ECGPEDIAA CONCISE HISTORY OF THE ECGCASES AND EXAMPLES ECGpedia has received more than 9.300.000 unique visits from 238

countries.

CASES AND EXAMPLES

Wide QRS Complexes in the Setting of Acute Myocardial Infarction: Good News or Bad? A 57-year-old man collapsed after one hour of angina

symptoms in the

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° to 140° >140° 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 fast

heart rates

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. 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

LATE POTENTIALS

Late potentials. Late potentials are thought to be caused by early afterdepolarizations of cells in the right ventricle (in ARVD ). Their amplitude is often too small to show up on a normal ECG. However, when multiple QRS recordings (typically 250 consecutive QRS complexes) are averaged, random noise is filtered out and late potentials can show

up.

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, but

generally

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 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.

PEDIATRIC 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) giving

different

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 fast

heart rates

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. 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

LATE POTENTIALS

Late potentials. Late potentials are thought to be caused by early afterdepolarizations of cells in the right ventricle (in ARVD ). Their amplitude is often too small to show up on a normal ECG. However, when multiple QRS recordings (typically 250 consecutive QRS complexes) are averaged, random noise is filtered out and late potentials can show

up.

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, but

generally

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.

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.

RATE - ECGPEDIA

The ECG has a grid with thick lines 5 mm apart (= 0,20 second) and thin lines 1 mm (0,04 second). There are three simple methods to determine the heart rate (HR) The square counting method. The square counting method is ideal for regular heart rates. Use the sequence 300-150-100-75-60-50-43-37. Count from the first QRS complex, the

first thick

MECHANISMS OF ARRHYTHMIAS Re-entry is a common cause of arrhythmias. Ventricular tachycardia and AV-nodal re-entry are typical examples. Re-entry can occur when a conduction path is partly slowed down. As a result of this, the signal is conducted by both a fast and a slow pathway. During normal sinus rhythm this generally does not cause problems, but when an VENTRICULAR FIBRILLATION Ventricular fibrillation (VF or V-fib) is chaotic depolarisation of the ventricles. Mechanically this results in an arrested cardiac pump function and immediate death. VF can only be treated by immediate defibrillation. If you consider ventricular fibrillation in a conscious patient, than you should look for a technical problem with

the ECG, eg

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.

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 fast

heart rates

LONG QT SYNDROME

The Long QT Syndrome (LQTS) is characterized on the ECG by prolongation of the heart rate corrected QT interval.This was first recognized by Dr. Jervell and Dr. Lange-Nielsen in 1957. They described 4 children with a long QT interval which was accompanied by hearing deficits, sudden cardiac death and an autosomal recessive inheritance. The Long QT syndrome may be divided into two ACCURACY OF COMPUTER INTERPRETATION Accuracy of Computer Interpretation. Modern ECG equipment often includes some form of algorithm that performs a computer interpretation of the electrocardiogram. It is useful to have some insight into the reliability and pitfalls of computer interpretation so as to be able to assess the value of these interpretations. 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 early

repolarization are:

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 during

ischemia

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.

RATE - ECGPEDIA

The ECG has a grid with thick lines 5 mm apart (= 0,20 second) and thin lines 1 mm (0,04 second). There are three simple methods to determine the heart rate (HR) The square counting method. The square counting method is ideal for regular heart rates. Use the sequence 300-150-100-75-60-50-43-37. Count from the first QRS complex, the

first thick

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.

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

PEDIATRIC 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) giving

different

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.

LONG QT SYNDROME

The Long QT Syndrome (LQTS) is characterized on the ECG by prolongation of the heart rate corrected QT interval.This was first recognized by Dr. Jervell and Dr. Lange-Nielsen in 1957. They described 4 children with a long QT interval which was accompanied by hearing deficits, sudden cardiac death and an autosomal recessive inheritance. The Long QT syndrome may be divided into two

BRUGADA 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.

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, but

generally

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.

RATE - ECGPEDIA

The ECG has a grid with thick lines 5 mm apart (= 0,20 second) and thin lines 1 mm (0,04 second). There are three simple methods to determine the heart rate (HR) The square counting method. The square counting method is ideal for regular heart rates. Use the sequence 300-150-100-75-60-50-43-37. Count from the first QRS complex, the

first thick

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.

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

PEDIATRIC 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) giving

different

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.

LONG QT SYNDROME

The Long QT Syndrome (LQTS) is characterized on the ECG by prolongation of the heart rate corrected QT interval.This was first recognized by Dr. Jervell and Dr. Lange-Nielsen in 1957. They described 4 children with a long QT interval which was accompanied by hearing deficits, sudden cardiac death and an autosomal recessive inheritance. The Long QT syndrome may be divided into two

BRUGADA 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.

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, but

generally

RATE - ECGPEDIA

The ECG has a grid with thick lines 5 mm apart (= 0,20 second) and thin lines 1 mm (0,04 second). There are three simple methods to determine the heart rate (HR) The square counting method. The square counting method is ideal for regular heart rates. Use the sequence 300-150-100-75-60-50-43-37. Count from the first QRS complex, the

first thick

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.

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 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 with

hyperkalemia.

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 early

repolarization are:

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. 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 VENTRICULAR FIBRILLATION Ventricular fibrillation (VF or V-fib) is chaotic depolarisation of the ventricles. Mechanically this results in an arrested cardiac pump function and immediate death. VF can only be treated by immediate defibrillation. If you consider ventricular fibrillation in a conscious patient, than you should look for a technical problem with

the ECG, eg

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 during

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.

MAIN PAGE

From ECGpedia

Jump to navigation Jump to search 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

* ECG textbook

* Practice ECGs

Jonas de Jong, cardiologist at the OLVG, The Netherlands & founder of

ECGpedia

THE ECG COURSE

The ECG Made Easy Tutorial The systematic approach to ECG interpretation

PRIMER:

* Introduction

* Basics

THE 7+2 STEP PLAN:

* Rhythm

* Rate

* Conduction (PQ,QRS,QT)

* Heart Axis

* P Wave Morphology

* QRS Morphology

* ST Morphology

INTERPRETATION:

* Compare with previous ECG

* Conclusion

REFERENCE CARD

* Download and print our ECG REFERENCE CARD AS PDF

, read the printing

instructions )

YOUTUBE VIDEOS

* Introduction to the ECG on YouTube

TEACHING FILES

* Watch our online presentations

(under development)

* Watch a collection of online VIDEO

material

* A Moodle ECG course with exam in

under development.

* Our Dutch website offers free ready-made presentation files for ECG courses (in Dutch)

,

which are being translated.

THE ECG TEXTBOOK

Browse the ECG Textbook :

* Normal tracing

* A Concise History of the ECG * Technical Problems

* Sinus Rhythms

* Sinus Tachycardia

* Sinus Bradycardia

* Arrhythmias:

* Supraventricular

* Junctional

* Ventricular

* Genetic

* LQTS

* Brugada

* ARVD

* CPVT

* Ectopic Complexes

* Conduction

* AV Conduction

* Intraventricular Conduction * Myocardial Infarction * Chamber Hypertrophy * Clinical Disorders * Electrolyte Disorders * Early Repolarization

* Pacemaker

* ECG in Athletes

* ECG and ethnicity

* ECG as a screening tool

* ECG in Children

* ECG in Congenital Heart Disease * Accuracy of computer interpretation

* Eponymous ECG's

CASES AND EXAMPLES

Cases:

* Learn from these cases and examples

* Guess the Culprit

* Rhythm Puzzles by Prof. A.A.M.

Wilde, MD, PhD

* Case reports by W.G. De Voogt, MD, PhD * The _De Voogt ECG Archive _ contains > 2000 ECGs * Case reports from the ICBA

, Argentina

* Case reports from Vincent de Rover, RN

* Rarities

* NEW Submit you own interesting ECG case or ECG problem

CASE OF THE MONTH

Previous case of the month

CONTRIBUTORS

MAIN AUTHORS

* J.S.S.G. de Jong, MD, PhD, cardiologist electrophysiologist, OLVG,

the Netherlands

* P.G. Postema, MD, PhD, cardiology fellow, AMC, the Netherlands,

author

* Rob Kreuger , illustrator, AMC, the Netherlands

ECGS

* A.A.M. Wilde, MD PhD, FACC, FESC, FAHA,AMC, The Netherlands * W.A. de Voogt, MD PhD, SLAZ, The Netherlands * Dr. Alberto Giniger, chief of the Electrophysiology and Arrhythmias Department of the Instituto Cardiovascular de Buenos Aires

(ICBA), Argentina.

* M. Rosengarten, BEng, MD, McGill University, Canada R.B.A. van den Brink, MD PhD, AMC, The Netherlands; Vincent de Rover, RN, AMC, The Netherlands; R.W. Koster, MD PhD, AMC, The Netherlands; K.J. Rooyaards, MD, OLVG, the Netherlands; L.R.C. Dekker, MD PhD, M. Meuwissen, MD, PhD; I.A. Khan, MD; M.L.J.M. van de Wetering, MD; D. Kuys; K. Arkenbout, MD, PhD CORRECTIONS, ADDITIONS AND OTHER CONTRIBUTIONS I.A.C. van der Bilt, MD; T.T. Keller, MD, PhD, Bart Duineveld, Abdelghani Bouhiouf, Sabriena Henderson, Amon Heijne, A.O. Verkerk; A.C.G. van Ginneken, K.H.W.J. Ten Tusscher, K. Goldin, MD, S. Rijkenberg, J. van der Hoek, Sebastiaan H. Hols.

POPULAR ITEMS

* The LinkedIn Cardionetworks Group

is a meeting for

interested users and editors. * The whole course on 1 A4 paper. * Left Bundle Branch Block * Measuring the QT Interval - Beginners

- advanced

* Calculate the QTc with the QTc Calculator Using the QT Interval and the Heart

Rate.

* Brugada Syndrome

* Accelerated Idioventricular Rhythm * Left Bundle Branch Block

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THE ECG COURSE

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THE ECG TEXTBOOK

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