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Kim A. Eagle, M.D. University of Michigan Health System ElectrocardiogramElectrocardiogram Cardiovascular Sequence Fall 2008
Electrocardiogram The Normal EKG: Outline Electrical Measurement - Single Cell EKG Reference System - Technical Considerations - Sequence of Activation Interpretation - Calibration - Rhythm - Rate - Intervals - QRS Axis - P-waves - QRS - ST-T wave abnormalities
Electrical Measurement Single Cell Key Concepts - Resting state - polarized - Depolarization - Repolarization - Directionality
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 81
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 82
EKG Lead Reference System Unipolar Bipolar Chest Leads
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Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 84
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 86
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85
Magnitude and Direction of Electrical Activity Key Principles: –Electrical force directed at (+) pole of a lead generates upward EKG deflection –Forces directed away from (+) pole generate downward deflection –Magnitude of deflection reflects how parallel the electrical force to lead –Forces directed perpendicular to a lead generate no activity or flat line
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Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 87
Sequence of Normal Cardiac Activation
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 87
A Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 89
DE Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 89 (Both Images)
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 90 (Both Images)
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 90
EKG Interpretation: 8 Steps 1.Check voltage calibration 2.Heart rhythm 3.Heart rate 4.Intervals (PR, QRS, ST) 5.Mean QRS axis 6.Abnormalities of P-waves 7.Abnormalities of QRS (hypertrophy, bundle branch block, infarction) 8.ST and T wave abnormalities
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Heart Rhythm Sinus Rhythm Rate > 60 BPM < 100 BPM
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Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 94
Electrocardiographic Intervals IntervalNormal Decreased in Increased in PR sec Pre excitation syndrome First-degree AV block (3-5 small boxes) Junctional rhythm QRS < 0.10 sec Bundle branch blocks (< 2.5 small boxes) Ventricular ectopic beat Toxic drug effect (e.g., quinidine) Toxic drug effect (e.g., quinidine) Severe hyperkalemia Severe hyperkalemia QT Corrected Qt a < 0.44 sec Hypercalcemia Hypocalcemia Tachycardia Hypokalemia ( QU interval due Tachycardia Hypokalemia ( QU interval due to U wave) to U wave) Hypomagnesemia Hypomagnesemia Myocardial ischemia Myocardial ischemia Congenital prolongation of QT Congenital prolongation of QT Toxic drug-effect (e.g., quinidine) Toxic drug-effect (e.g., quinidine) K. Eagle
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Atrial Abnormalities Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 97
Ventricular Hypertrophy Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 98
Ventricular Hypertrophy Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 98
Bundle Branch Blocks RBBB Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 99
Bundle Branch Blocks LBBB Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 99
The EKG of Myocardial Infarction Concept of ST elevation vs. Non STE Localization of MI Evolution of EKG changes in MI Concept of Q waves
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Localization of MI Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 104
Localization of MI Anatomic SitesEKG LeadsCoronary Anatomy InferiorII, III, AVFRCA SeptalV 1, V 2 LAD AnteriorV 3, V 4 LAD (distal) AnterolateralI, AVLLCX AnteroapicalV 5, V 6 Any of 3 K. Eagle
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Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 103
Additional Source Information for more information see: Slide 6: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 81 Slide 7: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 81 Slide 8: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 82 Slide 9: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 82 Slide 10: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 82 Slide 12: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 83 Slide 13: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 84 Slide 14: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 84 Slide 15: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 86 Slide 16: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85 Slide 18: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85 Slide 19: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85 Slide 20: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85 Slide 21: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85 Slide 22: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 87 Slide 24: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 87 Slide 25: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 89 Slide 26: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 89 Slide 27: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 89 (Both Images) Slide 28: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 90 (Both Images) Slide 29: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 90 (Both Images) Slide 30: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 90 Slide 32: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 91 Slide 34: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 93 Slide 35: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 93 Slide 36: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 94 Slide 37: K. Eagle Slide 38: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 95 Slide 39: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 97 Slide 40: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 98 Slide 41: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 98 Slide 42: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 99 Slide 43: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 99 Slide 45: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 106 Slide 46: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 106 Slide 47: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 104 Slide 48: K. Eagle
Slide 49: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 105 Slide 50: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 103 Slide 51: Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 103