ecg in gp by prof.dr.r.r.deshpande
DESCRIPTION
ECG PPT – Every Medical General Practitioner must Know Basics of ECG.This is important Diagnostic tool. This PPT of Prof.Dr.Deshpande will definitely built up confidence in Doctors. He has explained the importance of ECG waves, how to calculate Heart rate, how to decide right or left axis deviation, how to diagnose Heart Attack, Left & Right ventricular Hypertrophy(LVH& RVH),Bundle Branch Block(BBB) ,Electrolyte imbalance etc .Pictures are self explanatory .Also visit www.ayurvedicfriend.comTRANSCRIPT
2
1. Introduction 5 to 10
2. Electric circuit of heart 11
3. Waves of ECG 12
4. Normal ECG of chest leads 13
5. ECG of I,II,III,aVR,aVL,aVF leads 14
6. Sinus Rhythm 15 & 16
7. Sinus Bradycardia 17 & 18
8. Sinus Tachycardia 19 to 21
9. Left Axis Deviation 22 & 23
10. Right Axis Deviation 24 to 26
Slide Number TITLE
3
11. Normal pattern of QRS complex 27
12. LVH 28 to 31
13. RVH 32 to 34
14. RAH 35 to 37
15. LAH 38 to 40
16. M.I 41 to 43
17. Angina 44 to 47
18. M.I 48 to 63
19. Stress Test 64 to 66
20. 1st Degree Heart block 67 to 69
21. Mobitz type 1 AV block 70 to 72
22. Mobitz type 2 AV block 73 to 75
4
23. 3rd Degree Heart block 76 to 78
24. 2:1 AV Block 79 to 81
25. LBBB 82 to 84
26. RBBB 85 to 87
27. Hyper Ca++ 88 to 90
28. Hypo Ca++ 91 to 93
29. Hyper Kalaemia 94 & 95
30. Hypo Kalaemia 96 & 97
31. Digoxin effect 98 to 100
32. Dextrocardia 101 & 102
5
1) ECG (Electro Cardio Gram) :
It is the Graphical record of Electrical Activity of Heart.
2) What are Leads?
- Potentials produced in heart are conducted all over body. These
potentials are picked by electrodes, amplified & recorded on paper.
Electrodes are called as leads.
3) Classification of Leads :
i) Bipolar or standard Leads-
Two leads are used positive & Negative electrodes.
Leads – I, II, III
ii) Unipolar Lead-
Only one electrode is used, other is earthed.
2 Types-
a)Unipolar chest Leads (V1 to V6)
b)Unipolar Limb leads (aVR aVL, aVF)
Important definitions
6
ECG – Graph Measurements
i) X axis - Indicates Duration or Time
Dot square = 0.04 sec
Big square = 0.2 sec
ii) Y Axis - Indicates Intensity of contraction
1 Dot square = 0.1 mV (milli volt)
1 Big square = 0.5 mV = 5 mm
2 Big squares = 1.0 mV = 10 mm
7
1) P wave - contraction of Atria
Amplitude = 0.2 mV (2dot squares)
Duration = 0.08 sec (2 dot squares)
(Note - In Atrial Hypertrophy P wave is either Tall or broad)
2) QRS Complex - Depolarization of both ventricles
Amplitude = 1.5 – 2.5 mV (3-5 large squares)
Duration = 0.08 sec (2 dot squares)
(Note - In ventricular Hypertrophy QRS complexes are tall)
3) T wave - Depolarization of ventricles.
Amplitude = 0.04 mV (4 dot squares)
Duration = 0.24 sec (6 dot squares)
(Note : In M. I. – T wave is flat or inverted.)
4) PR Interval - Indicates AV conduction time.
Normal = 0.12 to 0.16 sec (3-4 dot squares)
(Note - PR Interval is prolonged in AV Heart block)
Important measurements
8
Position of Chest leads
(Note - Space just below the sternal angel is
2nd Intercostal space.)
V1 = 4th Intercostal space, at Right sternal border.
V2 = 4th Intercostal space at Left sternal border.
V3 = In between V2 & V4.
V4 = 5th Intercostal space, at mid clavicular line.
V5 = Same horizontal level at V4
– Anterior axillary line (6th Intercostal space)
V6 = Same horizontal level at V4
– mid axillary line (7th Intercostal space)
9
Bipolar & Unipolar leads
10
Normal waves
ECG
11
12
13
14
15
H. R = 60 – 100 / min.
- P is upright in II & inverted in
AVR
- Every P wave is followed by
QRS complex.
Sinus Rhythm
16
Sinus Rhythm
- Normal cardiac Rhythm in which SA Node acts as
Natural Pacemaker, discharging 60 – 100 times / min.
- H.R. - 60 – 100 / min.
- P is upright in II & inverted in aVR
- Every P wave is followed by QRS complex.
17
Sinus Brady cardia
H.R < 60 / min
18
Sinus Bradycardia
- H. R. < 60/min.
- P is upright in II & inverted in aVR
- Every P wave is followed by QRS.
- Unusual - sinus Bradycardia < 40/min.
( Consider – Heart Block)
- Normal in athletes or during sleep.
- Other causes –
- Drugs - Digoxin, Beta blockers (Including Eye drops)
- IHD or M.I.
- Hypothyroidism.
- Hypothermia
- Electrolyte abnormalities.
- Obstructive Jaundice
- Uraemia
- Raised Intracranial pressure
- Sick sinus syndrome.
19
Sinus Tachycardia
H. R > 100 / min.
20
Sinus Tachycardia -H. R. > 100 / min.
-P upright in II & Inverted in aVR
-Every P wave is followed by QRS.
Rare, that sinus Tachycardia > 180 / min.
(Difficult to differentiate P wave from T waves –
Rhythm can be mistaken for AV nodal Re-entry Tachycardia.)
Physiological causes:
(Anything which stimulate sympathetic N. S. –
Anxiety, Pain, Fever, Exercise.)
Other causes
- Drugs - Adrenaline, Atropine, Salbutamol (Inhalers & Nebulizers),
Caffeins & Alcohol.
- IHD or Acute M. I.
- Heart failure
- Fluid Loss
- Anemia
- Hyperthyroidism.
21
If Appropriate Tachycardia -
• (Compensating for Low Bp e.g. Fluid Loss / Anemia) –
• with β blockers is Dangerous.
But,
•If sinus Tachycardia is
Inappropriate (Anxiety or Hyperthyroidism) –
with β blocker is O. K.
•Warning :
•In sinus Tachycardia
• - Never use β blocker to slow the Heart Rate unless -
you establish the cause.
22
Lt. Axis Deviation
a) Left Leaves
b) QRS +ve in I & -ve in III
23
Lt. Axis Deviation
a) Left Leaves.
b) QRS +ve in I & -ve in III.
Causes -
- Sometimes in Normal
- WPW syndrome
- Lt. anterior hemi block.
- Ventricular tachycardia
24
In Right Axis Deviation
Right – Reaches
Nemonic
a) Lt Axis deviation -LVH, LBBB, Interior wall infarct.
b) Rt Axis deviation -RVH, RBBB, Anterior wall infarct.
I lead - R –ve
III lead - R +ve
25
Rt. Axis Deviation
a) Right Reaches
b) QRS is –ve in I & +ve in III
26
R.T Axis Deviation
a) Right Reaches
b) Observe only Lead I & III
c) QRS is –ve in I & +ve in III
Causes:
-May occur in Normal individual
-RVH
-Antero lateral M.I.
-Dextrocardia (Heart lies on Rt side of
chest)
-Lt. Posterior hemi block
-W.P.W Syndrome.
27
Ventricular Hypertrophy 1)Normal pattern & Amplitude of QRS complexes in chest ,
leads.
V1 = Small R wave & Deep S wave
V2
V3 When Proceeds towards
V4 V6 – Height of R wave increases & Depts.,
of s wave progressively decreases.
V5
V6
V1 V2 V3 V4 V5 V6
R
s
28
Pattern remains the same But Amplitude Increases.
If , SV1 > 25mm OR (5 Big squares).
RV6 > 25mm OR (5 Big squares).
SV1 + RV6 > 35 - LV (7 Big squares.)
Normal QRS complex = 3 to 5 large squares.
QRS - 1.5 – 2.5 mV - (3-5 large squares)
0.08 sec - (2dot squares)
LVH
V1 V2 V3 V4 V5 V6
R
s
29
a) R in V5 or V6 >25mm
b) S in V1 or V2 >25 mm
c) R + S > 35 mm
LVH
30 a) R in V5 or V6 > 25mm b) S in V1 or V2 > 25mm
31
LVH
-R in V5 or V6 > 25 mm.
S in V1 or V2 > 25 mm.
-R V5/V6 + S V1 / V2 > 35 mm
This is not diagnostic
Young, thin people with Normal hearts have
R & S >Normal.
-If LVH - Look for evidence of strain
(ST depression & T Inversion)
-Eco-cardiography is Diagnostic for LVH.
- according to cause.
Causes :
- Hypertension
- Aortic stenosis
- Coaractation of Aorta
- Hypertrophic cardiomyopathy.
32
RVH
Prominent R wave in V1 or Deep S wave in V6
SV1 to RV6 - Normal pattern.
OR
RV1 > 7 mm = 1 Big squares + 2 dot.
SV6 > 7 mm = 1 Big squares + 2 dot.
OR
RV1 + SV6 > 10 mm (2 big squares)
33
a) Rt. Axis Deviation.
(RT. Reaches – I & III)
b) Deep S waves in V5 &
V6
c) RBBB (Broad QRS & M
in V1 & W in V6)
RVH
34
RVH - Dominant R waves in V1 - V4
a) Rt Axis Deviation
b) Deep ‘S’ waves in V5 & V6
c) RBBB
- If strain - ST depression & T Inversion.
- Causes - Pulmonary Hypertension
Pulmonary stenosis
- - of underlying cause.
35
P – Pulmonale
-Rt. Atrial Enlargement
- Tall P wave > 2.5 mm.
(2.5 dot squares) in II, III, avF
36
Tall P wave > 2.5 mm.
(2.5 dot squares) in II, III, avF
37
P Pulmonale Rt Atrial Enlargement
= Tall P wave > 2.5 mm (2.5 dot squares) in II, III, avF.
= Causes - RA – Enlargement
- Primary Pulmonary Hypertension.
- Secondary Pulmonary (Chr. Bronchitis, Emphysema)
- Pulmonary stenosis
- Tricuspid stenosis.
= patient’s H/O, Chest x-ray
(to assess cardiac dimensions & lung fields)
- Echo-cardiogram-to assess valvular disorders
- Estimate pulmonary artery pressure.
38
P – mitrale
-Lt. Atrial Enlargement
- P. wide > 0.08 sec or
(2 dot squares) & Bifid
39
P. wide > 0.08 sec or (2 dot squares)
& Bifid
40
P-mitrale
Lt. Atrial Enlargement
= p wide > 0.08 sec, or
> 2 dot square
& Bifid
- Usually Result of mitral valve disease : called as P-mitrale.
-Lt. Atrial can also accompany LVH
(e.g. secondary to Hypertension, Aortic valve Disease
& Hypertrophic cardiomyopathy).
= - As like P pulmonale.
‘P mitrale’ – does not require treatment of its own.
41
Myocardial Infarction
3 cardinal signs on ECG in AMI -
1)Elevation of ST segment.
2)Inverted T wave.
3)Deep & wide Q wave.
42
Events in chronological Order
1)on 1st day - ST elevated
- with upright tall T wave
- but No Q wave
2)Over Next 2 day -
T wave will slowly become Inverted, ST seg still raised.
3)Towards the end of 1st wk -
- ST seg returning to base Level, T wave deeply inverted
- Q wave starts appearing.
- T wave - Pointed, Inverted & symmetrical Limbs.
43
4)In 3rd week -
- Q wave fully developed.
- ST - Base
- T – wave flat & Returning to Normal.
5)By the end of 3 month -
-St seg & T wave – Return to Normal.
-Only Q wave remains permanent.
(of course if size of infarct is TOO small -Q wave may disappear)
-Q wave size is proportional to size of infarct.
44
Acute myocardial Ischemia
Angina = I cry
-Atherosclerotic Narrowing of coronary vessels.
-Pt. is comfortable at rest but anginal pain after exertion.
-After exercise, myocardium demand increases but sufficient
blood flow can not occur due to,
partially occluded coronary artery.
-Anginal pain disappears after Rest when demand decreases.
-Acute myocardial ischemia can be seen during stress test.
-Positive stress test - ST Depression.
45
Types of ST seg Depression. 1) Horizontal or plain ST seg Depression.
This signifies myocardial ischemia.
2) Upward slopping ST seg Depression.
This is variant of Normal & significant only if,
point Depression > 2mm
46
1)Horizontality of ST seg -
-ST seg – Horizontal & Isoelectric
-This is early manifestation of ischemia.
2)Downward slopping of ST seg -
This indicates severe Ischaemia
– Also seen in Digitalis toxicity.
47
1)Slaggy, concave upward ST seg-
Suggestive of Ischaemia.
2)Non Acute myocardial Ischaema-
Slight ST depression in V5, V6 & similar T inversion (Limb leads)
OR
Sometimes flattening of T wave in V5 & V6
(Just like strain pattern LVH)
48
Anterior M.I.
= T Inversion in
V1 – V4
49
V1
V2
V3
50
Anterior M.I.
- Q waves in Lead V4 – V4
- T Inversion in V1 – V4
ECG recorded, 5 days after Anterior M.I.
- Q waves, start to appear within few hrs of onset
& in 90% cases, becomes permanent.
- Of M.I. – chest pain, Nausea, Sweating.
51
Anterior M.I.
= S T Elevation in V1 – V4
52
V2 V3 V1
53
Inferior M.I
i) Q in II, III aVF
ii) T Inversion in II, III, aVF
54
i) Q in II, III aVF
ii) T Inversion in II, III, aVF
55
Inferior M.I.
1.Q in II, III, aVF
2.T Inversion in II, III & aVF
(2 yrs. previously attack.)
56
Inferior M. I
i) Q in II, III avF
ii) ST Elevation in II, III & avF
57 i) Q in II, III avF ii) ST Elevation in II, III & avF
58
Lateral M. I.
- S T Elevation in I, aVL, V4 – V6
- Hyper acute T waves in V4 & V5
59
i) S T Elevation in I, avL, V4 – V6
ii) Hyper acute T waves in V4 & V5
60
Lateral M. I.
-ST elevation in I, aVL, V4-V6.
-Hyper – acute T waves in Leads V4 & V5.
-R in V1-V3
-ST depression in V1-V3
-Upright Tall T waves in V2 & V3
61
Post. M. I
i) S T Depression in V1 – V3
62
S T Depression in V1 – V3
63
i) Anterior M. I. - V1 to V4
ii) Lateral M. I. - I, aVL, V5 – V6
iii) Antero Lateral - I, aVL,
V1 – V6.
iv) Antero-septal - V1 – V3
v) Interior M.I. - II, III, aVF
vi) Infero Lateral - I, II, III
aVL, aVF,
V5-V6.
64
Exercise (stress) Test 1) ST Depression
2) Sometimes T Inversion
65
1) ST Depression
2) Sometimes T Inversion
66
Exercise Test
1. -Most common Indicator of coronary Artery Disease.
2. J point is the Junction of S wave & ST segment.
3. Measure ST Depression, 2 dot square after J point.
4. T Inversion, may develop during exercise (as may BBB)
5. A fall in systolic pressure indicates sever coronary Disease
6. Greater the Depression - Higher probability of coronary
Heart Disease.
-1st degree Heart Block.
-Long PR interval.
(Normal-PR)
= 0.12-0.20 sec.
= 3-5 dot squares.
68
(Normal-PR)
= 0.12-0.20 sec.
= 3-5 dot squares
69
1st Degree Heart block
Long PR Interval
0.12 - 0.2 sec
3 small sq. - 5 small sq.
Causes -IHD
-Hypokalaemia
(Low potassium, due to Diver tics)
-Acute Rheumatic myocarditis,
-Drugs (Digoxin ,B blockers,
Ca+ channel blocks)
= Asymptomatic.
= No specific Rx
= Not Indication for a pacemaker.
70
Mobitz Type1-AV Block
=Progressive lengthening
of PR interval.
=Then P wave-fails to be
conducted.
=PR interval Resets &
cycle repeats.
71
72
Mobitz Type I - AV Block
One of the types of 2nd degree
Heart block – Also known as “Wenckebach
phenomenon”.
a) Progressive Lengthening of PR Interval
b) Then p wave – fails to be conducted
c) PR Interval resets 7 cycle repeats
= Abnormal conducting, through AV node
(during High vagal activity – some times
during sleep.)
= In Generalized disease of conducting
tissues.
= Benign form of AV block .
(permanent pace maker not required)
– Temporary pacing before surgery.
73
Mobitz Type 2-AV Block
=PR Normal & constant.
=Occasional P wave-fails
to be conducted.
75
Mobitz Type II - AV Block
a) PR - Normal & Constant
b)Occasional P wave – fails to be conducted.
= Result from abnormal conduction,
below AV node (in Bundle of His)
= More serious than type I
= Refer to cardiologist: Pacemaker may be
needed
= Indications for pacing – Acute M.I or
pre-operatively.
76
3rd degrees Heart Block a) P wave (atrial) Rate = 85 / min
b) QRS complex (ventricular) rate = 54 / min
c) Broad QRS complexes
d) No Relation between – P waves & QRS complexes
Third-degree AV block
77
78
3rd degree Heart Block
Complete Heart Block
Complete Interruption of conduction between,
Atria & ventricles & two are working Independently.
- In Acute inferior M.I. - 3rd deg. AV Block – Pacing.
- Acute Anterior wall M.I – 3rd degree heart Block.
Indicates extensive infarct & poor prognosis.
- Temporary pacing – pri-operatively
- If due to 3rd degree Block
Heart failure, Dizziness, fall, loss of
consciousness-Permanent pacing is indicated.
a) P wave (atrial) rate = 85 / min.
b) QRS complex (ventricular) rate = 54 / min.
c) Broad QRS complexes.
d) No Relation between – P waves & QRS complexes
79
2 : 1 AV Block a) Alternate P waves fail to be conducted
(Alternate P waves are not followed by QRS
complexes)
b) AV block is a special form of 2nd degree Heart
block
2:1 AV
block
80
Non-conducted P
Wave
conducted P
Wave
81
2: 1 AV Block
- Alternate P waves fail to be conducted .
(Alternate P waves are not followed by
QRS complexes)
- AV block is a special form of 2nd degree
Heart Block.
82
LBBB
a) Broad QRS complexes.
Normal – QRS < 0.12 sec
QRS < 3 small
square
b) QRS looks like W in V1 &
M in V6 (william).
83
QRS looks like W in V1
& M in V6 (william).
Q
84
B.B.B
LBBB
a) Broad QRS complexes
b) QRS morphology – as explained in Text.
Normal: QRS < 0.12 sec
QRS < 3.5 small squares
QRS looks like W in V1 & M in V6 (William)
Causes-
- IHD
- LVH (Hypertension, aortic stenosis),
- Fibrosis of conduction system.
Asymptomatic & do not required of their own
right.
85
RBBB
a) Broad QRS complexes.
b) QRS looks like M in V1 &
W in V6
(M orro w)
86
QRS looks like M in
V1 & W in V6
(M orro w)
87
a)Broad QRS complexes
b)QRS morphology as explained in Text.
Normal QRS < 0.12 sec.
QRS < 3 dot squares.
QRS Looks like ‘M’ in Lead V1 & ‘w’ in lead V6 (morrow).
Causes -
- IHD,
- Cardiomyopathy,
- Atrial septal defects,
- Massive pulmonary embolism.
-RBBB is relatively common finding in otherwise normal
hearts.
-Both LBBB & RBBB are asymptomatic in themselves
& do not require treatment in their own right.
RBBB
88
Hyper Ca ++
Normal QTC
= 0.35 – 0.43 sec
Short QT
89
causes of hypercalcaemia -
- Hyperparathyroidism. (Primary or Tertiary)
- Malignancy (Myeloma)
- Drugs (Thiazide Diuretics, excessive vit D intake.
- Sarcoidosis
- Thyrotoxicosis.
= Risk of cardiac arrest
with Severe Hypercalcaemia.
= Severe symptoms :
- vomiting, Drowsiness & plasma Ca+ > 3.5 mmol / L -
Urgent Rx
- I / V - 0.9 % saline (3 to 4 lit / 24 hrs)
- I / V Frusemide (20-40 mg/ every 6 – 12 hrs)
- Disodium pamidronate – single Infusion.
Monitor Urea & Electrolytes ca+ level – Every 12 hrs
90
Hyper Ca+
- To calculate QT Interval is not straight forward:
Duration varies with H. R.
Faster H. R. - Shorter QT
QTC = QT
RR
Normal QTC = 0.35 - 0.43 sec.
= Fig. - QT = 0.26 sec.
HR = 100 / min.
QTC = 0.34 sec.
= Sym of Hypercalcaemia.
Anorexia, wt. Loss, Nausea, Vomiting, abdominal pain,
constipation, polydypsia, polyuria, weakness & depression.
= Prominent U wave
= Confirm by Plasma ca+ Level.
91
Hypocalcaemia
- Long QT Interval
92
Hypocalcaemia
-Long QT Interval (0.57 s)
-H. R = 51 / min.
-Q TC = 0.52 sec.
= C/F - Peripheral & circumoral paraesthesiae, Tetany,
Fits & Psychiatric Disturbance.
- Trousseaus sign :
(carpal spasm, when Brachial Artery is occluded with
BP cuff)
- Chovosteks sign :
Twitching of facial muscles, when tapping over facial
Nerve.
- Papilloedema
93
-Confirm -
- By plasma Ca+ level
-(Not forgetting to check simultaneous Alb. level)
Causes –
- Hypoparathyroidism.
(Following Thyroid surgery, Auto immune or Congenital)
- Chr. Renal failure
- Vit. D Deficiency
- Drugs like calcitonin
- Acute pancreatitis
= Inj. Ca- Gluconate 10% - 10ml.
94
Hyperkalaemia
= Tall Tented T waves
95
Hyperkalaemia
= Tall ‘Tented’ T wave
Hyperkalaemia also cause:
-Flattening & even loss of P wave.
-Lengthening of PR
-Widening of QRS complex.
-Arrhythmias.
- Confirmed by - Elevated plasma potassium level.
-Underlying cause - Renal Failure.
-Complete Drug H/O is Essential in any pt. with abnormal ECG.
96
Hypokalaemia
-Small T wave &
-Prominent U wave
-Changes, which may accompany Hypokalaemia:
- First degree Heart Block
- Depression of ST segment
- Prominent U wave.
= C/F - muscle weakness & cramps.
= Commonest cause for hypokalaemia is Diuretics.
97
Hypokalaemia
- Small T wave & Prominent U wave
98
= Reverse Tick (ST depression)
Digoxin Effect
99
Reverse Tick (ST depression)
100
Digoxin Effect
= “Reverse Tick” - ST depression
- Reduction of T wave size shortening of QT
At. Toxic level-
-T Inversion
-Arrhythmias, Sinus Bradycardia ,Ventricular
Tachycardia
= Reverse Tick.
101
- P wave Inverted in I &
Rt. Axis Deviation
- Decrease in R wave height,
across chest leads.
Heart Lies on Rt. side
102
Heart lies on Rt. side
-Decrease in R wave height across chest leads.
-Heart lies on RT side.
-P wave Inverted in I & Rt Axis Deviation.
-For - Location of Apex beat, do the chest x-ray
Kartagener’s syndrome:
-Dextrocardia + Bronachiectasis + sinusitis.
-No. specific .
103
1. Introduction 5 to 10
2. Electric circuit of heart 11
3. Waves of ECG 12
4. Normal ECG of chest leads 13
5. ECG of I,II,III,aVR,aVL,aVF leads 14
6. Sinus Rhythm 15 & 16
7. Sinus Bradycardia 17 & 18
8. Sinus Tachycardia 19 to 21
9. Left Axis Deviation 22 & 23
10. Right Axis Deviation 24 to 26
104
11. Normal pattern of QRS complex 27
12. LVH 28 to 31
13. RVH 32 to 34
14. RAH 35 to 37
15. LAH 38 to 40
16. M.I 41 to 43
17. Angina 44 to 47
18. M.I 48 to 63
19. Stress Test 64 to 66
20. 1st Degree Heart block 67 to 69
21. Mobitz type 1 AV block 70 to 72
22. Mobitz type 2 AV block 73 to 75
105
23. 3rd Degree Heart block 76 to 78
24. 2:1 AV Block 79 to 81
25. LBBB 82 to 84
26. RBBB 85 to 87
27. Hyper Ca++ 88 to 90
28. Hypo Ca++ 91 to 93
29. Hyper Kalaemia 94 & 95
30. Hypo Kalaemia 96 & 97
31. Digoxin effect 98 to 100
32. Dextrocardia 101 & 102
106