ecg skills enhancement

Postgraduate Education

BS Physical Therapy, Silliman University, 1996

BS Zoology, MSU-Iligan Institute of Technology 1999

Doctor of Medicine, Mindanao State University-College of Medicine

Post-graduate Internship

University of the Philippines, Philippine General Hospital

2003-2004

Internal Medicine Residency

University of the Philippines, Philippine General Hospital

2004-2007

Fellowship in Cardiology

University of the Philippines, Philippine General Hospital

2008-2011

Affiliations

Fellow, Philippine College of Physcians

Fellow, Philippine Heart Association

Diplomate, Philippine College of Cardiology

JILL IRENE Z. CAPISTRANO MD, FPCP, DPCC

Dr. Jill Irene Z. Capistrano, FPCP,DPCCINTERNAL MEDICINE-CARDIOLOGY

P

Q

R

T

QT

interval

PR

interval

ST

interval

QRS

interval

S

STsegment

PRsegment

J point

Normal Intervals

Heart rate 60 - 100 beats/min

bradycardia < 60

tachycardia > 100

PR interval 0.12 – 0.20 sec

QRS < 0.12 sec

QRS axis - 30º to + 110º

QTc < 0.45 sec

Normal P wave morphology

Normal QRS Complex Morphology

Normal T wave morphology

Guide in Reading ECG

• Standardization & technique

• Rhythm

• Rate: atrial & ventricular

• P wave morphology & duration

• P-R interval

• QRS complex morphology & duration

• ST segment

• T-wave

• U wave

• Q-T interval

Determination of Rhythm

RHYTHM

(Sinus? Regular? Irregular?)

• A.

• B.

• C.

• D.

RHYTHM

(Sinus? Regular? Irregular?)

• A.

• B.

• C.

• D.

Determination of Rate

v v

Measurement of Rate

Measurement of Rate

• Formula 1: 300

# big squares between R-R

• Formula 2: 1500

# small squares between R-R

Normal rate? Bradycardia? Tachycardia?

• A.

• B.

• C.

Determination of Axis

III

I

II

aVLaVR

aVF

Standard Locations of Limb Leads

Determination of Axis

Lead I

Lead aVF

Determine the axis of the ff:

• A.

• B.

• C.

Chamber Enlargement

Standard Locations of Chest Leads

Atrial Enlargement

Atrial EnlargementII V1

B

V1

Ventricular Enlargement

RIGHT VENTRICULAR

HYPERTROPHY

Sokolow-Lyon Criteria:

R in V1 + S in V5-V6 > 11 mm

R in V1 > 7mm

R : S in V1 > 1

RAD > +90 degrees

Additional Criteria:

QR in V1

S1 Q3 pattern

S1 S2 S3 pattern

p pulmonale

A 55F hypertensive sought consult at the ER for a blood pressure of

150/100. You requested for ancillary procedures, including an ECG.

20 X 2

Sinus rhythm, normal axis, left ventricular hypertrophy

13 X 2

S in V1 + R in V5 or V6 >

35mmLEFT VENTRICULAR

HYPERTROPHY

A 24 year-old male with Atrial Septal Defect

was admitted for shortness of breath.

Interval between QRS complex < 3major

divisions

1500/# small squares = 1500/12 = 125

beats/min

SINUS TACHYCARDIA

P waves tall and pointed in II and

aVF RIGHT ATRIAL

ENLARGEMENT

QRS downward in lead I and

upright in lead aVF

RIGHT AXIS

DEVIATION

Sinus tachycardia, right axis deviation, right atrial abnormality, right ventricular

hypertrophy

QRS upright in V1

RIGHT VENTRICULAR

HYPERTROPHY

Prominent S waves across precordial

leads

LAE, RAE, RVH

LAE

P pulmonale

RVH

Bundle Branch Block

A 24 year old female admitted for heart murmur.

Normal sinus rhythm, right bundle branch block

QRS complex >120 msec

Delayed intrinsicoid deflection time in

V1

Intrinsicoid

deflection time

RIGHT BUNDLE BRANCH

BLOCK

Normal sinus rhythm, right bundle branch block

RSR’ in V1

Wide S waves in I, V6

RIGHT BUNDLE BRANCH

BLOCK

A 50/M smoker diabetic admitted for

pain.

Sinus rhythm, left bundle branch block

Pseudoinfarct pattern in V1

Monophasic R / notched R in

V6LEFT BUNDLE BRANCH

BLOCK

Myocardial ischemia and

infarction

Myocardial Injury

Criteria:1. Elevation of the origin of ST segment at its junction (J point) with the QRS

of:

a. >1.0 mm (0.10 mV) in >2 limb leads lasting at least 80 msecs

or

b. >2.0 mm (0.20 mV) in >2 precordial leads

Myocardial Injury

Criteria:2. Depression of the origin of ST segment at the J point >1.0 mm

(0.20 mV) in at least 2 leads

*ST segment deviation typically either horizontal or slope toward the direction

of T waves

Myocardial Infarction

Criteria:

1. Development of new Q waves on areas overlying

the infarct which is:

a. >0.04. secs duration

b. >25% of the height of associated R wave

After 2days Several days or months

First dayFirst and second day

Normal

ECG

Onset and first several hours

Occlusion of left descending

coronary artery

Occlusion of left circumflex

coronary artery

Occlusion of right coronary

artery

Exercise ECGs

Thank You!