ECG Tutorial - Basic Principles of ECG Analysis

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ECGtutorial:BasicprinciplesofECGanalysis
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Author
SectionEditor
JordanMPrutkin,MD,MHS,FHRS AryLGoldberger,MD
DeputyEditor
GordonMSaperia,MD,FACC
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Mar2016.|Thistopiclastupdated:Oct29,2015.
INTRODUCTIONEventhoughtherecontinuestobenewtechnologiesdevelopedforthediagnosticevaluation
ofpatientswithcardiovasculardisease,theelectrocardiogram(ECG)retainsitscentralrole.TheECGisthemost
importanttestforinterpretationofthecardiacrhythm,conductionsystemabnormalities,andforthedetectionof
myocardialischemia.TheECGisalsoofgreatvalueintheevaluationofothertypesofcardiacabnormalities
includingvalvularheartdisease,cardiomyopathy,pericarditis,andhypertensivedisease.Finally,theECGcanbe
usedtomonitordrugtreatment(specificallyantiarrhythmictherapy)andtodetectmetabolicdisturbances.
AsystematicapproachtointerpretationoftheECGisimportantinordertoavoidoverlookingimportant
abnormalities.Patternrecognitioncanbeuseful,butonlyaftercertainsalientfeatureshavebeendetermined.This
topicreviewprovidestheframeworkforasystematicanalysisoftheECG.
ECGGRIDTheelectrocardiogram(ECG)isaplotofvoltageontheverticalaxisagainsttimeonthehorizontal
axis.Theelectrodesareconnectedtoagalvanometerthatrecordsapotentialdifference.Theneedle(orpen)of
theECGisdeflectedagivendistancedependinguponthevoltagemeasured.
TheECGwavesarerecordedonspecialgraphpaperthatisdividedinto1mm2gridlikeboxes(figure1).The
ECGpaperspeedisordinarily25mm/sec.Asaresult,each1mm(small)horizontalboxcorrespondsto0.04
second(40ms),withheavierlinesforminglargerboxesthatincludefivesmallboxesandhencerepresent0.20
sec(200ms)intervals.Onoccasion,thepaperspeedisincreasedto50mm/sectobetterdefinewaveforms.In
thissituation,thereareonlysixleadspersheetofpaper.Eachlargeboxisthereforeonly0.10secandeachsmall
boxisonly0.02sec.Inaddition,theheartrateappearstobeonehalfofwhatisrecordedat25mm/secpaper
speed,andalloftheECGintervalsaretwiceaslongasnormal.
Vertically,theECGgraphmeasurestheheight(amplitude)ofagivenwaveordeflection,as10mm(10small
boxes)equals1mVwithstandardcalibration.Onoccasion,particularlywhenthewaveformsaresmall,double
standardisused(20mmequals1mv).Whenthewaveformsareverylarge,halfstandardmaybeused(5mm
equals1mv).PaperspeedandvoltageareusuallyprintedonthebottomoftheECG.
COMPLEXESANDINTERVALSThenormalelectrocardiogram(ECG)iscomposedofseveraldifferent
waveformsthatrepresentelectricaleventsduringeachcardiaccycleinvariouspartsoftheheart(figure2).ECG
wavesarelabeledalphabeticallystartingwiththePwave,followedbytheQRScomplexandtheSTTUcomplex
(STsegment,Twave,andUwave).TheJpointisthejunctionbetweentheendoftheQRSandthebeginningof
theSTsegment(waveform1).
PwaveThePwaverepresentsatrialdepolarization.ThenormalsinusPwavedemonstratesrightfollowedby
leftatrialdepolarizationandisaninitiallowamplitudepositivedeflectionprecedingtheQRScomplex.Theduration
isgenerally<0.12sec(threesmallboxes)andtheamplitude<0.25mv(2.5smallboxes).Sincerightatrial
depolarizationprecedesthatoftheleftatrium(asthesinusnodeisinthehighrightatrium),thePwaveisoften
notchedinthelimbleadsandusuallybiphasicinleadV1.TheinitialpositivedeflectioninV1isduetorightatrial
depolarizationthatisdirectedanteriorly,whilethesecondnegativedeflectionrepresentsleftatrialdepolarization
thatisdirectedposteriorly.
Theatrialrepolarizationsequence(atrialSTandTwavephases)occursjustbefore,simultaneously,andjustafter
depolarizationoftheventricularmyocardium.Theatrial"Twave"itselfisusuallyhiddenbytheQRScomplexand
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notobservedontheroutineECG.Inaddition,theamplitudeoftheatrialTwaveisoftentoosmalltobeobserved
atstandardgain.Whentheheartrateisincreased(eg,withsinustachycardia)andthereisenhancedsympathetic
tone,thePRintervalisshortenedatrialrepolarization(theatrialTwave)maysometimesthenbeobservedatthe
veryendoftheQRScomplex,alteringtheJpoint,andresultinginJpointdepressionwithrapidlyupslopingST
segments,particularlyduringthefirst80msecaftertheQRScomplex.Thisfindingisphysiologicbutmaybe
confusedwithtrueSTdepression,generatingafalsepositivereading.Clinically,atrialrepolarization(theatrialST
phase)ismostevidentduringacutepericarditis,inwhichoneoftenseesPRsegmentelevationinleadaVRand
PRsegmentdepressionintheinferolateralleads,reflectinganatrialcurrentofinjury.ThelowamplitudeatrialT
wavemayalsobeunmaskedincertaincasesofhighdegreeAVblock,especiallywhentheatriaareenlarged.
Finally,alterationsintheatrialSTsegmentandTwavemayoccurwithotherpathologies,suchasatrialinfarction
oratrialtumorinvasion.
PRintervalThePRintervalincludesthePwaveaswellasthePRsegment.Itismeasuredfromthe
beginningofthePwavetothefirstpartoftheQRScomplex(whichmaybeaQwaveorRwave).Itincludestime
foratrialdepolarization(thePwave)andconductionthroughtheAVnodeandtheHisPurkinjesystem(which
constitutethePRsegment).ThelengthofthePRintervalchangeswithheartrate,butisnormally0.12to0.20sec
(threetofivesmallboxes).ThePRintervalisshorteratfasterheartratesduetosympatheticallymediated
enhancementofatrioventricular(AV)nodalconductionitislongerwhentherateisslowedasaconsequenceof
slowerAVnodalconductionresultingfromwithdrawalofsympathetictoneoranincreaseinvagalinputs.
QRScomplexTheQRScomplexrepresentsthetimeforventriculardepolarization.
Iftheinitialdeflectionisnegative,itistermedaQwave.SmallQwavesareoftenseeninleadsI,aVL,and
V4V6asaresultofinitialseptaldepolarizationandareconsiderednormal.
ThefirstpositivedeflectionoftheQRScomplexiscalledtheRwave.Itrepresentsdepolarizationoftheleft
ventricularmyocardium.Rightventriculardepolarizationisobscuredbecausetheleftventricularmyocardial
massismuchgreaterthanthatoftherightventricle.ThesmallRwaveinleadV1representsinitialseptal
depolarization.
ThenegativedeflectionfollowingtheRwaveistheSwave,whichrepresentsterminaldepolarizationofthe
highlateralwall.
Ifthereisasecondpositivedeflection,itisknownasanR'.
Lowercaseletters(q,r,ors)areusedforrelativelysmallamplitudewavesoflessthan0.5mV(lessthan5
mmwithstandardcalibration).
AnentirelynegativeQRScomplexiscalledaQSwave.
TheentireQRSdurationnormallylastsfor0.06to0.10seconds(1to2smallboxes)andisnotinfluencedby
heartrate.
TheRwaveshouldprogressinsizeacrosstheprecordialleadsV1V6.NormallythereisasmallRwaveinlead
V1withadeepSwave.TheRwaveamplitudeshouldincreaseinsizeuntilV4V6,duetomoreleftventricular
forcesbeingseen,whiletheSwavebecomeslessdeep.ThisistermedRwaveprogressionacrossthe
precordium.
STsegmentTheSTsegmentoccursafterventriculardepolarizationhasendedandbeforerepolarizationhas
begun.Itisatimeofelectrocardiographicsilence.TheinitialpartoftheSTsegment(theintersectionoftheendof
theQRScomplexandthebeginningoftheSTsegment)istermedtheJpoint(waveform1).
TheSTsegmentisusuallyisoelectric(ie,zeropotentialasidentifiedbytheTPsegment)andhasaslightupward
concavity.However,itmayhaveotherconfigurationsdependinguponassociateddiseasestates(eg,ischemia,
acutemyocardialinfarction,orpericarditis).Inthesesituations,theSTsegmentmaybeflattened,depressed
(belowtheisoelectricline)withanupsloping,horizontal,ordownslopingmorphology,orelevatedinaconcaveor
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convexdirection(abovetheisoelectricline).(See"Electrocardiograminthediagnosisofmyocardialischemiaand
infarction"and"ECGtutorial:STandTwavechanges"and"Clinicalpresentationanddiagnosticevaluationof
acutepericarditis",sectionon'Electrocardiogram'.)
Insomenormalcases(aswithsinustachycardia)theJpointisdepressedandtheSTsegmentisrapidly
upsloping,becomingisoelectricwithin0.08secondsaftertheendoftheQRScomplex.
TwaveTheTwaverepresentstheperiodofventricularrepolarization.Sincetherateofrepolarizationisslower
thandepolarization,theTwaveisbroad,hasaslowupstroke,andrapidlyreturnstotheisoelectriclinefollowing
itspeak(ie,slowupstroke,rapiddownstroke).Thus,theTwaveisasymmetricandtheamplitudeisvariable.In
addition,theTwaveisusuallysmoothupanddown.IfthereisanyirregularityontheTwave(bump,notch,
rippled,nipple,etc)asuperimposedPwaveshouldbeconsidered.
Sincedepolarizationbeginsattheendocardialsurfaceandspreadstotheepicardium,whilerepolarizationbegins
attheepicardialsurfaceandspreadstotheendocardium,thedirectionofventriculardepolarizationisoppositeto
thatofventricularrepolarization.Thus,theTwavevectorontheECGnormallyisinthesamedirectionasthe
majordeflectionoftheQRS.AnotherwayofsayingthisisthattheQRSandTwaveaxesaregenerally
concordant.VariousdiseasestatescanleadtoTwavediscordance.(See"ECGtutorial:STandTwave
changes".)
QTintervalTheQTintervalconsistsoftheQRScomplex,theSTsegment,andTwave.Thus,theQTinterval
isprimarilyameasureofventricularrepolarization.TheJTinterval,whichdoesnotincludetheQRScomplex,isa
moreaccuratemeasureofventricularrepolarizationsinceitdoesnotincludeventriculardepolarization,butinmost
clinicalsituations,theQTintervalisused.IftheQRScomplexdurationisincreased,thiswillleadtoanincrease
inQTintervalbutdoesnotreflectachangeinventricularrepolarization.AwidenedQRS,therefore,mustbe
consideredifaprolongedQTintervalisbeingevaluated.
ThetimeforventricularrepolarizationandthereforetheQT(orJT)intervalisdependentupontheheartrateitis
shorteratfasterheartratesandlongerwhentherateisslower.Thus,aQTintervalthatiscorrectedforheartrate
(QTc)isoftencalculatedasfollows(basedonBazett'sformula):
QTc=QTintervalsquarerootoftheRRinterval(insec)
Althoughthisapproachissimple,itisinaccurateatheartrateextremesandresultsinovercorrectingathighrates
andundercorrectingatlowones[1].
AnotherapproachcorrectstheQTintervaltothecubedrootoftheRRinterval[1,2].Linearandlogarithmic
regressionformulashavebeenusedtopredicttheeffectofheartrateonQTinterval[3,4].However,becauseof
substantialvariabilityoftheQTRRrelationshipamongindividuals,noformulaforheartratecorrectioncanbe
accurateforeveryone[5,6].
ThenormalvaluefortheQTcinmenis0.44secandinwomenis0.45to0.46sec.QTcvalues,however,areon
abellcurveandnormalpatientsmayhavelongerQTcvalues,whilethosewithLongQTsyndromemayhave
shorterQTvalues.(See"DiagnosisofcongenitallongQTsyndrome".)
SincetheQRSwidensinthesettingofabundlebranchblock,theQTintervalwillwiden.ThisincreaseinQT
intervaldoesnotreflectanabnormalityofventricularrepolarization,sincetheincreaseisduetoanabnormalityof
depolarization.TherehavenotbeenmanydescriptionsonhowtomeasureQTintervalinthesettingofQRS
widening.OnestudyshowedthattheQTincreased48.5percentofthewidthoftheQRSduetoaleftbundle
branchblock,andproposedaroughformulaofQTmodified=QTmeasured(QRSmeasured)tocalculatetheQT
interval[7].Thismustbestillbecorrectedforheartrate.AnotheroptionistomeasuretheJTinterval,correctedfor
rate:QTcQRS=JTc[8].Thisequationhassomelimitations,asitisdependentonheartrateandasnormal
valueshavenotbeenderived.
UwaveAUwavemaybeseeninsomeleads,especiallytheprecordialleadsV2toV4.Theexactcauseof
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thiswaveisuncertain,althoughithasbeensuggestedthatitrepresentsrepolarizationoftheHisPurkinjesystem.
Alternatively,somedatasuggestitmaybefromlaterepolarizationofthemidmyocardialMcells,duetoalonger
actionpotentialdurationcomparedwiththeendocardiumorepicardium,especiallyatslowheartrates[9].
TheamplitudeoftheUwaveistypicallylessthan0.2mVandisclearlyseparatefromtheTwave.Itismore
evidentinsomecircumstancessuchashypokalemiaandbradycardia.TheUwavemaymergewiththeTwave
whentheQTintervalisprolonged(aQTUwave),ormaybecomeveryobviouswhentheQTorJTintervalis
shortened(eg,withdigoxinorhypercalcemia).
HEARTRATEIfthecardiacrhythmisregular,theintervalbetweensuccessiveQRScomplexesdetermined
fromtheelectrocardiogram(ECG)gridcanbeusedtodetermineheartrate.
Thedivisionof300bythenumberoflargeboxescalculatestheheartrate.Iftheintervalbetweentwo
successivecomplexesisonelargebox,thentherateis300beats/min(3001=300beats/min).Ifthe
intervalistwolargeboxes,therateis150(3002=150beats/min).Thiscalculationmaybecarriedon
downthelineforeachadditionallargebox,to100beats/min,75beats/min,60beats/min,50beats/min,etc.
Alternatively,thetimebetweenQRScomplexescanbemeasuredinseconds.Thisnumbercanbedivided
into60toderivetheheartrate.Forinstance,ifthetimebetweentwoQRScomplexesis0.75seconds,the
heartrateis80beats/min(60seconds/minute0.75seconds/beat=80beats/min).
Iftherhythmisirregular,thesimplestwaytodeterminetherateisbycountingthenumberofcomplexesonthe
ECGandmultiplyingbysix,sincethestandardECGdisplays10secondsoftime.
Arateof60to100isconsiderednormal.Aratelessthan60isbradycardia,whilearateover100istachycardia
(algorithm1AB).
AXISTheelectricalsignalrecordedontheelectrocardiogram(ECG)containsinformationrelativetodirection
andmagnitudeofthevariouscomplexes.Theaveragedirectionofanyofthecomplexescanbedetermined.
ThenormalQRSelectricalaxis,asestablishedinthefrontalplane,isbetween30and90(directeddownwardor
inferiorandtotheleft)inadults[10].Anaxisbetween30and90(directedsuperiorandtotheleft)istermedleft
axisdeviation.Iftheaxisisbetween90and180(directedinferiorandtotheright),thenrightaxisdeviationis
present.Anaxisbetween90and180(directedsuperiorandtotheright)isreferredtoasextremerightorleft
axis.IftheQRSisequiphasicinallleadswithnodominantQRSdeflection,itisindeterminateaxis.TheQRS
axismovesleftwardthroughoutchildhoodandadolescence,fromanormalvalueof30to190atbirthto0to120
duringages8to16years.Thereissomedisagreementamongauthorsonthedefinitions(indegrees)ofanormal,
right,andleftaxis.(See"Leftanteriorfascicularblock"and"Leftposteriorfascicularblock".)
TheQRSaxiscanbedeterminedbyexaminingallofthelimbleads,buttheeasiestmethodinvolveslookingat
leadsI,II,andaVFonly(figure3).
IftheQRScomplexispositive(upright)inbothleadsIandII,thentheaxisfallsbetween30and90,and
theaxisisnormal.
IftheQRScomplexispositiveinleadIbutnegativeinleadII,thentheaxisisleftward(30to90).
IfthecomplexesarenegativeinleadIandpositiveinaVF,thentheaxisisrightward(90to180).
IfthecomplexesarenegativeinbothIandaVF,thentheaxisisextreme(180to90).
Anothermethodofaxisdeterminationistofindtheleadinwhichthecomplexismostisoelectrictheaxisis
directedperpendiculartothislead.Asanexample,iftheQRSisisoelectricinlead3whichisdirectedat120,
thentheelectricalaxisiseither30or150.
AthirdmethodistodeterminethefrontalleadinwhichtheQRSisofthegreatestpositiveamplitude.Theaxisis
paralleltothislead.
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BycombiningthequadrantdeterminedbyanalysisofleadsI,II,andaVFwiththeisoelectricleadinformation,one
canaccuratelyandrapidlydeterminetheelectricalaxis.
Thecausesofrightaxisdeviationinclude:
Normalvariation(verticalheartwithanaxisof90)
Mechanicalshifts,suchasinspirationandemphysema
Rightventricularhypertrophy
Rightbundlebranchblock
Leftposteriorfascicularblock
Dextrocardia
Ventricularectopicrhythms
Preexcitationsyndrome(WolffParkinsonWhite)
Lateralwallmyocardialinfarction
Secundumatrialseptaldefect
Causesforleftaxisdeviationinclude:
Normalvariation(physiologic,oftenwithage)
Mechanicalshifts,suchasexpiration,highdiaphragm(pregnancy,ascites,abdominaltumor)
Leftventricularhypertrophy
Leftbundlebranchblock
Leftanteriorfascicularblock
Congenitalheartdisease(primumatrialseptaldefect,endocardialcushiondefect)
Emphysema
Hyperkalemia
Ventricularectopicrhythms
Preexcitationsyndromes(WolffParkinsonWhite)
Inferiorwallmyocardialinfarction.
Theheartalsohasanaxisinthehorizontalplane,whichisdeterminedbyimaginingtheheartasviewedfrom
underthediaphragm.Iftheaxisisrotatedinaclockwisedirection,leftventricularforcesaredirectedmore
posteriorlyandoccurlaterintheprecordialleads.ThisistermedpoorRwaveprogressionandlatetransition.If
thereiscounterclockwiserotation,leftventricularforcesoccurearlierintherightprecordialleadsandthisis
termedearlytransitioninwhichthereisatallRwaveinleadV2.
ThereisnoagreementonhowtoestimatetheQRSaxisinpatientswithbundlebranchblock(BBB).Asthe
prolongedterminalpartoftheQRSinrightbundlebranchblockreflectsdelaysinrightventricularactivation,and
axisdeterminationisofimportanceindiagnosingfascicularblocks,onereasonableapproachistoestimatethe
frontalplaneQRSaxisbasedonjustthefirst80to100msoftheQRSdeflection(primarilyreflectingactivationof
theleftventricle).Forleftbundlebranchblockandotherintraventricularconductiondelays,theentireQRScanbe
usedorjusttheinitial80to100ms.
APPROACHTOECGINTERPRETATIONAsystematicapproachtointerpretinganelectrocardiogram(ECG)
isessentialforcorrectdiagnosis.
Step1:RateIstheratebetween60and100?Rateslessthan60arebradycardicandgreaterthan100are
tachycardic.
Step2:RhythmArePwavespresent?IsthereaPwavebeforeeveryQRScomplexandaQRScomplex
aftereveryPwave?ArethePwavesandQRScomplexesregular?IsthePRintervalconstant?(See'Rhythm
analysis'below.)
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Step3:AxisIsthereleftorrightaxisdeviation?(See'Axis'above.)
Step4:IntervalsWhatisthePRinterval?ShortPRintervalsaresuggestiveofWolffParkinsonWhite
syndrome.LongPRintervalsareusuallyseeninfirstdegreeAVblock,buttheremaybeothercauses.Whatis
theQRSinterval?LongQRSintervalsrepresentabundlebranchblock,ventricularpreexcitation,ventricular
pacing,orventriculartachycardia.WhatistheQTinterval?ShortandlongQTintervalsmaybepresent.
Step5:PwaveWhatistheshapeandaxisofthePwave?ThePwavemorphologyshouldbeexaminedto
determineiftherhythmissinusorfromanotheratriallocation.(See'Pwave'above.)Amplitudeandduration
shouldalsobeanalyzedtodetermineleftandrightatrialenlargement.(See"Normalsinusrhythmandsinus
arrhythmia".)
Step6:QRScomplexIstheQRSwide?Ifso,examinationofthemorphologycandetermineifthereisleftor
rightbundlebranchblockorpreexcitationpresent.Inaddition,increasedvoltagemayindicateleftorright
ventricularhypertrophy.AreQwavespresent,suggestiveofinfarction?
Step7:STsegmentTwaveIsthereSTelevationordepressioncomparedtotheTPsegment?TheTP
segment,betweentheTwaveofonebeatandthePwaveofthenextbeat,shouldbeusedasthebaseline.Are
theTwavesinverted?(See"ECGtutorial:STandTwavechanges".)AbnormalitiesoftheSTsegmentorTwave
mayrepresentmyocardialischemiaorinfarction,amongothercauses.
Step8:OverallinterpretationOnlyafterthepriorstepshavebeencompletedshouldanoverallinterpretation
andpossiblediagnosesbedetermined.ThisensuresassimilationofallinformationintheECGandthatnodetail
willbeoverlooked.
RHYTHMANALYSISInterpretingtherhythmoftheelectrocardiogram(ECG)issometimesdifficult.However,
asforECGinterpretationingeneral,asystematicapproachalongwithaknowledgeofarrhythmiasoftenleadstoa
correctdiagnosis.Calipersareextremelyhelpfulforrhythmanalysis.
Step1:LocatethePwaveThemostimportantandfirststepinrhythminterpretationistheidentificationofP
wavesandananalysisoftheirmorphology.Thereareseveralquestionsthatshouldbeaddressed:
ArePwavesvisible?EachleadneedstobeexaminedforPwaves,astheymaynotbeobviousinsome
leads.Onoccasion,PwavesmaybelocatedonorattheendofTwavesandnotobvious.Theywill
thereforecausetheTwaveupslopeordownstroketonolongerbesmooth.ItisalsoimportanttolookforP
wavesduringanypauseintherhythm.AbsenceofPwavesmayoccursecondarytoatrialfibrillation.
Alternatively,Pwavesmaybepresentbutnotvisibleiftheyaresimultaneouswithandburiedwithinthe
QRScomplexasinajunctionalrhythmoratrioventricular(AV)nodalreentranttachycardia.Inaddition,they
maybelocatedwithintheSTsegmentaswithanAVreciprocatingtachycardiaorventriculartachycardia.If
aPwaveishalfwaybetweentwoQRScomplexes,asecondPwaveisoftenburiedwithintheQRS
complex.
WhatistherateofthePwaves(ie,thePPinterval)?Iftherateislessthan60,thenabradycardiais
present.IftheatrialorPwaverateisover100,thenatachycardiaispresent.Ingeneral,sinustachycardia
occursatratesof100to180atrialtachycardia,AVnodalreentranttachycardia,orAVreciprocating
tachycardiaoccuratratesof140to220atrialratesof260to320areseenwithatrialflutter.
WhatisthemorphologyandaxisofthePwaves?ThenormalsinusPwaveisgenerallyuprightinleadsI,II,
aVF,andV4V6.ItisnegativeinleadaVR.ItmaybenegativeorbiphasicinleadsIIIandV1.AnegativeP
waveintheinferiorleadsorleadIsuggestsanectopicrhythm(lowatrialorleftatrialrespectively).Similarly,
acompletelypositivePwaveinV1suggestsaleftatriallocation.
Step2:EstablishtherelationshipbetweenPwavesandtheQRScomplexThenextstepistodetermine
therelationshipbetweenthePwavesandtheQRScomplexes,addressingthefollowingquestions:
ArethePwavesassociatedwithQRScomplexesina1:1fashion?Ifnot,aretheremoreorlessPwaves
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thanQRScomplexesandwhataretheatrialandventricularrates?IftherearemorePwavesthanQRS
complexes,thensomeformofAVblockispresent,whichmaybephysiologicifthereisaconcomitantatrial
tachycardiaorflutter.IftherearemoreQRScomplexesthanPwaves,thentherhythmisanaccelerated
ventricularorjunctionalrhythm.
DothePwavesprecedeeachQRScomplexasisthecasewithmostnormalrhythms?WhatisthePR
interval,andisthisintervalfixed?
DoPwavesoccuraftereachQRScomplex(ie,retrogradePwaves)asoccursinjunctionalorventricular
rhythmswithretrogradeVAconduction,orinAVnodalreentrantorAVreciprocatingtachycardias?TheRP
intervalshouldbenotedanditshouldbeestablishedifitisfixedorvariable.
Often,establishingtherelationshipbetweenthePwaveandtheQRScomplexisthemostimportantdiagnostic
stepinrhythminterpretation.(See'Overallapproachtorhythmanalysis'belowand"Approachtothediagnosisof
wideQRScomplextachycardias".)
Step3:AnalyzetheQRSmorphologyIftheQRScomplexesareofnormalduration(<0.12sec)and
morphology,thentherhythmissupraventricular.ItisessentialtoanalyzetheQRSinall12leadstobesurethatit
isnormal.
IftheQRSiswide(ie,>0.12sec),thentherhythmiseithersupraventricularwithaberrantconduction,pre
excitation,orventricularpacing,oritisofventricularorigin.Itmaybepossibletodifferentiatethembycareful
inspectionoftheQRSmorphology,especiallyiftheQRSmorphologyappearssimilartothebaselineQRS.(See
"ApproachtothediagnosisofwideQRScomplextachycardias"and"Basicapproachtodelayedintraventricular
conduction".)
Step4:SearchforothercluesOftenthediagnosisofarhythmdisturbancecanbemadebycluesprovidedby
breaksintherhythmorotherirregularitiesinanotherwiseregularrhythm.Asanexample,anincreaseinthe
degreeofAVblockasoccurswithcarotidsinusmassagemayunmasktheflutterwavesofatrialflutter.
Capturebeatsandfusionbeatsmaybethecluesthathelpestablishthediagnosisofventriculartachycardia.
TheregularityoftheQRScomplexesshouldbeestablishedbyaskingthefollowingquestions:
DotheQRScomplexesoccurwithregularintervalsoraretheyirregular?
Ifthecomplexesareirregular,isthereapatterntotheirregularity?Istherhythmregularlyirregular(ie,there
isarepeatingpatternofirregularity)oristherhythmirregularlyirregularwithoutanypatternofirregularity?At
leastfivesupraventricularrhythmsareirregularlyirregular:sinusarrhythmia(inwhichthereisonlyoneP
wavemorphologyandastablePRinterval)sinusrhythmwithprematureatrialcontractionssinusorother
rhythmwithvariableAVblockmultifocalatrialrhythm(wanderingatrialpacemaker)whentherateis<100or
multifocalatrialtachycardiawitharate>100(inwhichthereare3differentPwavemorphologiesandPR
intervals)oratrialfibrillation(inwhichthereisnoorganizedelectricalactivity).
Step5:InterprettherhythmintheclinicalsettingOften,theclinicalhistory,includingdrugsbeingtaken,can
behelpfulinestablishingadiagnosis.Asanexample,aregularwidecomplexrhythminanolderpatientwitha
historyofischemiccardiomyopathyismostlikelyventriculartachycardia.(See"Approachtothediagnosisofwide
QRScomplextachycardias".)Similarly,anarrowcomplextachycardiaofsuddenonsetinayoungpersonwithno
medicalhistoryislikelyAVnodalreentrantorAVreciprocatingtachycardia.(See"Clinicalmanifestations,
diagnosis,andevaluationofnarrowQRScomplextachycardias".)
However,theclinicalpresentationandassociatedhemodynamicfindingsdonotnecessarilycorrelatewiththe
etiologyofanabnormalrhythm.Thepresenceofhemodynamicstabilityduringatachycardia,forexample,does
notimplyasupraventricularetiology,nordoesinstabilitymeanthatthediagnosisisventriculartachycardia.
Hemodynamicchangesarerelatedtotherateofthearrhythmiaandthepresenceandextentofunderlyingheart
disease.
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OVERALLAPPROACHTORHYTHMANALYSISApproachingeachnewrhythmwithamethodicalstandard,
asshowninthefollowingalgorithms,permitthecorrectdiagnosistobeestablishedinmostcircumstances.An
approachtothediagnosisoftachycardiaandbradycardiaisshown(algorithm2ABandalgorithm1AB).This
issueisdiscussedinotherelectrocardiogram(ECG)tutorials.(See"ECGtutorial:Ventriculararrhythmias"and
"ECGtutorial:Atrialandatrioventricularnodal(supraventricular)arrhythmias"and"ECGtutorial:Rhythmsand
arrhythmiasofthesinusnode".)
SUMMARYTheelectrocardiogram(ECG)isagraphicalrepresentation(timeversusamplitudeofelectrical
vectorprojection)oftheelectricalactivityoftheheart.Whileimperfectasadiagnosticorprognostictool,it
containsawealthofinformationnecessaryforthepropercareofthepatientwithpotentialcardiovasculardisease.
TheelectricalactivityofeachnormalcardiaccycleisrepresentedinsequencebythePwave,thePRinterval,the
QRScomplex,theSTsegment,theTwave,and(sometimes)theUwave.Thefollowingpiecesofinformation
shouldbeevaluatedforeachofthese.
AsystematicapproachtointerpretationoftheECGiscriticallyimportant.(See'ApproachtoECGinterpretation'
above.)
RateIstheratebetween60and100?(See'Step1:Rate'above.)
RhythmIsitnormalsinusorother?(See'Step2:Rhythm'above.)
AxisIsthereaxisdeviation?(See'Step3:Axis'above.)
IntervalsAreallintervalsnormal?(See'Step4:Intervals'above.)
PwaveWhatisitsheight,width,andaxis?(See'Step5:Pwave'above.)
QRScomplexAretherepathologicQwaves,bundlebranchblock,orchamberhypertrophy?(See'Step6:
QRScomplex'above.)
STTwavesIsitisoelectric,elevated,ordepressedrelativetotheTPsegment?(See'Step7:ST
segmentTwave'above.)
OverallinterpretationWhatisthediagnosis?(See'Step8:Overallinterpretation'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
Topic2115Version15.0
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GRAPHICS
GridlinesandstandardizationoftheECG
Theelectrocardiogamisrecordedonpaperthathaslargeboxes
(heavylines)of0.5cmsides.Onthehorizontalaxis,eachlargebox,
whichrepresents0.2secondsatatypicalpaperspeedof25mm/sec,
isdividedintofivesmallerboxes,eachonerepresenting0.04
seconds.Ontheverticalaxis,thelargeboxalsohasfive
subdivisions,each1mminheight10mmequals1mVwithstandard
calibration.
Graphic62799Version1.0
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ECGcomplexesandintervals
ECGwavesarelabeledalphabeticallystartingwiththePwave,
followedbytheQRScomplex,andtheSTTcomplex(STsegmentand
Twave).TheJpointisthejunctionbetweentheendoftheQRSand
thebeginningoftheSTsegment.ThePRintervalismeasuredfrom
thebeginningofthePwavetothefirstpartoftheQRScomplex.The
QTintervalconsistsoftheQRScomplexwhichrepresentsonlyabrief
partoftheinterval,andtheSTsegmentandTwavewhichareof
longerduration.
http://www.uptodate.com.ezproxy.usach.cl/contents/ecgtutorialbasicprinciplesofecganalysis?topicKey=CARD%2F2115&elapsedTimeMs=0&source=se
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Jpoint
TheJpointisthejunctionbetweentheendoftheQRSandthebeginningofthe
STsegment.
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Approachtobradycardia
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Approachtotachycardia
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Calculationoffrontalplaneaxis
IftheQRScomplexispositiveinleadsIandII,itfallsbetween30and90andis
normal,asindicatedbytheyellowarea.IftheQRScomplexisnegativeinIand
positiveinaVF,thereisrightaxisdeviation.IftheQRScomplexispositiveinIand
negativeinII,thereisleftaxisdeviation.IftheQRScomplexisnegativeinIand
aVF,thereisextremeaxisdeviation.
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PwavebeforeeachQRScomplexwithconstantPR
relationship
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PwaveinfrontofeachQRScomplex:PwaveandQRS
related
*PwavemorphologyandPRintervalvariable.
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