Heart EKG

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Table of contents
Normal EKG with horizontal axis
Normal EKG with vertical axis
Anterolateral myocardial infarction
Inferior myocardial infarction
Right bundle branch block
Left bundle branch block
Left anterior fascicular block <
Left ventricular hypertrophy; diastolic overload
Left ventricular hypertrophy; systolic overload
Cor pulomnale
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Normal EKG

Normal EKG with horizontal axis


Upright P and T waves in lead I
PR > 0.20 sec
Duration of q > 0.02 sec in leads I and aVL
Frontal plane QRS vector 0-90 degrees.
Precordial progression from r in V1 to R in V5 and V6.
Concordance of T with QRS.
QTc > 0.44 sec

Anterolateral myocardial infarction
ST segment elevation in leads V2-V5 in an acute infarction
Absent R wave in V2-V5 (QS wave)
T wave inversion in leads V2-V5 in an old or evolving infarction
Q waves in leads I, aVL and V6 along with ST segment elevation in these leads is consistent with presence of additional infarction in the high anterior lateral wall

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Inferior myocardial infarction
ST segment elevation in leads II, III, and aVF in an acute infarction
Q waves longer than 0.04 sec in duration in leads II, III, and aVF
T wave inversionin leads II, III, and aVF in an old or evolving infarction
Common presence of a lateral wall component in inferior wall myocardial infarction (T wave changes in leads V4-V6)

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Right bundle branch block
QRS
Duration
Complete RBBB is > 0.13 sec.
Incomplete RBBB is between 0.09 and 0.12 sec
Morphology
Precordial leads
V1 = rsR' with CRBBB or V1 = rSr' with IRBBB
V6 = qRs with CRBBB or IRBBB
Limb leads
Axis can be right, left, or normal
Terminal 0.08 vector should be ignored when calculating axis
Lead I = qRs.
Orthogonal leads
Lead X = qRS (with IRBBB = qrS)
Lead Z = qRS (with CRBBB = qRs)
T wave always in the opposite direction from terminal S wave
Conduction abnormalities
Using the usual criteria, both LAFB and LPFB can occur with RBBB
Using the ususal criteria, LVH, ASMI, AMI, ACMI, and IMI can be diagnosed with RBBB.

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Left bundle branch block
QRS > 0.12 sec with mid-slurring
Variable frontal plane QRS vector variable
V1 rS along with upright T wave
Predominantly upright V5 and V6 along with inverted T wave
Predominantly upright lead I along with inverted T wave

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Left anterior fascicular block
QRS duration < 0.10 sec
QRS vector shows left axis deviation (LAD) in frontal plane > -30 degrees.
QRS morphology
Limb leads
qR in leads I and aVL.
rS in leads II, III, and aVF
R peaks in aVL before aVR
Precordial leads
Delayed R wave transition
Persistent S wave in V5-V6
Normal QRS morphology when precordial leads recorded in 2-3 interspaces higher
Orthogonal leads
qR in lead X
rS in lead Y

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LVH diastolic overload
P-wave abnormality of left atrial enlargement (LAE)
Tall, peaked T-waves in leads I, aVL, V5, and V6
Increased QRS duration
Instrinsicoid deflection > .09 sec.
Deep Q-waves in leads I, aVL, V5, and V6
Voltage Criteria
Limb leads
Lead I: R >15 mm or R >18 mm with left axis deviation (LAD)
Lead aVL: R >12 mm or R >16 mm with LAD
Lead II or III: R > 25 mm
Precordial leads
V5 > 26 mm
Sum of S wave in V2 and R wave in V5 > 36 mm
V6 > V5
Orthogonal leads
Transverse plane mean QRS vector > 20
Frontal plane mean QRS vector > 25

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Left ventricular hypertrophy; systolic overload

Abnormality of P wave due to left atrial enlargement
Increased QRS duration
Intrinsicoid deflection > 0.09 sec
Incomplete Left bundle branch block (ILBBB)
Loss of R wave in V1 and V2
Voltage criteria
Limb leads
Lead I: R > 15 mm or R > 18 mm with left axis deviation (LAD)
Lead aVL: R > 12 mm or R > 16 mm with LAD
Lead II or III: R > 25 mm
Precordial leads
V5 > 26 mm
Sum of S wave in V2 and R wave in V5 > 36 mm
V6 > V5
Orthogonal leads
Transverse plane mean QRS vector > 20 mm
Frontal plane mean QRS vector > 25 mm
Secondary ST-T changes

Cor pulmonale
P wave
Limb leads
Vertical axis
P > 3 mm in lead II or III
Precordial leads
Negative P in lead V1
QRS morphology
Limb leads
Right axis deviation
S > R in lead I
Precordial leads
R in V5 - V6
R in V2
Lead V1 rs, Rs, or rS
Orthogonal leads
R in lead X
Tall R wave in lead II
Variable T wave

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