Transcript Practice ECGs - Texas Tech University

Practice ECGs
Part I
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Objectives

Develop a systematic approach for infarct
recognition on the ECG.

Gain familiarity with 12-Lead ECG
interpretation.
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Reviewing a 12-Lead ECG

Assess the quality of the tracing.

Identify the rate and underlying rhythm.

Examine for evidence of infarction.
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Reviewing a 12-Lead ECG

Ascertain if infarct impostors are present that
may account for ECG changes.

Clinical presentation.

Interpret your findings.
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Infarct Impostors

Left bundle branch block

Ventricular rhythms

Left ventricular hypertrophy

Pericarditis

Early repolarization
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Figure 9-1
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Figure 9-1
Poor R wave progression
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Figure 9-1
Baseline wander
or artifact?
Baseline wander V1
Interpretation:
Underlying
rhythm?
Sinus rhythm at 83 bpm
Extensive anterior
infarction, reciprocal
changes
Pathologic Q
waves?
Leads: III?, V2, V3
Low voltage over
entire tracing
Poor R wave
progression?
Leads: V5
ST-segment
elevation?
Leads: I, aVL, V1 – V6
ST-segment
depression?
Leads: II, III, aVF
T wave changes?
Leads: Inversion III,
aVF; tall V3 – V5
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Practice 9-2

32-year-old Caucasian woman
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Practice 9-2

32-year-old Caucasian woman
Artifact
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Practice 9-2
Baseline
wander or
artifact?
Artifact in aVR
Underlying
rhythm?
Sinus rhythm
at 75 bpm
Interpretation:
Normal ECG
PR interval 160 ms
QRS 80 ms
QT/QTc 414/462 ms
P-R-T axes 62 42 31
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Figure 9-3
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Figure 9-3
Baseline wander
Baseline wander
Baseline wander
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Figure 9-3
Baseline
wander or
artifact?
Baseline wander
in II, III, aVL
Underlying
rhythm?
Sinus rhythm at
93 bpm
Pathologic Q
waves?
Leads: III, aVF
ST-segment
elevation?
Leads: V2, V3;
slight in V1
Interpretation:
Anteroseptal infarction,
previous inferior wall
infarction; low voltage in
lead II
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Figure 9-4
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Figure 9-4
Underlying
rhythm?
Sinus bradycardia at
55 bpm with
occasional PVCs
Interpretation:
Sinus bradycardia with
occasional PVCs,
otherwise normal ECG
PR interval 142 ms
QRS 94 ms
QT/QTc 436/417 ms
P-R-T axes 60 14 54
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Figure 9-5
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Figure 9-5
Baseline wander
Baseline wander
Baseline wander
Poor R wave progression
Baseline wander
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Figure 9-5
Baseline wander or
artifact?
Baseline wander in I, II,
V1, V6
Underlying rhythm?
Atrial fib at 100 bpm
Pathologic Q
waves?
Leads: aVL
Poor R wave
progression?
Leads: V2
ST-segment
elevation?
Leads: I, aVL, V1 – V5
ST-segment
depression?
Leads: II, III, aVF
T wave changes?
Leads: Peaked T wave
V2, tall/peaked V3, V4
Interpretation:
Anteroseptal
infarction with lateral
extension; reciprocal
changes noted
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Figure 9-6

67-year-old Caucasian woman
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Figure 9-6

67-year-old Caucasian woman
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Figure 9-6
Underlying
rhythm?
Sinus rhythm at
75 bpm
Interpretation:
Left bundle branch block
ST-segment
elevation?
Leads: V1 – V3
ST-segment
depression?
Leads: V4 – V6
PR interval 130 ms
QRS 144 ms
QT/QTc 406/453 ms
P-R-T axes 13 -16 58
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Figure 9-7

71-year-old Caucasian woman
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Figure 9-7

71-year-old Caucasian woman
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Figure 9-7
Underlying
rhythm?
Sinus bradycardia
at 56 bpm
ST-segment
elevation?
Leads: II, III, aVF
Interpretation:
Inferior infarction – age
undetermined, ST & T wave
abnormality – consider lateral
ischemia
PR interval 168 ms
ST-segment
depression?
T wave
changes?
Leads: I, aVL
QRS 88 ms
Leads: I, aVL
QT/QTc 424/402 ms
P-R-T axes 7 0 101
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Figure 9-8

42-year-old Caucasian woman
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Figure 9-8
Underlying
rhythm?
Sinus arrhythmia
at 67 bpm
Interpretation:
Normal ECG
ST-segment
depression?
Leads: III
T wave
changes?
Leads:
Inversion in V1
PR interval 164 ms
QRS 66 ms
QT/QTc 392/414 ms
P-R-T axes 81 84
61
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Figure 9-9
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Figure 9-9
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Figure 9-9
Baseline wander
or artifact?
Artifact I, II, III, aVL, V1
Underlying
rhythm?
Sinus rhythm at 77 bpm
Pathologic Q
waves?
Leads: V5, V6; Q wave
approaching 40 ms in V4
ST-segment
elevation?
Leads: V1, V2, V3
ST-segment
depression?
Leads: V5, V6
T wave changes?
Leads: Tall in V2-V4;
peaked in II, aVF, V2-V6;
inverted in aVL
Interpretation:
Anteroseptal infarction,
possible previous lateral
infarction. Nearing
voltage criteria for LVH.
Pattern similar to early
repolarization.
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Figure 9-10

58-year-old Caucasian man
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Figure 9-10

58-year-old Caucasian man
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Figure 9-10
Underlying
rhythm?
Sinus
bradycardia at
58 bpm
Interpretation:
ST-segment
elevation?
Leads: I, aVL,
V2 – V6
PR interval 184 ms
Extensive anterior
infarction
QRS 92 ms
QT/QTc 416/409 ms
ST-segment
depression?
Leads: II, III,
aVF
P-R-T axes 39 16 16
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Figure 9-11

42-year-old Caucasian man
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Figure 9-11
Underlying
rhythm?
Sinus
bradycardia at
56 bpm
Interpretation:
Sinus bradycardia,
otherwise normal ECG
PR interval 126 ms
QRS 100 ms
QT/QTc 432/416 ms
P-R-T axes 51 24 29
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Figure 9-12
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Figure 9-12
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Figure 9-12
Underlying
rhythm?
Sinus tachycardia at
107 bpm
ST-segment
elevation?
Leads: I, aVL, V1–V5
ST-segment
depression?
Leads: II, III, aVF
T wave
changes?
Leads: Tall/peaked
V2 – V4; inverted in III
Interpretation:
Anteroseptal
infarction, reciprocal
changes present
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Figure 9-13
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Figure 9-13
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Figure 9-13
Underlying
rhythm?
ST-segment
elevation?
ST-segment
depression?
Sinus rhythm
at 71 bpm
Leads: II, III,
aVF
Leads: V1 – V4
Interpretation:
Inferior infarction; low
QRS voltage (<0.5 mV)
in limb leads
PR interval 144 ms
QRS 108 ms
QT/QTc 376/398 ms
P-R-T axes 43 44 38
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Figure 9-14
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Figure 9-14
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Figure 9-14
Underlying
rhythm?
Junctional rhythm at
55 bpm
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Interpretation:
Inferior infarction;
marked ST depression
consistent with
subendocardial injury
PR interval 0 ms
Leads: I, aVL, V1 – V4
QRS 104 ms
QT/QTc 448/436 ms
P-R-T axes 999 58 84
T wave
changes?
Leads: Inverted in
aVL, V1
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Figure 9-15

71-year-old Caucasian woman
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Figure 9-15

71-year-old Caucasian woman
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Figure 9-15
Baseline
wander or
artifact?
Artifact V1,
baseline wander
V2
Underlying
rhythm?
Sinus rhythm at
74 bpm
Interpretation:
Right bundle branch
block, inferior infarction –
age undetermined
PR interval 168 ms
QRS 130 ms
QT/QTc 388/430 ms
Pathologic Q
waves?
Leads: III, aVF
T wave
changes?
Leads: Inverted
V1, V2
P-R-T axes 60 -21 46
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Figure 9-16
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Figure 9-16
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Figure 9-16
Underlying
rhythm?
Sinus rhythm at
67 bpm
Interpretation:
Right bundle branch block
PR interval
208 ms
QRS
122 ms
QT/QTc
P-R-T axes
430/454 ms
33 80 6
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Figure 9-17
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Figure 9-17
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Figure 9-17
Underlying
rhythm?
Sinus tachycardia
with short PR
interval, short QT
interval
Interpretation:
Inferior infarction
PR interval 116 ms
QRS 76 ms
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: I, aVL
T wave
changes?
Leads: Inverted
in aVL, V1
QT/QTc 228/306 ms
P-R-T axes 59 2 77
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Figure 9-18

59-year-old Caucasian woman
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Figure 9-18
Underlying
rhythm?
Sinus
bradycardia at
58 bpm
Interpretation:
Sinus bradycardia,
otherwise normal ECG
PR interval 122 ms
QRS 86 ms
QT/QTc 416/408 ms
P-R-T axes 41 54 22
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Figure 9-19
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Figure 9-19
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Figure 9-19
Underlying
rhythm?
Sinus rhythm
at 81 bpm
Pathologic Q
waves?
Leads: III
Interpretation:
Inferior infarction
PR interval 184 ms
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: I, aVL, V5, V6
T wave
changes?
QRS 92 ms
Leads: Inverted in I,
aVL
QT/QTc 352/389 ms
P-R-T axes 60 23 106
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Figure 9-20
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Figure 9-20
Poor R wave progression
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Figure 9-20
Baseline wander
or artifact?
Baseline wander and
artifact in lead I, artifact
in II, III, aVL
Underlying
rhythm?
Sinus rhythm at 91 bpm
Pathologic Q
waves?
Leads: II?, III, aVF
Poor R wave
progression?
Leads: V3; no initial R
wave in V1
ST-segment
elevation?
Leads: V1 – V4
ST-segment
depression?
Leads: II
T wave
changes?
Leads: Flattened T
wave aVL
Interpretation:
Anteroseptal
infarction,
possible previous
inferior infarction
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Figure 9-21
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Figure 9-21
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Figure 9-21
Baseline
wander or
artifact?
Baseline wander
V5, V6
Underlying
rhythm?
Sinus rhythm
at 95 bpm
ST-segment
elevation?
Leads: V1 – V3
ST-segment
depression?
Leads: II, III, V5, V6
T wave
changes?
Leads: Inverted in
aVL
Interpretation:
Septal infarction,
possible anterior
epicardial injury
PR interval 164 ms
QRS 96 ms
QT/QTc 380/433 ms
P-R-T axes 62 -62 83
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Figure 9-22

88-year-old Caucasian man
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Figure 9-22

88-year-old Caucasian man
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Figure 9-22
Underlying
rhythm?
ST-segment
depression?
Sinus rhythm at
65 bpm
Interpretation:
Inferolateral ischemia
Leads: II, III,
aVF, V4 – V6
Note: This is the same
patient as in figure 9-26 –
29 minutes after the ECG in
figure 9-26 was obtained
PR interval 182 ms
T wave
changes?
Leads: II, III,
aVF, V5 – V6
QRS 82 ms
QT/QTc 410/426 ms
P-R-T axes 76 52 -79
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Figure 9-23
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Figure 9-23
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Figure 9-23
Baseline wander
or artifact?
Baseline wander lead I
Underlying
rhythm?
Sinus rhythm at 88 bpm
Pathologic Q
waves?
Leads: V2-V4
ST-segment
elevation?
Leads: II, III, aVF, V4 – V6
ST-segment
depression?
Leads: V1
T wave
changes?
Leads: Peaked in II, III,
aVF, V3, V4
Interpretation:
Low voltage
throughout
tracing. Inferior
infarction, lateral
extension
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Practice 9-24

64-year-old Caucasian woman
Artifact
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Practice 9-24
Baseline
wander or
artifact?
Artifact in V1
Interpretation:
Normal ECG
Underlying
rhythm?
Sinus rhythm at
78 bpm
PR interval 154 ms
QRS 80 ms
QT/QTc 394/449 ms
P-R-T axes 77 78 55
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Figure 9-25
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Figure 9-25
Artifact
Artifact
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Figure 9-25
Underlying
rhythm?
Sinus rhythm at
69 bpm with
occasional PVCs
Interpretation:
RSR (QR) in V1/V2
consistent with right
ventricular conduction
delay
PR interval 172 ms
QRS
104 ms
QT/QTc 400/420 ms
P-R-T axes 74 69 44
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Figure 9-26
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Figure 9-26
Baseline wander
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Figure 9-26
Baseline
wander or
artifact?
Baseline wander
V2
Interpretation:
Lateral ischemia
Underlying
rhythm?
Sinus rhythm at
67 bpm with
occasional
PVCs
PR interval 190 ms
ST-segment
depression?
Leads: II,
aVF, V3-V6
P-R-T axes 76 53
111
T wave
changes?
Leads: V5, V6
QRS 82 ms
QT/QTc 408/431
ms
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Figure 9-27
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Figure 9-27
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Figure 9-27
Underlying
rhythm?
Sinus rhythm at
100 bpm
Pathologic Q
waves?
Leads: III
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: aVL
T wave
changes?
Leads: aVL
Interpretation:
Inferior infarction
PR interval 180 ms
QRS 96 ms
QT/QTc 380/436 ms
P-R-T axes 73 35 84
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Figure 9-28

88-year-old Caucasian woman
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Figure 9-28

88-year-old Caucasian woman
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Figure 9-28
Baseline
wander or
artifact?
Baseline wander
V5, V6
Interpretation:
Septal infarction,
possible anterior
epicardial injury
Underlying
rhythm?
Sinus rhythm at
95 bpm
ST-segment
elevation?
Leads: V1- V3
ST-segment
depression?
Leads: II, III, V5,
V6
QT/QTc 380/433
ms
T wave
changes?
Leads: Inverted
in aVL
P-R-T axes 62 -62
83
PR interval 164 ms
QRS 96 ms
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Figure 9-29
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Figure 9-29
Underlying
rhythm?
Electronic atrial
pacemaker at 80
bpm
Interpretation:
Electronic atrial pacemaker
PR interval 626 ms
QRS
92 ms
QT/QTc 358/412 ms
P-R-T axes 0 52 16
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Figure 9-30

39-year-old Caucasian man
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Figure 9-30
Underlying
rhythm?
Sinus tachycardia
with nonconducted
(blocked) premature
atrial complexes at 92
bpm
Interpretation:
Sinus tachycardia with
nonconducted
(blocked) premature
atrial complexes,
otherwise normal ECG
PR interval 156 ms
QRS 88 ms
QT/QTc 326/403 ms
P-R-T axes 54 26 54
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Figure 9-31
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Figure 9-31
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Figure 9-31
Underlying
rhythm?
Sinus rhythm at
62 bpm
ST-segment
elevation?
Leads: V2 – V5
Interpretation:
Anterolateral infarction;
meets minimal voltage
criteria for LVH, may be
normal variant
PR interval 168 ms
ST-segment
depression
?
Leads: II, III, aVF
QRS 100 ms
QT/QTc 388/393 ms
P-R-T axes 55 -29 35
T wave
changes?
Leads: Tall in
V2 – V5
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Figure 9-32

66-year-old Caucasian woman
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Figure 9-32

66-year-old Caucasian woman
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Figure 9-32
Underlying
rhythm?
ST-segment
elevation?
Sinus rhythm at
82 bpm
Leads: V1
Interpretation:
Incomplete right
bundle branch block
PR interval 136 ms
ST-segment
depression?
Leads: II, III,
aVF, V5, V6
QRS 96 ms
QT/QTc 388/453 ms
P-R-T axes 62 12 27
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Figure 9-33
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Figure 9-33
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Figure 9-33
Baseline wander
or artifact?
Baseline wander II, III,
aVL, aVF
Underlying
rhythm?
Sinus rhythm with firstdegree AV block at 66
bpm with occasional
supraventricular
premature complexes
Pathologic Q
waves?
Leads: II, III, aVF
ST-segment
elevation?
Leads: II, III, aVF
ST-segment
depression?
Leads: I, aVL, V1 – V6
T wave
changes?
Leads: Tall in II, III, aVF;
depressed in I, aVL,
V1 – V3
Interpretation:
Inferior infarction,
reciprocal changes
present
PR interval 260 ms
QRS 104 ms
QT/QTc 444/458 ms
P-R-T axes 90 -75
105
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Figure 9-34

86-year-old Caucasian woman
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Figure 9-34

86-year-old Caucasian woman
Baseline wander
Baseline wander
Baseline wander
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Figure 9-34
Baseline
wander or
artifact?
Underlying
rhythm?
Baseline wander
V4 – V6
Atrial fibrillation
at 107 bpm
Interpretation:
Atrial fibrillation with
rapid ventricular response
PR interval None
QRS 90 ms
QT/QTc 304/405 ms
ST-segment
depression?
Leads: V6
T wave
changes?
Leads: Tall in V2
P-R-T axes None 69 17
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Figure 9-35

69-year-old Caucasian woman
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Figure 9-35

69-year-old Caucasian woman
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Figure 9-35
Underlying
rhythm?
Sinus rhythm at
73 bpm
ST-segment
elevation?
Leads: V1 – V2
Interpretation:
Left bundle branch block
PR interval 136 ms
ST-segment
depression?
Leads: I, II, aVL,
aVF, V5 – V6
QRS 144 ms
QT/QTc 438/482 ms
P-R-T axes 28 -5 238
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