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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