ECG – ALL YOU WANTED TO KNOW, BUT
YOU WERE AFRAID TO ASK !
L.Křivan
Interní kardiologická klinika FN Brno
Nodes responsible for cardiac rhythm
Electrical cardiac activity can be recorded
ECG (Willem Einthoven 1893)
ECG – limb leads
ECG- precordial leads
ECG – intervals (PQ < 0.2s, QRS < 0.1s, QTc < 0.44s)
Electrical axis of the heart
ECG disorders
RATE
tachy
brady
ION. CHANNELS
LQT, BS
ISCHAEMIA
MI, SCD
CONDUCTION
AV, RBBB,
LBBB, WPW
ORIGIN
supra / ventricular
AVB ( I.st, II.nd, III.rd)
RBBB
LBBB
Conduction disorders
AVB I.st degree (PQ > 0,2s)
PQ = 0.28s
AVB II.nd degree (2/1)
AVB II.nd degree (Mobitz 3/1)
AVB III.rd degree (no secondary, tertiary autom. centre)
AVB III.rd degree (escape rhythm from AV junction)
AVB III.rd degree (escape ventricular rhythm)
Bundle branch block
Right bundle branch block - RBBB
Positive R
Negative S
Left bundle branch block - LBBB
Wide negative S
Wide positive R
Premature atrial contraction
Atrial fibrillation
Atrial flutter
AVNRT
AVRT (WPW)
Supraventricular arrhythmias
Premature atrial contraction (PAC)
Atrial fibrillation (AF)
Atrial fibrillation + slow ventricular response
Atrial flutter
saw tooth pattern II, III, aVF
AVNRT (Atrio Ventricular Nodal Reentry Tachycardia)
RA
LA
LV
RV
SN
AVN
AVNRT (Atrio Ventricular Nodal Reentry Tachycardia)
Accessory pathway
Preexcitation – delta wave
AVRT (Atrio Ventricular Reentry Tachycardia) ORTHO
AVRT (Atrio Ventricular Reentry Tachycardia) ANTI
Delta wave prior to treadmill test
Orthodromic tachycardia (AVRT) with RBBB
Orthodromic tachycardia (AVRT) with RBBB
Atrial fibrillation + accessory pathway
Premature ventricular contraction (PVC)
Ventricular tachycardia
Ventricular fibrillation
Ventricular arrhythmias
PVC (Premature ventricular contractions - bigeminy)
VT LBBB – like
VT RBBB – like
Differential diagnosis of wide complex tachycardia
Wide complex tachycardia (WCT)
WCT
AVRT antidromic
(WPW)
SVT +
frequency BBB
SVT + chronic
BBB
Ventricular
tachycardia
AF with frequency BBB
AF + accessory pathway
VT RBBB – like, VA dissociation and fusion beat
Identic QRS orientation in precordial leads
RS duration > 100ms
100ms
Absence of typical BBB pattern
Ventricular fibrillation (VF terminated by ICD shock)
Subendocardial – angina pectoris
STE Myocardial Infarction
Post MI changes
Ischaemia
ST depressions during treadmill test
STEMI in left main artery occlusion
STEMI in left anterior descending artery occlusion
STEMI inferior wall
STEMI anterior wall (AE)
Post STEMI with formating aneurysm of ant. wall
Terminal rhythm - Electro mechanic dissociation
LQT syndrome
Brugada syndrome
Catecholaminergic polymorphic VT
Ionic channel disorders
LQT syndrome
LQT syndrome + TWA
VF TdP type (Torsades de pointes)
Brugada syndrome
Autosomal hereditary
disorder of genes
responsible for Na and
Ca channels.
Brugada P., Am Coll Cardiol 1992
CPVT – Catecholaminergic polymorphic VT
Mutation of cardiac proteins of Ca exchange. Malignant arrhythmias during
excersice
Bytešník., et al. Cor Vasa 2011;53(Suppl 1)
Anti – bradycardia pacing
Anti – tachycardia pacing
Resynchronization pacing
Pacing
Sinus bradycardia
External pacing
Temporary transvenous pacing
Transvenous pacing from 1958
Arne Larsson 1915 - 2001
Elmquist + Senning 8.10.1958
Single and dual chambre PM
Pacing
UNIPOLAR BIPOLAR
Antitachycardia pacing in ICD
Resynchronization therapy
Principle of CRT
Katz AM. Am J Cardiol. 1988
Effect of resynchronization
LBBB prior to CRT implantation Narrow QRS after CRT implantation
ECG 1
ECG 2
ECG 3
ECG 4 Tachycardia during treadmill test
Wide QRS tachycardia
ECG 4 Tachycardia during treadmill test
Wide QRS tachycardia
Turns to narrow QRS tachycardia
ECG 4 Tachycardia during treadmill test
Conversion to s.r. after CSM
ECG 5
ECG 6
ECG 7
ECG 8
ECG 9
ECG 10
ECG 11
ECG 12
ECG 13
ECG 14
ECG 15
ECG 16
ECG 17
ECG 18