Electrocardiography; Types, Indications/Uses, Procedures

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

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Electrocardiography (ECG or EKG) is the process of recording the electrical activity of the heart over a period of time using electrodes placed on the skin. These electrodes detect the tiny electrical changes on the skin that arise from the heart muscle’s electrophysiologic pattern of depolarizing and repolarizing during each heartbeat. It is a very commonly performed cardiology test.

In a conventional 12-lead ECG, ten electrodes are placed on the patient’s limbs and on the surface of the chest. The overall magnitude of the heart’s electrical potential is then measured from twelve different angles (“leads”) and is recorded over a period of time (usually ten seconds). In this way, the overall magnitude and direction of the heart’s electrical depolarization is captured at each moment throughout the cardiac cycle. The graph of voltage versus time produced by this noninvasive medical procedure is an electrocardiogram.

Medical Uses

A 12-lead ECG of a 26-year-old male with an incomplete RBBB

The overall goal of performing electrocardiography is to obtain information about the structure and function of the heart. Medical uses for this information are varied and generally relate to having a need for knowledge of the structure and/or function. Some indications for performing electrocardiography include:

  • Suspected myocardial infarction (heart attack) or new chest pain
  • Suspected pulmonary embolism or new shortness of breath
  • A third heart sound, fourth heart sound, a cardiac murmur or other findings to suggest structural heart disease
  • Perceived cardiac dysrhythmias either by pulse or palpitations
  • Monitoring of known cardiac dysrhythmias
  • Chest pain
  • Atypical chest pain
  • Epigastric pain
  • Back, neck, jaw or arm pain without chest pain
  • Palpitations
  • Syncope or near syncope
  • Pulmonary edema
  • Exertional dyspnea
  • Weakness
  • Diaphoresis unexplained by ambient temperature
  • Feel of anxiety or impending doom
  • Suspected diabetic ketoacidosis
  • Fainting or collapse
  • Seizures
  • Monitoring the effects of a heart medication (e.g. drug-induced QT prolongation)
  • Assessing severity of electrolyte abnormalities, such as hyperkalemia
  • Hypertrophic cardiomyopathy screening in adolescents as part of a sports physical out of concern for sudden cardiac death (varies by country)
  • Perioperative monitoring in which any form of anesthesia is involved (e.g. monitored anesthesia care, general anesthesia); typically both intraoperative and postoperative
  • As a part of a pre-operative assessment some time before a surgical procedure (especially for those with known cardiovascular disease or who are undergoing invasive or cardiac, vascular or pulmonary procedures, or who will receive general anesthesia)
  • Cardiac stress testing
  • Computed tomography angiography (CTA) and Magnetic resonance angiography (MRA) of the heart (ECG is used to “gate” the scanning so that the anatomical position of the heart is steady)
  • Biotelemetry of patients for any of the above reasons and such monitoring can include internal and external defibrillators and pacemakers
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Diagnosis

Numerous diagnoses and findings can be made based upon electrocardiography, and many are discussed above. Overall, the diagnoses are made based on the patterns. For example, an “irregularly irregular” QRS complex without P waves is the hallmark of atrial fibrillation; however, other findings can be present as well, such as a bundle branch block that alters the shape of the QRS complexes. ECGs can be interpreted in isolation but should be applied – like all diagnostic tests – in the context of the patient. For example, an observation of peaked T waves is not sufficient to diagnose hyperkalemia; such a diagnosis should be verified by measuring the blood potassium level. Conversely, a discovery of hyperkalemia should be followed by an ECG for manifestations such as peaked T waves, widened QRS complexes, and loss of P waves. The following is an organized list of possible ECG-based diagnoses.

Rhythm disturbances/arrhythmias:

  • Atrial fibrillation & atrial flutter without rapid ventricular response
  • Premature atrial contraction (PACs) & Premature ventricular contraction (PVCs)
  • Sinus arrhythmia
  • Sinus bradycardia & sinus tachycardia
  • Sinus pause & sinoatrial arrest
  • Sick sinus syndrome: bradycardia-tachycardia syndrome
  • Supraventricular tachycardia
    • Atrial fibrillation (afib) with rapid ventricular response
    • Atrial flutter with rapid ventricular response
    • AV nodal reentrant tachycardia
    • Atrioventricular reentrant tachycardia
    • Junctional ectopic tachycardia
    • Atrial tachycardia
      • Ectopic atrial tachycardia (unicentric)
      • Multifocal atrial tachycardia
      • Paroxysmal atrial tachycardia
    • Sinoatrial nodal reentrant tachycardia
  • Torsades de pointes (polymorphic ventricular tachycardia)
  • Wide complex tachycardia
    • Ventricular flutter
    • Ventricular fibrillation
    • Ventricular tachycardia (monomorphic ventricular tachycardia)
  • Pre-excitation syndrome
    • Lown–Ganong–Levine syndrome
    • Wolff–Parkinson–White syndrome
  • J wave/Osborn wave

Heart block and conduction problems:

  • Aberration
  • Sinoatrial block: first, second, and third-degree
  • AV node
    • First-degree AV block
    • Second-degree AV block (Mobitz I & II; Mobitz I aka Wenckebach)
    • Third-degree AV block/complete AV block
  • Right bundle
    • Incomplete right bundle branch block
    • Complete right bundle branch block (RBBB)
  • Left bundle
    • Complete left bundle branch block (LBBB)
    • Incomplete left bundle branch block
    • Left anterior fascicular block (LAFB)
    • Left posterior fascicular block (LPFB)
    • Bifascicular block (LAFB plus LPFB)
    • Trifascicular block (LAFP plus FPFB plus RBBB)
  • QT syndromes
    • Brugada syndrome
    • Short QT syndrome
    • Long QT syndromes, genetic and drug-induced
  • Right and left atrial abnormality

Electrolytes disturbances & intoxication:

  • Digitalis intoxication
  • Calcium: hypocalcemia and hypercalcemia
  • Potassium: hypokalemia and hyperkalemia

Ischemia and infarction:

  • Wellens’ syndrome (LAD occlusion)
  • de Winter T waves (LAD occlusion) 
  • ST elevation and ST depression
  • High Frequency QRS changes
  • Myocardial infarction (heart attack)
    • Non-Q wave myocardial infarction
    • NSTEMI
    • STEMI
    • Sgarbossa’s criteria for ischemia with a LBBB

Structural

  • Acute pericarditis
  • Right and left ventricular hypertrophy
  • Right ventricular strain/S1Q3T3 (can be seen in pulmonary embolism)

Grid and Leads

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
The ECG grid

Axis

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Atrial Enlargement

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Normal:
First portion of deflection is RA, second is LA
Right Atrial Enlargement:
P-wave amplitude > 2.5mm in inferior leads
Normal duration P-wave
Left Atrial Enlargement:
P-wave duration increased (terminal negative portion >0.04s)
Amplitude of terminal negative component >1mm below isoelectric line in V1

Ventricular Hypertrophy

Right Ventricular Hypertrophy:
Right axis deviation
Abnormal R-wave progression

  • Increased R-wave amplitude in leads overlying the right ventricle (V1)
  • Increased S-wave amplitude in leads overlying the left ventricle (V6)
Criteria

  • V1: R>S
  • V6: S>R
Left Ventricular Hypertrophy:
Left axis deviation
Increased R-wave amplitude in leads overlying the LV (I, aVL, V5, V6)
Increased S-wave amplitude in leads overlying the RV (V1)
Criteria:

  • Precordial Leads
    • R-wave in V5/V6 + S-wave in V1/V2 > 35mm
    • R-wave in V5 > 26mm
    • R-wave in V6 > 20mm
  • Limb Leads
    • R-wave in aVL > 11mm
    • R-wave in aVF > 20mm
  • Combined
    • R-wave in aVL + S-wave in V3 > 20mm (F), 28mm (M)

Secondary Repolarization Abnormalities

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Downsloping ST-segment depression
  • Asymmetric T-wave inversion

Bundle Branch Blocks

Left Bundle Branch Block

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • QRS duration > 0.12s (3 boxes)
  • Broad or notched R-wave with prolonged upstroke in I, aVL, V5, V6
  • Associated ST-segment depression and T-wave inversion
  • Reciprocal changes in V1, V2 (deep S-wave)
  • Possible LAD

Right Bundle Branch Block

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • QRS duration > 0.12s (3 boxes)
  • RSR’ in V1, V2
  • Reciprocal changes in I, aVL, V5, V6 (deep S-wave)
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Hemiblocks

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Other Blocks

  • Non-specific intraventricular conduction delay: QRS >0.10s without BBB
  • Incomplete BBB: LBBB/RBBB pattern with non-prolonged QRS
  • Bifascicular block: RBBB + LAFB/LPFB (by axis deviation)

Ischemia and Infarction

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  1. Hyperacute T-waves
  2. T-wave inversion: Symmetric, compared to TWI associated with repolarization abnormalities
  3. ST-elevation: Unlike J-point elevation, ST-segment merges with T-wave
  4. Q-waves
    1. Duration > 0.04s
    2. Amplitude > 1/3 R-wave
    3. Normal in aVR

Coronary Artery Territories

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

DISTRIBUTIONCORONARY ARTERYLEADSRECIPROCAL CHANGES
1. InferiorRCA, PDAII, III, aVFAnterior, Lateral
2. LateralLCxI, aVL, V5, V6Inferior
3. AnteriorLADV1-V6Inferior
4. PosteriorRCAPosteriorAnterior (esp. V1)

ECG Guide: Pediatrics

ECG Standard

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Full standard: no adjustment
  • Half-standard: commensurate reduction in amplitude (usually 50%)
  • Mixed: reduction in amplitude of precordial leads

Atrial Abnormalities

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Right Atrial Abnormality (P pulmonale)
Peaked P-wave in II (>3mm from 0-6mo or >2.5mm >6mo)
Causes: right atrial volume overload, ASD, Ebstein, Fontan
Left Atrial Abnormality (P mitrale)
Wide, notched P-wave in II or biphasic in V1
Causes: MS, MR

Axis

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Anatomical dominance of right ventricle until approximately 6mo
  • RAD normal
  • eRAD suggests AV canal defect

T-waves

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  •  1st week of life: Upright
  •  Adolescent: Inverted
  •  Adult: Upright

Ventricular Hypertrophy

Right Ventricular Hypertrophy
R-wave height >98% for age in lead V1
S-wave depth >98% for age in lead V6
T-wave abnormality (ex. upright in childhood)
Causes: pHTN, PS, ToF
Left Ventricular Hypertrophy
R-wave height >98% for age in lead V6
S-wave depth >98% for age in lead V1
Adult-pattern R-wave progression in newborn (no large R-waves and small S-waves in right precordial leads)
Left-axis deviation
Causes: AS, coarctation, VSD, PDA

Examples

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Normal Neonatal ECG

  • 2mo old
  • RAD
  • Inverted T-waves (normal)
  • Tall R-waves in V1-V3

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Extreme Axis Deviation

  • Neonate with Down syndrome
  • Isoelectric in I, Negative in aVF negative in II  mean QRS vector -87°
  • Extreme RAD suggestive of AV canal defect

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
LVH:

  • Unrepaired Coarctation
  • Deep S-wave in V1 (>98%)
  • Tall R-wave in V6 (>98%)

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
RVH:

  • 10 year-old boy with pulmonary Hypertension
  • RAD after expected age for normal RAD
  • Tall R-waves in V1 (>98%)
  • Deep S-wave in V6 (>98%)

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
STEMI

  • ALCAPA (anomalous origin of the left coronary artery from the pulmonary artery): coronary artery arises anomalously from the pulmonary artery; as pulmonary arterial pressure falls during the first 6 months of infancy, prograde flow through the left coronary artery ceases and may even reverse.
  • HLHS (hypoplastic left heart syndrome): coronary arteries are perfused from a hypoplastic, narrow aorta that is susceptible to flow disruption
  • Orthotopic heart transplant with allograft vasculopathy
  • Kawasaki: coronary artery aneurysm with subsequent thrombosis

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Benign early repolarization

  • 14 year-old male
  • Concave ST-segment elevation

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Left Atrial Abnormality:

  • 9mo female with mitral insufficiency
  • Broad biphasic P-wave in V1
  • Tall, notched P-wave in II

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Prolonged QT interval

  • 18-year-old female
  • Familial long QT syndrome and a history of cardiac arrest

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
WPW:

  • Delta wave, shortened PR interval

ECG Guide: Part II

STEMI

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • ST-segment elevation ≥ 1mm in two contiguous leads
  • : ≥ 2mm V2-V3
  • : ≥ 1.5mm V2-V3

Posterior STEMI

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • ST-segment depression V1-V3  Posterior ECG
  • ST-segment elevation ≥ 0.5mm in V7-V9

Sgarbossa Criteria

  • Evaluation for STEMI in LBBB or paced rhythm
  • Normal: ST-segment discordant with QRS
    •  QRS associated with ST-segment depression
    •  QRS associated with (commensurate) ST-segment elevation
  • Score ≥ 3 98% specific for MI

Elevation

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Concordant ST-segment elevation ≥ 1mm in any lead (5 points)

Depression

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Concordant ST-segment depression ≥ 1mm in V1-V3 (3 points)

Discordant Elevation

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Discordant ST-segment elevation ≥ 5mm in any lead (2 points)

Modified Sgarbossa Criteria

  • ST:S ratio ≥ 0.25 in any lead
  • Presence of any criterion is positive
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Other Causes of ST-segment Elevation

Benign Early Repolarization

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Concave ST-segment elevation
  • Notch at J-point
  • Asymmetric T-waves (steeper descent)

Pericarditis

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Diffuse ST-segment elevation (except aVR)
  • PR-segment depression
  • Ratio: ST-elevation to T-wave amplitude ≥ 0.25 in V6 suggests pericarditis

LVH Strain

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • ST-segment elevation in V1-V3 in the setting of LVH

LV Aneurysm

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Q-waves with ST-segment elevation in precordial leads

Ischemia and Prior Infarcts

Wellens: Type A

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Suggestive of proximal LAD lesion

Wellens: Type B

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Q-waves

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • ≥ 40ms duration
  • Depth ≥ 25% of R-wave height

Syncope

ARVD

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Epsilon wave

Brugada Syndrome: Type 1

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Type 1: Coved ST-segment elevation

Brugada Syndrome: Type 2

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Type 2: Saddle-back ST-segment elevation
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HCM

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Deep, narrow Q-waves

Wolff-Parkinson-White

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Shortened PR-interval
  • Delta-wave

Other

Atrial Abnormalities

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  1. Normal
  2. RAA: P-wave amplitude > 2.5mm in inferior leads
  3. LAA: P-wave duration increased (terminal negative portion >0.04s), amplitude of terminal negative component >1mm below isoelectric line in V1

Left Bundle Branch Block

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • QRS duration > 0.12s (3 boxes)
  • Broad or notched R-wave with prolonged upstroke in I, aVL, V5, V6
  • Associated ST-segment depression and T-wave inversion
  • Reciprocal changes in V1, V2 (deep S-wave)
  • Possible LAD

Right Bundle Branch Block

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • QRS duration > 0.12s (3 boxes)
  • RSR’ in V1, V2
  • Reciprocal changes in I, aVL, V5, V6 (deep S-wave)

Axes

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

All ECG tracings are available for free, licensed (along with all content on this site) under Creative Commons Attribution-ShareAlike 4.0 International Public License.

Bradycardia

Brief H&P

A 38 year-old male with no medical history presents to the emergency department with abdominal pain. He had one episode each of non-bloody emesis followed by watery, non-bloody diarrhea and cited several sick contacts at home with similar symptoms. Vital signs were notable for bradycardia with a heart rate ranging from 38-46bpm though he was normotensive. The examination including abdominal examination was benign. A 12-lead electrocardiogram was obtained which demonstrated sinus bradycardia. The patient was asymptomatic during episodes of bradycardia and his heart rate responded appropriately during activity and on further history reported that he was an endurance athlete and runs multiple marathons each year. He was discharged after symptomatic improvement with anti-emetics.

Bradycardia

  • Definition: heart rate <60bpm
  • Sinus rhythm: upright P-wave in I, II, aV; inverted P-wave in aVR

Electrocardiographic Findings

  • Sinus bradycardia
    • Potentially asymptomatic and present in healthy individuals
  • Sinoatrial node dysfunction (sick sinus syndrome, SSS)
    • Sinus bradycardia
    • Sinus arrest
    • Tachy-brady syndrome (sinus bradycardia/arrest interspersed with SVT)
  • Atrioventricular block
    • 1st degree: PR prolongation, rarely symptomatic
    • 2nd degree: Intermittent interruption of conduction of atrial impulses to ventricles
      • Type 1: progressive PR prolongation leading to interrupted conduction
      • Type 2: fixed PR interval with interrupted conduction
    • 3rd degree: atrioventricular dissociation
  • Slow atrial fibrillation
    • Irregular RR interval without recognizable P-wave

Epidemiology

  • Analysis of 277 patients presenting to the emergency department with “compromising” bradycardia.
  • Symptoms
    • Syncope (33%)
    • Dizziness (22%)
    • Angina (17%)
    • Dyspnea/Heart Failure (11%)
  • ECG
    • High-grade AV block (48%)
    • Sinus bradycardia (17%)
    • Sinus arrest (15%)
    • Slow atrial fibrillation (14%)
  • Cause
    • Primary (49%)
    • Drug (21%)
    • Ischemia/Infarction (14%)
    • Pacemaker failure (6%)
    • Intoxication (6%)
    • Electrolyte disorder (4%)

Important Historical Features

  • Fever/travel
  • Chest pain
  • Cold intolerance, weight gain
  • Headache, AMS, trauma
  • Abdominal pain/distension
  • Medication changes

Important Examination Findings

  • Perfusion (temperature, capillary refill)
  • Presence of fistula or hemodialysis catheter
  • Existing device (malfunction)

Workup

  • ECG
  • Continuous telemetry monitoring
  • Labs
    • Potassium
    • Digoxin level
    • TFT
    • Infection titers (RPR, Lyme)
    • Cardiac enzymes

Management

  • Unstable
    • Airway
    • Atropine 0.5mg IV q3-5min (maximum 3mg)
    • Dopamine/epinephrine infusion
    • Temporary pacemaker (transcutaneous, transvenous) with blood-pressure preserving sedation
    • Admission and evaluation for permanent pacemaker placement
  • Stable (outpatient evaluation)
    • Event monitor
    • Stress test (chronotropic incompetence)

Algorithm for the Evaluation and Management of Bradycardia

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx HarunWellens Syndrome

Case Presentation

49M with a history of hypertension who presented to his primary physician for routine follow-up and was referred to the ED for an abnormal ECG. He denied chest pain, shortness of breath, or any limitation to baseline exercise tolerance. His vital signs were notable for systolic hypertension and his examination was unremarkable. A chest x-ray showed no acute cardiopulmonary findings. His initial ECG demonstrated a biphasic T-wave in V2 and deep, symmetric T-wave inversions in V3-V6. His initial serum troponin was markedly elevated at 3.499. He was admitted and urgent coronary angiography revealed proximal LAD stenosis (70%), mid-LAD stenosis (85%) and 1st right posterolateral stenosis (85%) which were stented. He was discharged on post-procedure day one and has remained asymptomatic at outpatient follow-up.

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Presentation ECG

Biphasic T-wave in V2, deep and symmetric T-wave inversions in V3-V4

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Post-Catheterization ECG

Resolution of biphasic T-wave and T-wave inversions

Presentation ECG
Post-Catheterization ECG
History

Initially described in 1982 where a subset of patients who did poorly with medical management of “impending myocardial infarction” (essentialy unstable angina) were found to have characteristic ECG changes. These patients were noted to be at increased risk for extensive anterior wall myocardial infarctions due to proximal LAD stenosis.

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Criteria

  1. History of chest pain
  2. Normal or slightly-elevated cardiac enzymes
  3. No precordial Q-waves
  4. Isoelectric or <1mm ST-segment elevation
  5. Pattern present in pain-free state
  6. Type A (25%): Biphasic T-wave in V2/V3
  7. Type B (75%): Deep, symmetrically inverted T-waves in V2/V3

Clinical Significance

Wellens Syndrome (or LAD coronary T-wave syndrome) represents a “pre-infarction” stage of coronary artery disease manifested by critical LAD stenosis. The natural history includes progression to extensive anterior wall myocardial infarction, often associated with severe left ventricular systolic dysfunction, cardiogenic shock and death. These changes may be mistaken for “non-specific” T-wave changes (which in the presence of a non-concerning history and typically non-elevated cardiac markers) may lead providers to inappropriate dispositions such a stress testing which is contraindicated. Recognition of this pattern and its appropriate management (urgent coronary angiography) is critical.

Case Summary

The case presented above is atypical. The patient had no history of chest pain and cardiac enzymes were significantly elevated – two features which are uncommon in Wellens Syndrome. However, the patient’s elevated cardiac biomarkers led to admission and angiography with identification of the characteristic proximal LAD stenosis (and other disease).

Nonsustained Ventricular Tachycardia

Case 1

64M with a history of HFrEF (LVEF 20-25%), CAD, AICD (unknown indication), COPD, CKD III presenting with gradual onset shortness of breath, progressive bilateral lower extremity edema.
Examination consistent with severe acute decompensated heart failure presumed secondary to left ventricular dysfunction.
Telemetry monitoring with multiple episodes of nonsustained ventricular tachycardia.

In the ED, the patient developed worsening respiratory failure despite initiation of therapy, requiring endotracheal intubation. Continuous cardiac monitoring revealed persistent salvos of NSVT, progressing to slow ventricular tachycardia without device intervention.
Device interrogation revealed multiple events, 3 shocks, several ATP’s over the recorded period.

Evaluation and Management:

  • NSVT with known (severe) ischemic heart disease
  • For repetitive monomorphic ventricular tachycardia: amiodarone, beta-blockade (if tolerated), procainamide (IIA, C)

ECG’s

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

ECG 1

Non-specific IVCD, LAA, VPC

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

ECG 2

VT initiated by fusion complex

ECG 1
ECG 2

Case 2

31F with the autoimmune polyglandular syndrome (adrenal, thyroid and endocrine pancreatic insufficiency), presenting with fever and cough.
Evaluation consistent with sepsis presumed secondary to the pulmonary source.
Telemetry monitoring initially with ventricular bigeminy, then nonsustained ventricular tachycardia.

In the ED, the patient developed pulseless ventricular tachycardia – apparently polymorphic. Chest compressions and epinephrine produced the return of spontaneous circulation with recovery to baseline neurologic function.
ECG revealed prolonged QTc and chemistry panel notable for critical hypokalemia/hypomagnesemia.

Evaluation and Management:

  • NSVT progressing to VT
  • Initially attributed to electrolyte disturbances. However, serial ECG’s continued to show prolonged QTc (possibly acquired, home medications included metoclopramide and erythromycin). Early echocardiography demonstrated global hypokinesis with EF 30-35% attributed to severe sepsis and recurrent defibrillation. Cardiac CT after resolution of acute illness showed persistently depressed ejection fraction without coronary atherosclerosis. The presence of NICM associated with malignant dysrhythmias warranted ICD placement.
  • Cardioversion for hemodynamic compromise (I, B), B-blockade (I, B), amiodarone if no LQTS (I, C), urgent angiography if ischemia not excluded (I, C)1
  • Correction of electrolyte abnormalities (specifically hypokalemia) may decrease progression to VF.

ECG’s

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

ECG 1

Ventricular bigeminy

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

ECG 2

Long-QT

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

VT on Telemetry

Non-sustained ventricular tachycardia noted on telemetry monitoring

ECG 1
ECG 2
VT on Telemetry
  • > 3-5 consecutive beats originating below the AV node
  • Rate > 100bpm
  • Duration <30s

Epidemiology

    • Occurs in 0-4% of ambulatory patients
    • Increased frequency in males and with increasing age

In some patients, NSVT is associated with an increased risk of sustained tachyarrhythmias and sudden cardiac death. In others, it is of little prognostic significance.

Evaluation

    In all patients:History: including arrhythmogenic medications/substances, pertinent family historyPhysical examinationECG/CXRTTEIn selected patients exercise-testing advanced imaging (CT/C-MR)Electrophysiologic studies genetic testing

NSVT in the absence of structural heart disease

NSVT in Idiopathic Ventricular Tachycardia

Ventricular outflow arrhythmias:
RVOT: 70-80%, LBBB pattern
LVOT: 20-30%, RBBB pattern
Mechanism:
Adrenergically mediated
Occur during exercise, resolve as heart-rate increases, recur during recovery
Management:
Exclude arrhythmogenic right ventricular cardiomyopathy (imaging, myocardial biopsy)
If symptomatic, beta-blockade, ± IC anti-arrhythmic, CCB (verapamil) for ILVT
Prognosis:
Good, rare tachycardia-induced cardiomyopathy, rare SCD

NSVT in Polymorphic Ventricular Tachycardia

Mechanism
LQTS (acquired or inherited)
Familial catecholaminergic polymorphic VT
Management
Symptomatic (ex. syncope, cardiac arrest): ICD
Asymptomatic QTc > 550ms: consider ICD
Prognosis
Increased risk SCD

Arrhythmogenic Right Ventricular Cardiomyopathy

Mechanism
Fibrosis, fibro-fatty replacement of myocardium in RVIT/RVOT/RV apex
May occur with only subtle structural abnormalities of the right ventricle
LBBB morphology
Management
Anti-arrhythmias of limited utility
Catheter ablation, ICD backup
Prognosis
Increased risk SCD

NSVT with apparent structural heart disease1

Hypertension and LVH

Mechanism
Stretch-induced abnormal automaticity
Fibrotic tissue
Presence of NSVT correlates with the degree of hypertrophy and subendocardial fibrosis
Management
Evaluation for ischemic heart disease
Aggressive medical management of hypertension (including beta-blockade)
Prognosis
Unclear

Valvular Disease

Mechanism
High incidence in AS, severe MR (25%)
Mechanical stress from dysfunctional valvular apparatus
Management
Beta-blockade if symptomatic
Prognosis
No evidence that NSVT is an independent predictor of SCD.

Ischemic Heart Disease9-14

Mechanism
Monomorphic VT associated with re-entry at the borders of ventricular scars
Ischemia induces polymorphic NSVT/VF
Management
Revascularization, beta-blockade, statin, ACE/ARB
MADIT I, MUSTT: ICD for ICM LVEF <40%, NSVT, EPS inducible VT
MADIT II, SCD-HeFT: ICD for moderate-to-severe LV dysfunction irrespective of NSVT or EPS findings
Prognosis
NSTEMI with NSVT >48h after admission 2x risk SCD (MERLIN-TIMI 36)
STEMI with NSVT common, not as predictive of ACM or SCD as LVEF (CARISMA)
NSVT <24h after admission for NSTEMI/STEMI not of prognostic significance.

Hypertrophic Cardiomyopathy

Mechanism
Genetic myocardial disease
Myocyte disarray, fibrosis, ischemia result in arrhythmogenic substrate
Management

Restriction of physical activity

(NSVT, LV thickness, FH SCD, syncope, abnormal BP response to exercise)
Beta-blockade, anti-arrhythmic for symptoms
Prognosis
Increased risk SCD (1% annual)

Other Conditions

  • Non-ischemic dilated cardiomyopathy
  • Giant-cell myocarditis
  • Repaired TOF
  • Amyloidosis
  • Sarcoidosis
  • Chagas cardiomyopathy

Algorithm for the Evaluation of NSVT

Low Voltage ECG

Definition

  • QRS in limb leads <5mm
  • QRS in precordial leads <10mm

General Causes

  • Fluid, fat or air attenuating signal
  • Myocardial infiltration
  • Loss of viable myocardium

Example

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Low Voltage ECG

ECG of patient with pericardial effusion

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Baseline ECG

Old ECG from same patient

Low Voltage ECG
Baseline ECG

Differential Diagnosis of Low Voltage ECG

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx HarunECG Guide

The format of this article is atypical for the structure and concept of the website – but it’s always been about learning. Here is a simplified guide to ECG interpretation with a focus on the aspects I find more challenging to understand or recall.

Grid and Leads

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun
The ECG grid

Axis

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Atrial Enlargement

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Normal:
First portion of deflection is RA, second is LA
Right Atrial Enlargement:
P-wave amplitude > 2.5mm in inferior leads
Normal duration P-wave
Left Atrial Enlargement:
P-wave duration increased (terminal negative portion >0.04s)
Amplitude of terminal negative component >1mm below isoelectric line in V1

Ventricular Hypertrophy

Right Ventricular Hypertrophy:
Right axis deviation
Abnormal R-wave progression

  • Increased R-wave amplitude in leads overlying the right ventricle (V1)
  • Increased S-wave amplitude in leads overlying the left ventricle (V6)
Criteria

  • V1: R>S
  • V6: S>R
Left Ventricular Hypertrophy:
Left axis deviation
Increased R-wave amplitude in leads overlying the LV (I, aVL, V5, V6)
Increased S-wave amplitude in leads overlying the RV (V1)
Criteria:

  • Precordial Leads
    • R-wave in V5/V6 + S-wave in V1/V2 > 35mm
    • R-wave in V5 > 26mm
    • R-wave in V6 > 20mm
  • Limb Leads
    • R-wave in aVL > 11mm
    • R-wave in aVF > 20mm
  • Combined
    • R-wave in aVL + S-wave in V3 > 20mm (F), 28mm (M)

Secondary Repolarization Abnormalities

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • Downsloping ST-segment depression
  • Asymmetric T-wave inversion

Bundle Branch Blocks

Left Bundle Branch Block

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • QRS duration > 0.12s (3 boxes)
  • Broad or notched R-wave with prolonged upstroke in I, aVL, V5, V6
  • Associated ST-segment depression and T-wave inversion
  • Reciprocal changes in V1, V2 (deep S-wave)
  • Possible LAD

Right Bundle Branch Block

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  • QRS duration > 0.12s (3 boxes)
  • RSR’ in V1, V2
  • Reciprocal changes in I, aVL, V5, V6 (deep S-wave)

Hemiblocks

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Other Blocks

  • Non-specific intraventricular conduction delay: QRS >0.10s without BBB
  • Incomplete BBB: LBBB/RBBB pattern with non-prolonged QRS
  • Bifascicular block: RBBB + LAFB/LPFB (by axis deviation)

Ischemia and Infarction

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

  1. Hyperacute T-waves
  2. T-wave inversion: Symmetric, compared to TWI associated with repolarization abnormalities
  3. ST-elevation: Unlike J-point elevation, ST-segment merges with T-wave
  4. Q-waves
    1. Duration > 0.04s
    2. Amplitude > 1/3 R-wave
    3. Normal in aVR

Coronary Artery Territories

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

DISTRIBUTIONCORONARY ARTERYLEADSRECIPROCAL CHANGES
1. InferiorRCA, PDAII, III, aVFAnterior, Lateral
2. LateralLCxI, aVL, V5, V6Inferior
3. AnteriorLADV1-V6Inferior
4. PosteriorRCAPosteriorAnterior (esp. V1)

References

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

Electrocardiography, Electrocardiography; Types, Indications/Uses, Procedures, Rx Harun

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    Referring to the last days, this could only be speaking of a cashless society, which we have yet to see, but are heading towards. Otherwise, we could still buy or sell without the mark amongst others if physical money was still currency. This Mark couldn’t be spiritual because the word references two different physical locations. If it was spiritual it would just say in the forehead. RFID microchip implant technology will be the future of a one world cashless society containing digital currency. It will be implanted in the right-hand or the forehead, and we cannot buy or sell without it. Revelation 13:11-18 tells us that a false prophet will arise on the world scene doing miracles before men, deceiving them to receive this Mark. Do not be deceived! We must grow strong in Jesus. AT ALL COSTS, DO NOT TAKE IT!

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    “EITHER HUMAN INTELLIGENCE ULTIMATELY OWES ITS ORIGIN TO MINDLESS MATTER OR THERE IS A CREATOR…” – JOHN LENNOX

    We all know God exists. Why? Because without Him, we couldn’t prove anything at all. Do we live our lives as if we cannot know anything? No. So why is God necessary? In order to know anything for certain, you would have to know everything, or have revelation from somebody who does. Who is capable of knowing everything? God. So to know anything, you would have to be God, or know God.

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    It has been calculated by Roger Penrose that the odds of the initial conditions for the big bang to produce the universe that we see to be a number so big, that we could put a zero on every particle in the universe, and even that would not be enough to use every zero. What are the odds that God created the universe? Odds are no such thing. Who of you would gamble your life on one coin flip?

    Is there evidence that the Bible is the truth? Yes. Did you know that the creation accounts listed in the book of Genesis are not only all correct, but are also in the correct chronological order? That the Bible doesn’t say the Earth was formed in six 24-hour days but rather six long but finite periods of time? That the Bible makes 10 times more creation claims than all major “holy” books combined with no contradictions, while these other books have errors in them? The Bible stood alone by concurring with the big bang saying, “In the beginning God created the heaven and the earth” (Genesis 1:1); and says our universe is expanding, thousands of years before scientists discovered these things. Watch a potential life-changing video on the website listed below with Astronomer(PhD) Hugh Ross explaining all these facts based on published scientific data. He has authored many books, backed even by atheist scientists.

    Jesus came to pay a debt that we could not; to be our legal justifier to reconcile us back to a Holy God; only if we are willing to receive Him: “For the wages of sin is death…” (Romans 6:23).

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    Jesus came to free us from the bondage of sin. The everlasting fire was prepared for the devil and his angels due to disobedience to God’s law. If we do the same, what makes us any different than the devil? Jesus says unless we repent, we shall perish. For sin is the transgression of the law. We must walk in the Spirit so we may not fulfill the lusts of the flesh, being hatred, fornication, drunkenness and the like. Whoever practices such things will not inherit the kingdom (Galatians 5:16-26). If we sin, we may come before Jesus to ask for forgiveness (1 John 2:1-2). Evil thoughts are not sins, but rather temptations. It is not until these thoughts conceive and give birth by our own desires that they become sin (James 1:12-15). When we sin, we become in the likeness of the devil’s image, for he who sins is of the devil (1 John 3:8); but if we obey Jesus, in the image of God. For without holiness, we shall not see the Lord (Hebrews 12:14).

    The oldest religion in the world is holiness through faith (James 1:27). What religion did Adam and Eve follow before the fall? Jesus, Who became the last Adam, what religion does He follow? Is He not holy? He never told us to follow the rituals and traditions of man but to take up our cross and follow Him (Luke 9:23). There are many false doctrines being taught leading people astray. This is why we need the Holy Spirit for discernment. Unlike religion, holiness cannot be created. It is given to us from above by the baptism of the Spirit. Jesus is more than a religion; He is about having a personal relationship with the Father. Start by reading the Gospel of Matthew, to hear the words of God, to know His character and commandments. Follow and obey Jesus, for He is the way, the truth, and the life!

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