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Practice ECGs
Part I
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Obectives
!evelop a syste"atic approach #or in#arctrecognition on the ECG.
Gain #a"iliarity $ith %2&'ead ECG
interpretation.
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(evie$ing a %2&'ead ECG
Assess the )*ality o# the tracing.
Identi#y the rate and *nderlying rhyth".
E+a"ine #or evidence o# in#arction.
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(evie$ing a %2&'ead ECG
Ascertain i# in#arct i"postors are present that
"ay acco*nt #or ECG changes.
Clinical presentation. Interpret yo*r #indings.
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In#arct I"postors
'e#t b*ndle branch bloc,
-entric*lar rhyth"s
'e#t ventric*lar hypertrophy
Pericarditis
Early repolariation
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/ig*re &%
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/ig*re &%
Poor R wave progression
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/ig*re &%
Leads: Inversion III,aVF; tall V
3 – V
5
T wave changes?
Leads: II, III, aVFT!seg"entdepression?
Leads: I, aVL, V# – V
$T!seg"entelevation?
Leads: V5
Poor R waveprogression?
Leads: III?, V%, V
3Pathologic &
waves?
in's rh(th" at )3 *p"+nderl(ingrh(th"?
Interpretation:-tensive anteriorin.arction, reciprocalchanges
Low voltage over
entire tracing
/aseline wander V#/aseline wanderor arti.act?
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Practice &2
12&year&old Ca*casian $o"an
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Practice &2
12&year&old Ca*casian $o"an
Arti#act
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Practice &2
in*s rhyth"at 34 bp"
5nderlyingrhyth"
Interpretation7
8or"al ECG
P( interval %60 "s
9( :0 "s
9;
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/ig*re &1
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/ig*re &1
/aseline wander /aseline wander
/aseline wander
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/ig*re &1
Leads: V%, V
3;
slight in V#
T!seg"entelevation?
Leads: III, aVFPathologic &waves?
in's rh(th" at03 *p"
+nderl(ingrh(th"?
Interpretation:
1nteroseptal in.arction,previo's in.erior wallin.arction; low voltage inlead II
/aseline wander
in II, III, aVL
/aseline
wander orarti.act?
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/ig*re &=
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/ig*re &=
Interpretation:
in's *rad(cardia withoccasional PV2s,otherwise nor"al 2
PR interval #4% "s
&R 04 "s
&T&Tc 43$4#6 "s
P!R!T a-es $7 #4 54
in's *rad(cardia at55 *p" withoccasional PV2s
+nderl(ingrh(th"?
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/ig*re &4
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/ig*re &4
/aseline wander /aseline wander
/aseline wander
/aseline wander
Poor R wave progression
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/ig*re &4
Leads: Pea8ed T waveV
%, tallpea8ed V
3, V
4
T wave changes?
Leads: II, III, aVFT!seg"entdepression?
Leads: I, aVL, V# – V
5T!seg"entelevation?
Leads: V%
Poor R waveprogression?
Leads: aVLPathologic &
waves?
1trial .i* at #77 *p"+nderl(ing rh(th"?
Interpretation:
1nteroseptalin.arction with laterale-tension; reciprocalchanges noted
/aseline wander in I, II,V
#, V
$
/aseline wander orarti.act?
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/ig*re &6
63&year&old Ca*casian $o"an
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/ig*re &6
63&year&old Ca*casian $o"an
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/ig*re &6
Leads: V4 – V
$T!seg"entdepression?
Leads: V#
– V3
T!seg"entelevation?
Interpretation:
Le.t *'ndle *ranch *loc8
PR interval #37 "s
&R #44 "s
&T&Tc 47$453 "s
P!R!T a-es #3 !#$ 5)
in's rh(th" at65 *p"
+nderl(ingrh(th"?
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/ig*re &3
3%&year&old Ca*casian $o"an
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/ig*re &3
3%&year&old Ca*casian $o"an
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/ig*re &3
Leads: I, aVLT wavechanges?
Leads: I, aVLT!seg"entdepression?
Leads: II, III, aVFT!seg"entelevation?
Interpretation:In.erior in.arction – age'ndeter"ined, T 9 T wavea*nor"alit( – consider lateralische"ia
PR interval #$) "s&R )) "s
&T&Tc 4%447% "s
P!R!T a-es 6 7 #7#
in's *rad(cardiaat 5$ *p"+nderl(ingrh(th"?
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/ig*re &:
=2&year&old Ca*casian $o"an
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/ig*re &:
Leads: Inversionin V
#
T wavechanges?
Leads: IIIT!seg"entdepression?
Interpretation:
or"al 2
PR interval #$4 "s
&R $$ "s&T&Tc 30%4#4 "s
P!R!T a-es )# )4$#
in's arrh(th"iaat $6 *p"
+nderl(ingrh(th"?
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/ig*re &
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/ig*re &
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/ig*re &
Leads: Tall in V%!V
4;
pea8ed in II, aVF, V%!V
$;
inverted in aVL
T wave changes?
Leads: V5, V$T!seg"entdepression?
Leads: V#, V
%, V
3T!seg"entelevation?
Leads: V5, V
$; & wave
approaching 47 "s in V4
Pathologic &
waves?
in's rh(th" at 66 *p"+nderl(ingrh(th"?
Interpretation:1nteroseptal in.arction,possi*le previo's lateralin.arction earingvoltage criteria .or LV
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/ig*re &%0
4:&year&old Ca*casian "an
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/ig*re &%0
4:&year&old Ca*casian "an
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/ig*re &%0
Interpretation:
-tensive anteriorin.arction
PR interval #)4 "s
&R 0% "s
&T&Tc 4#$470 "s
P!R!T a-es 30 #$ #$Leads: II, III,
aVF
Leads: I, aVL,V
% – V
$
in's*rad(cardia at5) *p"
T!seg"ent
depression?
T!seg"entelevation?
+nderl(ingrh(th"?
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/ig*re &%%
=2&year&old Ca*casian "an
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/ig*re &%%
Interpretation:
in's *rad(cardia,otherwise nor"al 2
PR interval #%$ "s
&R #77 "s
&T&Tc 43%4#$ "s
P!R!T a-es 5# %4 %0
in's*rad(cardia at5$ *p"
+nderl(ingrh(th"?
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/ig*re &%2
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/ig*re &%2
Interpretation:
1nteroseptalin.arction, reciprocalchanges present
Leads: Tallpea8edV
% – V
4; inverted in III
Leads: II, III, aVF
Leads: I, aVL, V# –V
5
in's tach(cardia at#76 *p"
T wavechanges?
T!seg"entdepression?
T!seg"entelevation?
+nderl(ingrh(th"?
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/ig*re &%1
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/ig*re &%1
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/ig*re &%1
Interpretation:
In.erior in.arction; low&R voltage >75 "V@in li"* leads
PR interval #44 "s&R #7) "s
&T&Tc 36$30) "s
P!R!T a-es 43 44 3)Leads: V
# – V
4
Leads: II, III,aVF
in's rh(th"at 6# *p"
T!seg"entdepression?
T!seg"entelevation?
+nderl(ingrh(th"?
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/ig*re &%=
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/ig*re &%=
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/ig*re &%=
Interpretation:In.erior in.arction;"ar8ed T depressionconsistent withs'*endocardial inA'r(
PR interval 7 "s
&R #74 "s
&T&Tc 44)43$ "s
P!R!T a-es 000 5) )4
Leads: Inverted inaVL, V
#
Leads: I, aVL, V# – V
4
Leads: II, III, aVF
B'nctional rh(th" at55 *p"
T wavechanges?
T!seg"entdepression?
T!seg"ent
elevation?
+nderl(ingrh(th"?
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/ig*re &%4
3%&year&old Ca*casian $o"an
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/ig*re &%4
3%&year&old Ca*casian $o"an
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/ig*re &%4
Interpretation:Right *'ndle *ranch*loc8, in.erior in.arction –age 'ndeter"ined
PR interval #$) "s
&R #37 "s
&T&Tc 3))437 "s
P!R!T a-es $7 !%# 4$
Leads: InvertedV
#, V
%
Leads: III, aVF
in's rh(th" at64 *p"
1rti.act V#,*aseline wanderV
%
T wavechanges?
Pathologic &waves?
+nderl(ingrh(th"?
/aselinewander orarti.act?
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/ig*re &%6
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/ig*re &%6
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/ig*re &%3
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/ig*re &%3
T wavechanges?
T!seg"ent
depression?
T!seg"entelevation?
Interpretation:
In.erior in.arction
PR interval ##$ "s
&R 6$ "s
&T&Tc %%)37$ "sP!R!T a-es 50 % 66
Leads: Invertedin aVL, V
#
Leads: I, aVL
Leads: II, III, aVF
in's tach(cardia
with short PRinterval, short &Tinterval
+nderl(ing
rh(th"?
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/ig*re &%:
Interpretation:in's *rad(cardia,otherwise nor"al 2
PR interval #%% "s&R )$ "s
&T&Tc 4#$47) "s
P!R!T a-es 4# 54 %%
in's*rad(cardia at5) *p"
+nderl(ingrh(th"?
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/ig*re &%
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/ig*re &%
Interpretation:
In.erior in.arction
PR interval #)4 "s
&R 0% "s
&T&Tc 35%3)0 "s
P!R!T a-es $7 %3 #7$
Leads: Inverted in I,
aVL
Leads: I, aVL, V5, V$
Leads: II, III, aVF
Leads: III
in's rh(th"
at )# *p"
T wave
changes?
T!seg"ent
depression?
T!seg"ent
elevation?
Pathologic &
waves?
+nderl(ing
rh(th"?
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/ig*re &20
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/ig*re &20
Poor R wave progression
/i 20
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/ig*re &20
Leads: Flattened Twave aVL
T wavechanges?
Leads: IIT!seg"entdepression?
Leads: V# – V
4T!seg"entelevation?
Leads: V3;
no initial R
wave in V#
Poor R waveprogression?
Leads: II?, III, aVFPathologic &
waves?
in's rh(th" at 0# *p"+nderl(ingrh(th"?
Interpretation:
1nteroseptalin.arction,possi*le previo'sin.erior in.arction
/aseline wander and
arti.act in lead I, arti.actin II, III, aVL
/aseline wander
or arti.act?
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/ig*re &2%
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/ig*re &2%
/i 2%
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/ig*re &2%
Interpretation:
eptal in.arction,possi*le anteriorepicardial inA'r(
PR interval #$4 "s
&R 0$ "s
&T&Tc 3)7433 "s
P!R!T a-es $% !$%)3
Leads: Inverted inaVL
Leads: II, III, V5, V
$
Leads: V# – V
3
in's rh(th"at 05 *p"
/aseline wander
V5, V$
T wavechanges?
T!seg"ent
depression?
T!seg"entelevation?
+nderl(ingrh(th"?
/aseline
wander orarti.act?
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/ig*re &22
::&year&old Ca*casian "an
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/ig*re &22
::&year&old Ca*casian "an
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/ig*re &22
Interpretation:In.erolateral ische"ia
ote: This is the sa"e
patient as in .ig're 0!%$ –
%0 "in'tes a.ter the 2 in
.ig're 0!%$ was o*tained
PR interval #)% "s
&R )% "s
&T&Tc 4#74%$ "s
P!R!T a-es 6$ 5% !60
Leads: II, III,
aVF, V5 – V
$
Leads: II, III,
aVF, V4 – V$
in's rh(th" at$5 *p"
T wave
changes?
T!seg"ent
depression?
+nderl(ingrh(th"?
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/ig*re &21
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/ig*re &21
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/ig*re &21
Interpretation:Low voltagethro'gho'ttracing In.eriorin.arction, lateral
e-tension
Leads: Pea8ed in II, III,aVF, V
3, V
4
Leads: V#
Leads: II, III, aVF, V4 – V
$
Leads: V%!V4
in's rh(th" at )) *p"
/aseline wander lead I
T wavechanges?
T!seg"ent
depression?
T!seg"entelevation?
Pathologic &waves?
+nderl(ingrh(th"?
/aseline wanderor arti.act?
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Practice &2=
6=&year&old Ca*casian $o"an Arti#act
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Practice &2=
Interpretation:or"al 2
PR interval #54 "s
&R )7 "s
&T&Tc 304440 "s
P!R!T a-es 66 6) 55
in's rh(th" at6) *p"
1rti.act in V#
+nderl(ingrh(th"?
/aselinewander orarti.act?
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/ig*re &24
Arti#act
Arti#act
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/ig*re &24
Interpretation:RR >&R@ in V#V%consistent with rightventric'lar cond'ctiondela(
PR interval #6% "s
&R #74 "s
&T&Tc 4774%7 "s
P!R!T a-es 64 $0 44
in's rh(th" at$0 *p" withoccasional PV2s
+nderl(ingrh(th"?
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/ig*re &26
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/ig*re &26
/aseline wander
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/ig*re &26
Interpretation:Lateral ische"ia
Leads: V5, V$
/aseline wanderV%
T wavechanges?
T!seg"entdepression?
+nderl(ingrh(th"?
/aselinewander orarti.act?
in's rh(th" at$6 *p" with
occasionalPV2s
PR interval #07 "s
&R )% "s
&T&Tc 47)43#"s
P!R!T a-es 6$ 53###
Leads: II,aVF, V3!V$
2
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/ig*re &23
/i 23
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/ig*re &23
/i 23
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/ig*re &23
Interpretation:In.erior in.arction
PR interval #)7 "s
&R 0$ "s&T&Tc 3)743$ "s
P!R!T a-es 63 35 )4
Leads: aVL
Leads: aVL
Leads: II, III, aVF
Leads: III
in's rh(th" at#77 *p"
T wavechanges?
T!seg"entdepression?
T!seg"entelevation?
Pathologic &waves?
+nderl(ingrh(th"?
/i 2:
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/ig*re &2:
::&year&old Ca*casian $o"an
/i 2:
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/ig*re &2:
::&year&old Ca*casian $o"an
/i 2:
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/ig*re &2:
Interpretation:eptal in.arction,possi*le anteriorepicardial inA'r(
/aseline wanderV5, V$
T wavechanges?
T!seg"entelevation?
+nderl(ingrh(th"?
/aselinewander orarti.act?
in's rh(th" at05 *p"
PR interval #$4 "s
&R 0$ "s
&T&Tc 3)7433"s
P!R!T a-es $% !$%)3
Leads: II, III, V5,
V$
Leads: V#! V3
T!seg"entdepression?
Leads: Invertedin aVL
/i 2
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/ig*re &2
/i 2
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/ig*re &2
Interpretation:lectronic atrial pace"a8er
PR interval $%$ "s
&R 0% "s&T&Tc 35)4#% "s
P!R!T a-es 7 5% #$
lectronic atrialpace"a8er at )7*p"
+nderl(ingrh(th"?
/i 10
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/ig*re &10
1&year&old Ca*casian "an
/i 10
-
8/16/2019 Practice Ekg Part i
88/103
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/ig*re &10
Interpretation:in's tach(cardia withnoncond'cted>*loc8ed@ pre"at'reatrial co"ple-es,
otherwise nor"al 2
PR interval #5$ "s
&R )) "s
&T&Tc 3%$473 "sP!R!T a-es 54 %$ 54
in's tach(cardiawith noncond'cted>*loc8ed@ pre"at'reatrial co"ple-es at 0%*p"
+nderl(ingrh(th"?
/i 1%
-
8/16/2019 Practice Ekg Part i
89/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &1%
/i 1%
-
8/16/2019 Practice Ekg Part i
90/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &1%
/ig*re &1%
-
8/16/2019 Practice Ekg Part i
91/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re 1%Interpretation:1nterolateral in.arction;"eets "ini"al voltagecriteria .or LV
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8/16/2019 Practice Ekg Part i
92/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &12
66&year&old Ca*casian $o"an
/ig*re 12
-
8/16/2019 Practice Ekg Part i
93/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &12
66&year&old Ca*casian $o"an
/ig*re 12
-
8/16/2019 Practice Ekg Part i
94/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &12
PR interval #3$ "s
&R 0$ "s
&T&Tc 3))453 "s
P!R!T a-es $% #% %6
Inco"plete right*'ndle *ranch *loc8
Interpretation:
Leads: II, III,aVF, V
5, V
$
Leads: V#
in's rh(th" at)% *p"
T!seg"entdepression?
T!seg"ent
elevation?
+nderl(ingrh(th"?
/ig*re 11
-
8/16/2019 Practice Ekg Part i
95/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &11
/ig*re 11
-
8/16/2019 Practice Ekg Part i
96/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &11
/ig*re &11
-
8/16/2019 Practice Ekg Part i
97/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re 11Interpretation:In.erior in.arction,
reciprocal changespresent
PR interval %$7 "s
&R #74 "s
&T&Tc 44445) "s
P!R!T a-es 07 !65#75
Leads: Tall in II, III, aVF;depressed in I, aVL,V
# – V
3
Leads: I, aVL, V# – V$
Leads: II, III, aVF
Leads: II, III, aVF
in's rh(th" with .irst!degree 1V *loc8 at $$*p" with occasionals'praventric'larpre"at're co"ple-es
/aseline wander II, III,aVL, aVF
T wavechanges?
T!seg"entdepression?
T!seg"entelevation?
Pathologic &waves?
+nderl(ingrh(th"?
/aselinewander or
arti.act?
/ig*re 1=
-
8/16/2019 Practice Ekg Part i
98/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &1=
:6&year&old Ca*casian $o"an
/ig*re 1=
-
8/16/2019 Practice Ekg Part i
99/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &1=
Baseline wander
Baseline wander
Baseline wander
:6&year&old Ca*casian $o"an
/ig*re &1=
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8/16/2019 Practice Ekg Part i
100/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re 1=Interpretation:
1trial .i*rillation withrapid ventric'lar response
PR interval one
&R 07 "s
&T&Tc 374475 "s
P!R!T a-es one $0 #6
Leads: Tall in V%
Leads: V$
1trial .i*rillation
at #76 *p"
/aseline wander
V4 – V$
T wavechanges?
T!seg"entdepression?
+nderl(ing
rh(th"?
/aseline
wander orarti.act?
/ig*re 14
-
8/16/2019 Practice Ekg Part i
101/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &14
6&year&old Ca*casian $o"an
/ig*re 14
-
8/16/2019 Practice Ekg Part i
102/103
Copyright © 2006 by Mosby Inc. All rights reserved.
/ig*re &14
6&year&old Ca*casian $o"an
/ig*re 14
-
8/16/2019 Practice Ekg Part i
103/103
/ig*re &14
PR interval #3$ "s
&R #44 "s
&T&Tc 43)4)% "s
P!R!T a-es %) !5 %3)
Interpretation:Le.t *'ndle *ranch *loc8
Leads: I, II, aVL,aVF, V
5 – V
$
Leads: V# – V
%
in's rh(th" at63 *p"
T!seg"entdepression?
T!seg"ent
elevation?
+nderl(ingrh(th"?