The electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-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 in EKG

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

Conduction System

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

Tachyarrhythmias

Atrial Arrhythmias

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

Ventricular Arrhythmias

• Ventricular tachycardia
• Ventricular fibrillation
• Differential diagnosis of tachycardia with a wide QRS complex
• Accelerated idioventricular rhythm
• Ventricular parasystole
• Premature ventricular contractions
• Ventricular Tachycardia Including Torsades De Pointes and Polymorphic Ventricular Tachycardia
• Sudden cardiac death

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

Drug Effects on the EKG

• Digitalis
• Quinidine
• Procainamide
• Disopyramide
• Lidocaine
• Tocainide and Mexiletine
• Phenytoin
• Encainide, Flecainide and Propafenone
• β-blockers
• Amiodarone
• Bretylium
• Ca Channel Blockers
• Adenosine
• Phenothiazines
• Tricyclic Antidepressants
• Lithium

Technical Issues and Potential Errors in Interpretation

• EKG Artifacts
• EKG lead placement errors
• EKG in a patient with a pacemaker
• EKG in athletes

Additional Information

• History of the EKG