The electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-in-Chief: Rim Halaby

Fundamentals of EKG

Basic Principles of Interpretation of an EKG

• Introduction to EKG
• How to read an EKG
• Normal sinus rhythm
• QRS axis and voltage
• Overall overview on electrocardiography

EKG Complexes

• P wave
• QRS complex
• ST segment
• T wave

EKG Intervals

• PR interval
• QRS interval
• QT interval
• ST interval

Abnormal Findings on the EKG

• Delta wave
• H wave
• K wave
• Low QRS voltage
• Nonspecific ST-segment and T-wave changes
• NSSTW changes
• Osborn wave
• P wave alternans
• Poor R wave progression
• PR interval alternans
• QRS complex alternans
• QT prolongation
• Retrograde P wave
• Sine wave pattern
• T wave alternans
• T wave inversion
• Tombstone ST elevation
• U wave

Conduction System

• Cardiac pacemaker
• SA node
• AV node
• Bundle of His
• Purkinje fibers

Tachyarrhythmias

Atrial Arrhythmias

• Atrial fibrillation
• Atrial flutter
• Ectopic atrial rhythm
• Multifocal atrial tachycardia (MAT)
• Paroxysmal atrial tachycardia (PAT) with block
• Premature atrial contractions (PAC)
• Sinus tachycardia
• Supraventricular tachycardia
• Wandering atrial pacemaker

Ventricular Arrhythmias

• Accelerated idioventricular rhythm
• Ventricular fibrillation
• Ventricular parasystole
• Ventricular tachycardia
• Wide complex tachycardias

Bradycardia and Conduction Abnormalities

• Sinus bradycardia
• First degree AV block
• Second degree AV block
• Complete or third-degree AV block
• Concealed conduction
• AV junctional rhythms
• Wolff-Parkinson-White syndrome
• Left bundle branch block
  • Left anterior hemi-block
  • Lefo posterior hemi-block
• Right bundle branch block
• Trifascicular block

EKG Findings in Diseases

Cardiac Hypertrophy and Dilatation

• Left ventricular hypertrophy (LVH)
• Right ventricular hypertrophy (RVH)
• Biventricular hypertrophy
• Left atrial enlargement
• Right atrial enlargement
• Biatrial enlargement

Acute Myocardial Infarction

• NSTEMI
• STEMI
• Tombstone ST elevation
• Right ventricular myocardial infarction
• Atrial infarction

Pre-excitation Syndromes

• Wolff-Parkinson-White syndrome
• Lown-Ganong-Levine syndrome
• Mahaim type preexcitation

Cardiomyopathies

• Arrhythmogenic right ventricular dysplasia
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy

Congenital Heart Diseases

• Dextrocardia
• Atrial septal defect
• Ventricular septal defect
• Tetralogy of Fallot
• The heart in conjoined twins
• Congenital heart block

Inherited Diseases

• Brugada syndrome

Other Heart Diseases

• Pericarditis
• Myocarditis
• Cardiac tamponade
• Sick sinus syndrome
• Long QT syndrome

EKG in Other Disease States

• CNS disease
• Cardiac transplantation
• Trauma
• Hypothermia
• Insect bites

EKG Abnormalities in Electrolyte Disturbances

• Hyperkalemia
• Hypokalemia
• Hypercalcemia
• Hypocalcemia

EKG Abnormalities in Normal Pregnancy (Physiological Changes)

• Left axis deviation
• Right axis deviation
• Q wave in lead III
• T wave inversion
• Increased R/S ratio in V1 and V2
• ST-segment depression (usually after anesthesia for C-section)

Drug Effects on the EKG

• Adenosine
• Amiodarone
• β-blockers
• Bretylium
• Calcium channel blockers
• Digitalis
• Disopyramide
• Encainide
• Flecainide
• Lidocaine
• Lithium
• Phenothiazines
• Phenytoin
• Procainamide
• Propafenone
• Quinidine
• Tocainide
• Tricyclic antidepressants

Technical Issues and Potential Errors in Interpretation

• EKG Artifacts
• EKG lead placement errors
• EKG in a patient with a pacemaker
• EKG in athletes
• Persistent juvenile T-wave pattern
• Postprandial EKG changes

Additional Information

• History of the EKG
• SCP-ECG
• 80 lead ECG