ECGs ECGs

NORMAL ECG FIRST DEGREE HEART BLOCK

> P wave: atrial depolarisation
> QRS complex: ventricular depolarisation Defined as a consistently prolonged PR
> T wave: ventricular repolarisaton interval lasting >0.20 seconds
QRS complex

PR segment ST segment
T Occurs due to slowed conduction from the
P AV node
Usually an incidental finding and
asymptomatic
Q Causes include:
PR interval S > electrolyte disturbances
QT interval > acute MI
> PR interval: movement of electrical activity > enhanced vagal tone
from atria to ventricles > medication
> ST segment: time between ventricular e.g. beta blockers, calcium channel
depolarisation and repolarisation, i.e. blockers, cholinesterase inhibitors
ventricular contraction
> QT interval: time taken for ventricles to
depolarise, contract, and repolarise
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ECGs ECGs
ATRIAL FLUTTER ATRIAL FIBRILLATION
Tachycardic atrial activity, ~300bpm Tachyarrhythmia characterised by absent
Characteristic 'sawtooth' baseline P waves, irregular RR intervals, loss of
isoelectric baseline, and narrow QRS

Due to a re-entry circuit in the right atrium

Ventricular rate determined by the degree of Occurs due to disorganised electrical activity
AV block; commonly 2:1 -> rate of ~150bpm in the atria and uncoordinated contraction
NB. Presentation may include:
atrial flutter: regular but tachycardic > tachycardia
atrial fibrillation: irregular > irregularly irregular
> palpitations pulse
Common symptoms: > chest pain > syncope
> palpitations > syncope > SOB/fatigue
> shortness of breath > may be
> lightheadedness asymptomatic Most common causes:
> ischaemic heart > thyrotoxicosis
Causes include: disease > sepsis
> coronary heart disease > hypertension > hypertension
> valvular disease > cardiomyopathy > mitral valve pathology
High ventricular rate -> haemodynamic Risk of embolism/stroke due to stagnated
instability -> risk of VF/cardiac arrest blood, and heart failure due to poor
ventricular filling and impaired output
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 ECGs ECGs
PACED RHYTHM SECOND DEGREE HEART BLOCK
Regulation of heart rhythm
MOBITZ TYPE I
Characteristic spike on ECG Characterised by progressive prolongation
of the PR interval, with an eventual
skipped QRS complex

In atrial pacing, the pacing spike precedes aka. Wenckebach phenomenon

the P wave Occurs due to AV node dysfunction
In ventricular pacing, the spike precedes cells fatigue -> prolonged conduction time
the QRS complex -> eventual skipped QRS, i.e. no conduction
Above is dual chamber pacing (spikes to ventricles
before both) Causes include:
> electrolyte disturbances
Indications for a permanent pacemaker: > myocardial ischaemia
> symptomatic bradycardia > valvular disease
e.g. AV node dysfunction in heart block > medications
e.g beta blockers, calcium channel
> arrhythmias e.g. long QT syndrome blockers)
> neuromuscular disease
> cardiac transplantation Often asymptomatic but may involve
lightheadedness or dizzy spells
Further management rarely required
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ECGs ECGs
SECOND DEGREE HEART BLOCK SHOCKABLE RHYTHMS
MOBITZ TYPE II ventricular fibrillation
Characterised by intermittent skipped QRS
complexes without PR interval prolongation

pulseless ventricular tachycardia

Occurs due to failure of the His-Purkinje
conduction system
Causes include:
> MI > myocardial disease
> fibrosis > medications e.g. beta NON-SHOCKABLE RHYTHMS
> inflammation e.g. blockers, calcium pulseless electrical activity (PEA)
rheumatic fever channel blockers may resemble recognisable trace
Associated with:
> haemodynamic instability
> syncope
> severe bradycardia asystole
Requires cardiac monitoring and usually a
permanent pacemaker
May progress to third-degree/complete heart
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 ECGs ECGs
SINUS RHYTHM SUPRAVENTRICULAR TACHYCARDIA
Default heart rhythm Electrical signal re-entering the atria from
the ventricles
Characteristic narrow complex tachycardia

AV NODAL RE-ENTRANT TACHYCARDIA

Normal conduction, around 60-100bpm Signal travels back through the AV node and
Tachycardia: >100bpm causes additional ventricular contraction
Bradycardia: <60bpm paroxysmal SVT: recurs and remits
Symptoms include palpitations, SOB,
Check: lightheadedness, and syncope
> rate
> regular rhythm Three types:
> axis > atrioventricular nodal re-entrant
> P waves present tachycardia: re-entry through AV node
> PR interval 120-200ms > atrioventricular re-entrant tachycardia:
> QRS width 0.12 seconds or less re-entry through accessory pathway
> isoelectric ST segment > atrial tachycardia: signal originates
> T waves not tall or inverted somewhere other than the sinoatrial node,
i.e. abnormally generated
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ECGs ECGs
THIRD DEGREE/COMPLETE VENTRICULAR FIBRILLATION
HEART BLOCK Life-threatening arrhythmia characterised
No relationship between P waves and QRS by disorganised, high-frequency ventricular
complexes contractions
Patient does not have a pulse

Occurs due to failure of the His-Purkinje

conduction system Fibrillatory baseline, usually >300bpm, often
preceded by ventricular tachycardia
Presentation may include:
> syncope > irregular pulse Presents as sudden haemodynamic instability
> palpitations > severe bradycardia -> loss of consciousness -> cardiac death
> chest pain > haemodynamic Early signs may include:
> SOB instability > chest pain > shortness of breath
Causes: > palpitations > fatigue
> MI > iatrogenic > dizziness
> fibrosis > medications e.g. beta Most common cause is coronary artery
> valvular disease blockers, calcium disease, in addition to:
> infection channel blockers > previous MI > valvular disease
Significant risk of ventricular arrhythmias or > electrophysiological disorders e.g. long QT
asystole; cardiac monitoring and permanent VF is a shockable rhythm and requires
pacemaker generally required immediate defibrillation and resuscitation
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 ECGs ECGs
VENTRICULAR TACHYCARDIA WOLFF-PARKINSON-WHITE
Characterised by broad QRS complexes SYNDROME
and AV dissociation; may degenerate into Congenital additional electrical pathway
ventricular fibrillation between atria and ventricles causing
episodes of tachyarrthymia

MONOMORPHIC: most common

Changes include short PR interval, wide QRS,

POLYMORPHIC: varying amplitudes and duration and delta wave (slurred upstroke on QRS)
Sustained VT: >30 sec, requires intervention Symptoms include:
Non-sustained: 3+ ventricular complexes > palpitations
terminating spontaneously > chest pain
> lightheadedness > syncope
VT with a pulse: Pulseless VT: > SOB
> chest pain > cardiac arrest
> palpitations Definitive management is through
> SOB radiofrequency ablation of the extra pathway
Most common cause is myocardial ischaemia NB. anti-arrhythmics e.g. beta blockers, calcium
Sustained VT requires immediate intervention channel blockers are contraindicated in patients
due to haemodynamic compromise with WPW and either of atrial flutter/fibrillation
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ECGs

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