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CASES AND EXAMPLES
Example 23. Go to case. Case provided by. Example 24. Typical Brugada syndrome ST segments in right precordial ECG leads (on spot diagnosis) aka 'type-1 Brugada ECG' with 1st degree AV block and broad P-waves. Go to case. Case provided by W.G. de Voogt, MD, PhD. Example 25. ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY Arrhythmogenic Right Ventricular Cardiomyopathy, (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart.Most commonly the right ventricle apex and outflow tract are involved. However the left ventricle can be affected too. As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease EARLY REPOLARIZATION Early Repolarization is a term used classically for ST segment elevation without underlying disease. It probably has nothing to do with actual early repolarization. It is commonly seen in young men. It is important to discern early repolarization from ST segment elevation from other causes such as ischemia.Characteristics of earlyrepolarization are:
MYOCARDIAL INFARCTIONBRUGADA SYNDROME
PACEMAKER - ECGPEDIA Pacemaker. A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The pacemaker rhythm can easily be recognized on the ECG. It shows pacemaker spikes: vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing. MI DIAGNOSIS IN LBBB OR PACED RHYTHM MI Diagnosis in LBBB or paced rhythm. In case of a left bundle branch block (LBBB), infarct diagnosis based on the ECG is difficult. The baseline ST segments and T waves tend to be shifted in a discordant direction with LBBB, which can mask or mimic acute myocardial infarction. However, serial ECGs may show a moving ST segment duringischemia
PATHOLOGIC Q WAVES
Pathologic Q waves are a sign of previous myocardial infarction. They are the result of absence of electrical activity. A myocardial infarction can be thought of as an elecrical 'hole' as scar tissue is electrically dead and therefore results in pathologic Q waves. Pathologic Q waves are not an early sign of myocardial infarction, butgenerally
ROMHILT-ESTES SCORE
1. Negative terminal P mode in V 1 1 mm in depth and 0.04 sec in duration (indicates left atrial enlargement) 3. Left axis deviation (QRS of -30° or more) 2. QRS duration ≥0.09 sec. 1. Delayed intrinsicoid deflection in V 5 or V 6 (>0.05 sec) 1. ECGPEDIAA CONCISE HISTORY OF THE ECGCASES AND EXAMPLES Welcome to ECGpedia, a free electrocardiography (ECG) tutorial and textbook to which anyone can contribute , designed for medical professionals such as cardiac care nurses and physicians. ECGpedia has received more than 9.300.000 unique visits from 238 countries. Also visit our new Textbook of Cardiology. ECG course.CASES AND EXAMPLES
Example 23. Go to case. Case provided by. Example 24. Typical Brugada syndrome ST segments in right precordial ECG leads (on spot diagnosis) aka 'type-1 Brugada ECG' with 1st degree AV block and broad P-waves. Go to case. Case provided by W.G. de Voogt, MD, PhD. Example 25. ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY Arrhythmogenic Right Ventricular Cardiomyopathy, (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart.Most commonly the right ventricle apex and outflow tract are involved. However the left ventricle can be affected too. As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease EARLY REPOLARIZATION Early Repolarization is a term used classically for ST segment elevation without underlying disease. It probably has nothing to do with actual early repolarization. It is commonly seen in young men. It is important to discern early repolarization from ST segment elevation from other causes such as ischemia.Characteristics of earlyrepolarization are:
MYOCARDIAL INFARCTIONBRUGADA SYNDROME
PACEMAKER - ECGPEDIA Pacemaker. A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The pacemaker rhythm can easily be recognized on the ECG. It shows pacemaker spikes: vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing. MI DIAGNOSIS IN LBBB OR PACED RHYTHM MI Diagnosis in LBBB or paced rhythm. In case of a left bundle branch block (LBBB), infarct diagnosis based on the ECG is difficult. The baseline ST segments and T waves tend to be shifted in a discordant direction with LBBB, which can mask or mimic acute myocardial infarction. However, serial ECGs may show a moving ST segment duringischemia
PATHOLOGIC Q WAVES
Pathologic Q waves are a sign of previous myocardial infarction. They are the result of absence of electrical activity. A myocardial infarction can be thought of as an elecrical 'hole' as scar tissue is electrically dead and therefore results in pathologic Q waves. Pathologic Q waves are not an early sign of myocardial infarction, butgenerally
ROMHILT-ESTES SCORE
1. Negative terminal P mode in V 1 1 mm in depth and 0.04 sec in duration (indicates left atrial enlargement) 3. Left axis deviation (QRS of -30° or more) 2. QRS duration ≥0.09 sec. 1. Delayed intrinsicoid deflection in V 5 or V 6 (>0.05 sec) 1.BASICS - ECGPEDIA
The QRS complex is the average of the depolarization waves of the inner (endocardial) and outer (epicardial) cardiomyocytes. As the endocardial cardiomyocytes depolarize slightly earlier than the outer layers, a typical QRS pattern occurs (figure). The TPEDIATRIC ECGS
Most often 260–300 b/min. Atrial 300–500 b/min. Vent. 1:1 to 4:1 conduction. 200–500 b/min. R-R interval variation. Over several seconds may get faster and slower. After first 10–20 beats, extremely regular. May have variable block (1:1, 2:1, 3:1) givingdifferent
ELECTROLYTE DISORDERS The initial part of the QRS complex is often spared as purkinje fibers are less sensitive to hyperkalemia. These changes can also occur in acidosis (via the same mechanism) and during Class IC anti-arrhythmic intoxication. At concentrations > 7.5 mmol/L atrial and ventricular fibrillation can occur. Consecutive ECGs of a patient withhyperkalemia.
QRS AXIS - ECGPEDIA
A left heart axis is present when the QRS in lead I is positive and negative in II and AVF. (between -30 and -90 degrees) A right heart axis is present when lead I is negative and AVF positive. (between +90 and +180) An extreme heart axis is present when both I and AVF are negative. (axis between +180 and -90 degrees). This is a rare finding.P WAVE MORPHOLOGY
The Normal P wave. The P wave morphology can reveal right or left atrial hypertrophy or atrial arrhythmias and is best determined in leads II and V1 during sinus rhythm. Characteristics of a normal p wave: The maximal height of the P wave is 2.5 mm in leads II and / or III. The p wave is positive in II and AVF, and biphasic in V1. MYOCARDIAL INFARCTION A myocardial infarction is defined as: The ECG shows ST elevation or depression. So detection of elevated serum cardiac enzymes is more important than ECG changes. However, the cardiac enzymes can only be detected in the serum 5-7 hours after the onset of the myocardial infarction.RBBB - ECGPEDIA
Incomplete RBBB is defined by QRS duration between 110 and 120 ms in adults, between 90 and 100 ms in children between 4 and 16 years of age, and between 86 and 90 ms in children less than 8 years of age. Other criteria are the same as for complete RBBB. In children, incomplete RBBB may be diagnosed when the terminal rightwarddeflection is
REPOLARIZATION (ST-T,U) ABNORMALITIES Repolarization can be influenced by many factors, including electrolyte shifts, ischemia, structural heart disease (cardiomyopathy) and (recent) arrhythmias. Although T/U wave abnormalities are rarely specific for one disease, it can be useful to know which conditions can change repolarization. Early repolarization is a normal variant of the STAVNRT - ECGPEDIA
AV Nodal Re-entry Tachycardia (AVNRT) or Atrial-Ventricular Nodal Re-entry Tachycardia is a supra-ventricular arrhythmia, and more precisely, a nodal arrhythmia. AVNRT is the most frequently occurring form of regular tachycardia. More females than males have signs of AVNRT. The ratio is approximately 3:1. Symptoms are bouts of fastheart rates
APPROACH TO THE WIDE COMPLEX TACHYCARDIA Approach to the Wide Complex Tachycardia. During wide complex tachycardia (heart rate > 100/min, QRS > 0.12 sec) the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation (below). ECGPEDIAA CONCISE HISTORY OF THE ECGCASES AND EXAMPLES Welcome to ECGpedia, a free electrocardiography (ECG) tutorial and textbook to which anyone can contribute , designed for medical professionals such as cardiac care nurses and physicians. ECGpedia has received more than 9.300.000 unique visits from 238 countries. Also visit our new Textbook of Cardiology. ECG course. BASICS - ECGPEDIAI.A.C. VAN DER BILT, MDI.A.C. VAN DER BILT, MD The QRS complex is the average of the depolarization waves of the inner (endocardial) and outer (epicardial) cardiomyocytes. As the endocardial cardiomyocytes depolarize slightly earlier than the outer layers, a typical QRS pattern occurs (figure). The T wave represents the repolarization of the ventricles.CASES AND EXAMPLES
Example 23. Go to case. Case provided by. Example 24. Typical Brugada syndrome ST segments in right precordial ECG leads (on spot diagnosis) aka 'type-1 Brugada ECG' with 1st degree AV block and broad P-waves. Go to case. Case provided by W.G. de Voogt, MD, PhD. Example 25. ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY Arrhythmogenic Right Ventricular Cardiomyopathy, (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart.Most commonly the right ventricle apex and outflow tract are involved. However the left ventricle can be affected too. As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this diseaseRBBB - ECGPEDIA
Incomplete RBBB is defined by QRS duration between 110 and 120 ms in adults, between 90 and 100 ms in children between 4 and 16 years of age, and between 86 and 90 ms in children less than 8 years of age. Other criteria are the same as for complete RBBB. In children, incomplete RBBB may be diagnosed when the terminal rightwarddeflection is
MI DIAGNOSIS IN LBBB OR PACED RHYTHM MI Diagnosis in LBBB or paced rhythm. In case of a left bundle branch block (LBBB), infarct diagnosis based on the ECG is difficult. The baseline ST segments and T waves tend to be shifted in a discordant direction with LBBB, which can mask or mimic acute myocardial infarction. However, serial ECGs may show a moving ST segment duringischemia
AVNRT - ECGPEDIA
AV Nodal Re-entry Tachycardia (AVNRT) or Atrial-Ventricular Nodal Re-entry Tachycardia is a supra-ventricular arrhythmia, and more precisely, a nodal arrhythmia. AVNRT is the most frequently occurring form of regular tachycardia. More females than males have signs of AVNRT. The ratio is approximately 3:1. Symptoms are bouts of fastheart rates
PACEMAKER - ECGPEDIA Pacemaker. A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The pacemaker rhythm can easily be recognized on the ECG. It shows pacemaker spikes: vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing. EARLY REPOLARIZATION Early Repolarization is a term used classically for ST segment elevation without underlying disease. It probably has nothing to do with actual early repolarization. It is commonly seen in young men. It is important to discern early repolarization from ST segment elevation from other causes such as ischemia.Characteristics of earlyrepolarization are:
BRUGADA SYNDROME
ECGPEDIAA CONCISE HISTORY OF THE ECGCASES AND EXAMPLES Welcome to ECGpedia, a free electrocardiography (ECG) tutorial and textbook to which anyone can contribute , designed for medical professionals such as cardiac care nurses and physicians. ECGpedia has received more than 9.300.000 unique visits from 238 countries. Also visit our new Textbook of Cardiology. ECG course. BASICS - ECGPEDIAI.A.C. VAN DER BILT, MDI.A.C. VAN DER BILT, MD The QRS complex is the average of the depolarization waves of the inner (endocardial) and outer (epicardial) cardiomyocytes. As the endocardial cardiomyocytes depolarize slightly earlier than the outer layers, a typical QRS pattern occurs (figure). The T wave represents the repolarization of the ventricles.CASES AND EXAMPLES
Example 23. Go to case. Case provided by. Example 24. Typical Brugada syndrome ST segments in right precordial ECG leads (on spot diagnosis) aka 'type-1 Brugada ECG' with 1st degree AV block and broad P-waves. Go to case. Case provided by W.G. de Voogt, MD, PhD. Example 25. ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY Arrhythmogenic Right Ventricular Cardiomyopathy, (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart.Most commonly the right ventricle apex and outflow tract are involved. However the left ventricle can be affected too. As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this diseaseRBBB - ECGPEDIA
Incomplete RBBB is defined by QRS duration between 110 and 120 ms in adults, between 90 and 100 ms in children between 4 and 16 years of age, and between 86 and 90 ms in children less than 8 years of age. Other criteria are the same as for complete RBBB. In children, incomplete RBBB may be diagnosed when the terminal rightwarddeflection is
MI DIAGNOSIS IN LBBB OR PACED RHYTHM MI Diagnosis in LBBB or paced rhythm. In case of a left bundle branch block (LBBB), infarct diagnosis based on the ECG is difficult. The baseline ST segments and T waves tend to be shifted in a discordant direction with LBBB, which can mask or mimic acute myocardial infarction. However, serial ECGs may show a moving ST segment duringischemia
AVNRT - ECGPEDIA
AV Nodal Re-entry Tachycardia (AVNRT) or Atrial-Ventricular Nodal Re-entry Tachycardia is a supra-ventricular arrhythmia, and more precisely, a nodal arrhythmia. AVNRT is the most frequently occurring form of regular tachycardia. More females than males have signs of AVNRT. The ratio is approximately 3:1. Symptoms are bouts of fastheart rates
PACEMAKER - ECGPEDIA Pacemaker. A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The pacemaker rhythm can easily be recognized on the ECG. It shows pacemaker spikes: vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing. EARLY REPOLARIZATION Early Repolarization is a term used classically for ST segment elevation without underlying disease. It probably has nothing to do with actual early repolarization. It is commonly seen in young men. It is important to discern early repolarization from ST segment elevation from other causes such as ischemia.Characteristics of earlyrepolarization are:
BRUGADA SYNDROME
ST MORPHOLOGY
Early repolarization is a term used for ST segment elevation without underlying disease. It probably has nothing to do with actual early repolarization. It is commonly seen in young men. It is important to discern early repolarization from ST segment elevation from other causes such as ischemia.Characteristics of early repolarization are: an upward concave elevation of the RS-T segment with ELECTROLYTE DISORDERS The initial part of the QRS complex is often spared as purkinje fibers are less sensitive to hyperkalemia. These changes can also occur in acidosis (via the same mechanism) and during Class IC anti-arrhythmic intoxication. At concentrations > 7.5 mmol/L atrial and ventricular fibrillation can occur. Consecutive ECGs of a patient withhyperkalemia.
QRS AXIS - ECGPEDIA
A left heart axis is present when the QRS in lead I is positive and negative in II and AVF. (between -30 and -90 degrees) A right heart axis is present when lead I is negative and AVF positive. (between +90 and +180) An extreme heart axis is present when both I and AVF are negative. (axis between +180 and -90 degrees). This is a rare finding.ATRIAL TACHYCARDIA
Atrial tachycardia has a more or less regular heart rate > 100 bpm, with narrow QRS complexes but P-waves that do not originate from the sinus node but from another site in the atria. The P-waves therefore have a different configuration and their non-sinus origin can easily be recognized if the P waves are negative in I and/or aVF.AVNRT - ECGPEDIA
AV Nodal Re-entry Tachycardia (AVNRT) or Atrial-Ventricular Nodal Re-entry Tachycardia is a supra-ventricular arrhythmia, and more precisely, a nodal arrhythmia. AVNRT is the most frequently occurring form of regular tachycardia. More females than males have signs of AVNRT. The ratio is approximately 3:1. Symptoms are bouts of fastheart rates
P WAVE MORPHOLOGY
The Normal P wave. The P wave morphology can reveal right or left atrial hypertrophy or atrial arrhythmias and is best determined in leads II and V1 during sinus rhythm. Characteristics of a normal p wave: The maximal height of the P wave is 2.5 mm in leads II and / or III. The p wave is positive in II and AVF, and biphasic in V1. MYOCARDIAL INFARCTION A myocardial infarction is defined as: The ECG shows ST elevation or depression. So detection of elevated serum cardiac enzymes is more important than ECG changes. However, the cardiac enzymes can only be detected in the serum 5-7 hours after the onset of the myocardial infarction. MI DIAGNOSIS IN RBBB As shown in the examples below, myocardial infarction diagnosis in right bundle branch block is not very different from normal MI diagnosis. As repolarisation in leads V1-V3 is often abnormal in RBBB, these leads cannot always be used for the diagnosis of ischemia. LOCALISATION OF THE ORIGIN OF A VENTRICULAR TACHYCARDIA Posterior / lateral is located on the part between anterior and inferior. Adapted from Miller et al. The localisation of the origin (or exit site) of a ventricular tachycardia can be helpful in understanding the cause of the VT and is very helpful when planning an ablation procedure to treat a ventricular tachycardia. ECGPEDIATRANSLATE THIS PAGE Welkom bij ECGpedia, een gratis ecg-cursus en tekstboek waaraan iedereen kan bijdragen, speciaal voor artsen, verpleegkundigen en studenten. ECGpedia kreeg al meer dan 1.250.000 bezoeken uit 222 landen. Ecg-cursus. Ecg-tekstboek. Oefen-ecg's. ECGPEDIAA CONCISE HISTORY OF THE ECGCASES AND EXAMPLES ECGpedia has received more than 9.300.000 unique visits from 238countries.
ST MORPHOLOGY
Early repolarization is a term used for ST segment elevation without underlying disease. It probably has nothing to do with actual early repolarization. It is commonly seen in young men. It is important to discern early repolarization from ST segment elevation from other causes such as ischemia.Characteristics of early repolarization are: an upward concave elevation of the RS-TQRS AXIS - ECGPEDIA
Click and drag the arrow in the above animation to change the heart axis and see how the ECG changes. The electrical heart axis is an average of all depolarizations in the heart.PEDIATRIC ECGS
8 to 16 years 0° to 120° >120° Right-axis deviation 5 to 8 years 0° to 140° >140° 120° Right-axis deviation 5 to 8 years 0° to140° >140°
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