVL, V5, V6)
QS or rS in V1-V3
V5,V6 -> late (>0.06 s) intrinsicoid
Possible changes in ST and T opposite to QRS amplitude (if not -> consider myocardial infarction)
Always look for STEMI criteria with LBBB

Equivalents of STEMI new LBBB criteria

LBBB criteria + 1 of:

ST elevation ≥ 0.1 mV in a lead with upward QRS complex
ST depression ≥ 0.1 mV in V1, V2, or V3
ST elevation ≥ 0.5 mV in a lead with downward (discordant) QRS complex

QS in V1-V4 or Q in V5 or V6 can suggest new or past MI

Ventricular preexcitation ecg criteria

PR interval duration < 0.12 s
Delta wave at the beginning of the QRS complex
QRS > 0.12 s
Changes in ST segment and T wave -> usually opposite side of the QRS complex

Brugada syndrome ECG

-> in V1-V3
Type I -> ST elevation (usually in J point) ≥0.2 mV with coved ST segment with ST segment decreasing -> to negative T wave
Type II -> High J-point eleviation ≥2mm, saddleback ST first decreasing (but > 1mm above baseline) but T wave positive or biphasic
Type III -> J point eleviation ≥ 2 mm with ST elevation < 1mm (saddleback), positive T wave

Eleviation of ST causes

Electrolites (Hyperkaliemia)
LBBB
Early repolarization (benign)
Ventricular hypertrophy
A3 -> Arrhyrhmia (VT, Brugada), Aneurysm of LV, Aortic dissection
T -> TBA - Traumatic brain injury or Takotsubo disease
Infarction
Osborn waves (hypothermia)
Non-artherosclerotic vasospasm (Prinzmetal angina)

Equivalents of STEMI (signs allowing to diagnose STEMI without additional criteria)

new LBBB with addition criteria
Posterior MI
LMCA Occlusion
Wellen’s Syndrome
De Winter’s T Waves

Posterior MI

RCA (90%), LCX (10%)
V2, V3 -> ST depression ≥ 0.05 mV
Usually broad, prominent and tall R waves in V1-V2 (R≥S, R ≥ 40ms)
V7-V9 ST elevation ≥ 0.05 mV

LMCA Occlusion

1. ST elevation in aVR with diffuse (at least 8) ST depressions

Wellen's Syndrome

1. Deeply-inverted or biphasic T waves in V2-3 (V1-V4) with or without ST elevation 2. Suggests critical LAD occlusion

De Winter’s T Waves

1. Precordial ST-segment depression at the J-point 2. Tall, peaked, symmetric T waves in the precordial leads 3. Suggest LAD occlusion

ECG localization of STEMI

1. Anterior (LAD): V1-V4 - > Anteroseptal (LAD, diagonal) -> V1-V2 - > Anteroapical (distal LAD) -> V3-V4 2. Lateral (LCX) -> I, aVL, V5-V6 3. Inferior (PDA) -> II, III, aVF -> + in 1/3 RV ischemia 4. Posterior (PDA) -> ST depressions in V1-V3 with tall R waves, V7-V9 ST elevation 5. RV (RCA, acute/right marginal artery) -> VR3-VR4, suggested by eleviation of ST in V1

Progression of STEMI ECG waves and segements with time

1. Increase in T wave amplitude, tombstoning 2. ST elevation -> Pardee waves 3. Q waves (takes several hours to days to develop) and decreasing R wave amplitude 4. Invertion of T waves (negative), ST return to isoelectric

Acute pericarditis ECG

STAGE 1 -> because inflammation involves epicardial myocardium 1. Widespread ST elevations, often horizontal or upward 2. Upright T waves 3. PR depression (50%) STAGE 2 1. ST return to normal 2. T waves become inverted

Pericardial effusion and chronic constriction ECG

1. Low voltage 2. Widespread ST-elevation 3. Total electrical alternans -> alternating high and low voltages of all ECG waveforms between cardiac cycles within a given lead 4. T-wave inversion 5. AF in 1/3

PE ECG

1. Tachycardia 2. Nonspecific ST and T changes 3. Negative T waves in V2-V4 4. QR in V1 5. SIQIIITIII -> rarely 6. Acute Cor Pulmonale, RV overload -> rarely, in massive PE

Cor Pulmonale (Pulmonary hypertension, RV overload features) ECG

1. RV dilation/ hypertrophy 2. RBBB 3. Rightward axis devation 4. P pulmonale

Hypothermia in ECG

1. Osborn waves -> deflections at the J point at the same direction as QRS complex -> height roughly proportional to the degree of hypothermia 2. PR and QT prolongation 3. Widening of QRS

Hypokaliemia in ECG

LUFTP -> Low K - U waves, Flattened T, Prolongation of QTc 1. Flattening or invertion of T wave 2. ↑ prominence of U waves 3. ↑ of QTc (and sometimes PR interval) 4. Slight depression of ST segment -> hyperpolarization + often premature beats and sustained tachyarrhythmias, tordases de pointes ALKALOSIS

Hyperkaliemia in ECG

1. Tall, peaked T waves (from 5.5 mM) 2. Loss or flattening of P waves (from 6.5 mM) 3. Widened QRS (from 7 mM) 4. ↓ of QTc 5. ↑ of PR 6. Sine wave appearance (K levels 7-8 mM) -> decrease of potential, AV blocks, VF, Asystolia ACIDOSIS

Hypocalcemia and hypercalcemia in ECG

Hypocalcemia -> ↑ QTc | Hypercalcemia -> ↓ QTc

Digitalis effect on ECG

1. Coved ST-segement depression -> “Salvador Dali sagging” appearance 2. Flattened T wave 3. ↓ QTc interval

Tricyclic Antidepressant (TGA) ECG

1. Wide QRS complex | 2. ↑ of QTc

Class 1 Antiarrhythmics on ECG

1A -> ↑ of QTc, ↓ T wave and ↑ U wave amplitude toxicity -> prolongation of QRS 1B -> usually no effect on ECG 1C -> broadening of QRS, without affecting interval between J point and T wave

Class 2, 3, 4 Antiarrhythmics on ECG

``` 2 and 4 -> sinus bradycardia, ↑ PR 3 -> ↑QTc (Amiodaron has class 1, 2, 3 effect) ```