What is the most striking abnormaility?
What else does this ECG show?
Atrial Fibrillation
- Rate: 72
- Rhythm: irregularly irregular
- P waves: no - coarse fibrillatory waves are visible in V1
- QRS: narrow (normal)
- Q waves: no
- ST segment: normal
- T waves: normal
- NB:
What is the most striking abnormaility in this ECG?
Does it show anything else?
Second Degree Heart Block (Mobitz II) 2:1 block
- Rate: 48
- Rhythm: regular
- P waves: Alternately conducted P waves
- QRS: narrow (normal)
- Q waves: ?V1, V2 (possibly deep S wave)
- ST segment: normal
- T waves: normalish
What is the most striking abnormaility?
What else does this ECG show?
Anterior-inferior STEMI
- Rate:66
- Rhythm: reg
- P waves: yes
- QRS: narrow (normal)
- Q waves: Q waves are forming in V1-3, as well as leads III and aVF
- ST segment: ST elevation is present throughout the precordial and inferior leads
- T waves: Hyperacute T waves, most prominent in V1-3
- NB: This pattern is suggestive of occlusion occurring in “type III” or “wraparound” LAD (i.e. one that wraps around the cardiac apex to supply the inferior wall)
https://litfl.com/anterior-myocardial-infarction-ecg-library/
What does this ECG show?
Atrial Fibrillation
- Rate: 124
- Rhythm: irreg-irreg
- P-waves: No
- QRS: Narrow (normal)
- Axis: Normal
- ST: Normal
- T-waves: Normal
What is the most striking abnormaility in this ECG?
Does it show anything else?
1st degree heart block
- Rate:
- Rhythm: regular
- P waves: PR interval > 5 small squares
- QRS: narrow (normal)
- Q waves: no
- ST segment: normal
- T waves: normal
- NB:
What is the most striking abnormaility in this ECG?
Does it show anything else?
Supraventricular Tachycardiac (SVT)
- Rate: 144
- Rhythm: regular
- P waves: no (they’re T waves you can see)
- QRS: Narrow complex tachycardia
- Q waves: no
- ST segment: normal
- T waves: normal
- NB:
https://litfl.com/supraventricular-tachycardia-svt-ecg-library/
What is the most striking abnormaility in this ECG?
Does it show anything else?
Wolff-Parkinson-White (WPW) Syndrome
- Rate: 60
- Rhythm: regular
- P waves: very short PR interval (< 3 small squares/120 ms)
- QRS: Broad QRS complexes because of a slurred upstroke to the QRS complex — the delta wave
- Q waves: negative delta wave in aVL simulating a Q wave
- ST segment: normal
- T waves: Tall R waves and inverted T waves in V1-3 mimicking right ventricular hypertrophy — these changes are due to WPW and do not indicate underlying RVH
- NB: This is rather beyond your necessary knowledge but since you all love guessing WPW in any ECG teaching I thought I’d put it in ;-)
What is the most striking abnormaility?
What else does this ECG show?
Atrial Flutter with 2:1 Block
- Rate: 150
- Rhythm: reg
- P waves: ‘saw-tooth’ inverted flutter waves in II, III + aVF at a rate of 300 bpm (one per big square)
- QRS: narrow (normal)
- Q waves: no
- ST segment: normal
- T waves: normal where seen
- NB: 2:1 AV block resulting in a ventricular rate of 150bpm
What is the most striking abnormaility?
What else does this ECG show?
Atrial Flutter with variable blockRate: ~90
- Rhythm: reg irreg
- P waves: ‘saw-tooth’ inverted flutter waves in II, III + aVF with atrial rate ~ 300 bpm
- QRS: narrow (normal)
- Q waves: no
- ST segment: normal
- T waves: normal where seen
- NB: The degree of AV block varies from 2:1 to 4:1
What is the most striking abnormaility in this ECG?
Does it show anything else?
Ventricular Tachycardia (VT/VTach)
- Rate: 156
- Rhythm: regular
- P waves: no
- QRS: Very Broad (5 small squares/200ms)
NB: Notching near the nadir of the S wave in lead III = Josephson’s sign
https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/
What is the most striking abnormaility?
What else does this ECG show?
Extensive AnteriorLateral STEMI
- Rate: 66
- Rhythm: reg
- P waves: yes
- QRS: narrow (normal)
- Q waves: Q waves in V1-2
- ST segment:
- ST elevation in V1-6 plus I and aVL (most marked in V2-4)
- Minimal reciprocal ST depression in III and aVF
- NB: There is a premature ventricular complex (PVC/ectopic) with “R on T’ phenomenon at the end of the ECG; this puts the patient at risk for malignant ventricular arrhythmias
https://litfl.com/anterior-myocardial-infarction-ecg-library/
What is the most striking abnormaility?
What else does this ECG show?
Atrial Flutter 4:1
- Rate: 66
- Rhythm: reg
- P waves: ‘Saw-tooth’ inverted flutter waves in II, III + aVF at a rate of 260 bpm
- QRS: boarderline broad
- Axis: LAD
- Q waves: no
- ST segment: normal
- T waves: ?
- NB: There is 4:1 block, resulting in a ventricular rate of 65 bpm
What is the most striking abnormaility?
What else does this ECG show?
Old Anteroseptal / Lateral MI
- Rate: 48
- Rhythm: reg
- P waves: yes
- QRS: narrow (normal)
- Q waves: Deep Q waves in V1-3
- ST segment: ST elevation in V1-3
- T waves: Inverted T waves in I, aVL, V1-5
- NB: markedly reduced R wave height in V4
https://litfl.com/anterior-myocardial-infarction-ecg-library/
What is the most striking abnormaility in this ECG?
Does it show anything else?
Complete Heart Block (3rd degree block)
- Rate: 30 (!)
- Rhythm: regularly
- P waves: yes, but not all followed by a QRS and a variable gap between those that are conducted
- QRS: broad
- Q waves: no
- ST segment: ?
- T waves: inverted in many leads
- NB: Apparent disassociation between P waves and a slow, broad QRS suggest complete heart block
What is the most striking abnormaility in this ECG?
Does it show anything else?
2nd Degree Block - Mobitz I (Wenckebach)
- Rate: 72
- Rhythm: regularly irregular
- P waves: PR interval progressively increases from one complex to the next until a P wave is not conducted
- QRS: narrow (normal)
- Q waves: no
- ST segment: normal
- T waves: normal
- NB: The P:QRS conduction ratio varies from 5:4 to 6:5
https://litfl.com/av-block-2nd-degree-mobitz-i-wenckebach-phenomenon/
What is the most striking abnormaility?
What else does this ECG show?
Atrial Fibrillation
- Rate: 108
- Rhythm: irregularly irregular
- P waves: no - coarse fibrillatory waves are visible in V1
- QRS: narrow (normal)
- Q waves: no
- ST segment: ST depression is visible in V6, II, III and aVF
- T waves:
- NB: “Sagging” ST segment depression is visible in V6, II, III and aVF, suggestive of digoxin effect
What is the most striking abnormaility in this ECG?
Does it show anything else?
Ventricular Tachycardia (VT/VTach)
Rate: 156
Rhythm: regular
P waves: no
QRS: Very Broad (>5 small squares/200ms)
NB: Joesphson’s sign – Notching near the nadir of the S wave is seen in leads II, III, aVF
https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/
What is the most striking abnormaility?
What else does this ECG show?
Anterioseptal/lateral STEMI.
- Rate 78
- Rhythms: reg
- P-waves: Prolonged PR
- QRS: Narrow
- Axis: Normal
- ST: Elevation V1-V5 & I
- T-wave: Inverted in III
- Q-waves: V3 & V4
- NB: Ventricular ectopic
https://litfl.com/anterior-myocardial-infarction-ecg-library/
What is the most striking abnormaility?
What else does this ECG show?
Extensive anterior MI (“tombstoning” pattern)
- Rate: 120
- Rhythm: essentially regular
- P waves: difficult to determine
- QRS: narrowish (difficult to determine start/end of QRS complex)
- Q waves:
- ST segment: Massive ST elevation throughout the precordial (V1-6) and high lateral leads (I, aVL)
- T waves: “tombstone” morphology is present
- NB: This pattern is seen in proximal LAD occlusion and indicates a large territory infarction with a poor LV ejection fraction and high likelihood of cardiogenic shock and death
https://litfl.com/anterior-myocardial-infarction-ecg-library/
What is the most striking abnormaility in this ECG?
Does it show anything else?
Supraventricular Tachycardiac (SVT)
- Rate: 222
- Rhythm: regular
- P waves: no (they’re T waves you can see)
- QRS: Narrow complex tachycardia
- Q waves: no
- ST segment: ST depression in all leads
- T waves: normal
- NB: Widespread ST depression — this is a common electrocardiographic finding in AVNRT and does not necessarily indicate myocardial ischaemia, provided the changes resolve once the patient is in sinus rhythm
https://litfl.com/supraventricular-tachycardia-svt-ecg-library/
What is the most striking abnormaility in this ECG?
Does it show anything else?
2nd Degree Block - Mobitz I (Wenckebach)
- Rate: 66
- Rhythm: regularly irregular
- P waves: PR interval progressively increases from one complex to the next until a P wave is not conducted
- QRS: narrow (normal)
- Q waves: none
- ST segment: normal
- T waves: normal
- NB:
- The Wenckebach pattern here is repeating in cycles of 5 P waves to 4 QRS complexes (5:4 conduction ratio).
- The increase in PR interval from one complex to the next is subtle. However, the difference is more obvious if you compare the first PR interval in the cycle to the last.
- The P-P interval is relatively constant despite the irregularity of the QRS complexes.
https://litfl.com/av-block-2nd-degree-mobitz-i-wenckebach-phenomenon/
What is the most striking abnormaility in this ECG?
Does it show anything else?
Inferior STEMI (with a Heart Block)
- Rate: 48
- Rhythm: regular (mostly)
- P waves: alternately unconducted P waves*
- QRS: narrow (normal)
- Q waves: no
- ST segment: Elevation in the inferior leads II, III and aVF (with reciprocal changes in the hight lateral leads I and aVL)
- T waves: Inverted in V1, V2
- NB: If you said a block then congratulate yourself.
- The majority of the rhythm strip shows 2:1 AV conduction, which makes identification of the type of block difficult (i.e. it could represent Mobitz I or Mobitz II).
- However, there is a single 3:2 Wenckebach cycle visible in the middle of the rhythm strip (QRS complexes 5 + 6). If you look hard, you can see a non-conducted P wave deforming the downslope of the T wave in complex 6.
- Continuous rhythm strip recording revealed that this patient was indeed in Mobitz I AV block.
What is the most striking abnormaility?
What else does this ECG show?
AF with rapid ventricular response
- Rate: 132
- Rhythm: irregularly irregular
- P waves: no - coarse fibrillatory waves in V1
- QRS: narrow (normal)
- Q waves: no
- ST segment: normal
- T waves: normal
- NB:
What is the most striking abnormaility?
What else does this ECG show?
Extensive Anterolateral STEMI
- Rate: 84
- Rhythm: reg
- P waves: yes
- QRS: Narrow (normal)
- Axis: ?LAD
- Q waves: No
- ST segment:
- ST elevation in V2-6, I and aVL
- Reciprocal ST depression in III and AVF
- T waves: upright apart from aVR & V1 (normal)
https://litfl.com/anterior-myocardial-infarction-ecg-library/
