Ecg format 10 disease
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Here is the complete ECG guide for 10 diseases, sourced from Rosen's Emergency Medicine, Harrison's, Goldman-Cecil, Braunwald's Heart Disease, and other authoritative textbooks:
ECG Patterns in 10 Diseases
1. STEMI (ST-Elevation Myocardial Infarction)
Anterior STEMI - ST elevation in V1-V4 (LAD territory):
Anterolateral STEMI - ST elevation in V2-V6, I, aVL:
| Territory | Leads with STE | Culprit Artery |
|---|---|---|
| Anterior | V1-V4 | LAD |
| Inferior | II, III, aVF | RCA / LCx |
| Lateral | I, aVL, V5-V6 | LCx |
| Posterior | V7-V9 (ST depression V1-V3) | RCA / LCx |
| RV | V3R-V4R | Proximal RCA |
Key features:
- ST elevation (obliquely straight or convex morphology) ≥1 mm in ≥2 contiguous limb leads, or ≥2 mm in precordial leads
- Reciprocal ST depression in opposite leads
- Subsequent T-wave inversion and Q-wave formation
- aVR elevation >0.5 mV suggests left main disease (78% sensitive, 83% specific)
- De Winter pattern: J-point depression + prominent T waves in precordials + STE in aVR - indicates proximal LAD occlusion
- Rosen's Emergency Medicine, block 11
2. Left Bundle Branch Block (LBBB)
| Feature | Finding |
|---|---|
| QRS duration | >120 ms (broad) |
| V5/V6 pattern | Broad, notched R wave (M-shape - "plateau") |
| V1 pattern | Deep, broad QS or rS complex |
| Lateral leads (I, V5-V6) | Upright T waves expected (discordant T is abnormal) |
| Septal Q waves | Absent in I, V5-V6 |
New LBBB in the right clinical context is treated as STEMI equivalent. Sgarbossa criteria help identify AMI superimposed on LBBB:
- Concordant ST elevation ≥1 mm in any lead (5 points)
- Concordant ST depression ≥1 mm in V1-V3 (3 points)
- Discordant STE ≥5 mm (2 points) - score ≥3 = AMI
Right Bundle Branch Block (RBBB) features:
- QRS >120 ms
- rSR' ("rabbit ears" / M-shape) in V1
- Wide S wave in I and V6
- ST-T changes discordant with terminal QRS deflection
- Goldman-Cecil Medicine, block 6; Morgan & Mikhail's Clinical Anesthesiology, block 3
3. Atrial Fibrillation (AF)
| Feature | Finding |
|---|---|
| P waves | Absent - replaced by irregular fibrillatory baseline (f-waves) |
| RR intervals | Irregularly irregular |
| QRS morphology | Usually narrow (unless aberrant conduction or WPW) |
| Ventricular rate | Variable (60-200 bpm uncontrolled) |
- No identifiable repeating P-wave morphology
- Baseline shows fine or coarse fibrillatory waves (350-600/min)
- In WPW + AF: rapid, irregular, wide-complex rhythm (pre-excited AF) - life-threatening if rate >200 bpm
- Tintinalli's Emergency Medicine
4. Wolff-Parkinson-White (WPW) Syndrome
The ECG triad during sinus rhythm:
| Feature | Finding |
|---|---|
| PR interval | <120 ms (short) |
| Delta wave | Slurred upstroke on QRS onset |
| QRS duration | >120 ms (broadened by delta wave) |
- Delta wave represents early ventricular activation via the accessory pathway (Bundle of Kent)
- Secondary ST-T changes (discordant to delta wave direction)
- Pseudo-infarct Q waves may occur (mimics inferior or lateral MI)
- Type A WPW: Positive delta waves in V1 (left-sided pathway)
- Type B WPW: Negative delta waves in V1 (right-sided pathway)
- During AVRT: narrow complex tachycardia most common (orthodromic - down AV node, up accessory pathway)
- Tintinalli's Emergency Medicine, block 11
5. Hyperkalaemia
ECG changes progress with rising K⁺ level (Harrison's Principles, 2025):
| Serum K⁺ | ECG Change |
|---|---|
| 5.5-6.5 mM | Tall, peaked (tented), symmetric T waves; shortened QT |
| 6.5-7.5 mM | Loss of P waves; PR prolongation |
| 7.0-8.0 mM | Widened QRS complex |
| >8.0 mM | Sine wave pattern, VF, asystole |
- T waves are narrow-based, symmetric, tall - best seen in precordial leads
- "Sine wave" morphology = impending cardiac arrest
- Treatment: IV calcium gluconate first (membrane stabilization), then insulin/dextrose, sodium bicarbonate, salbutamol
- Harrison's Principles of Internal Medicine 22E, block 6; Miller's Anesthesia, block 12
6. Left Ventricular Hypertrophy (LVH)
Voltage criteria (any one sufficient):
- Sokolow-Lyon: S in V1 + R in V5 or V6 ≥35 mm
- Cornell: R in aVL + S in V3 >28 mm (men), >20 mm (women)
- R in aVL ≥11 mm
Associated features (increase specificity):
- ST depression + T-wave inversion in lateral leads (V5-V6, I, aVL) = "strain pattern"
- Left axis deviation
- Broad, notched P wave in II (P mitrale) - left atrial enlargement
- Deep S in V1-V2
7. Pulmonary Embolism (PE)
ECG changes reflect acute right heart strain - seen in massive/submassive PE:
| Feature | Significance |
|---|---|
| Sinus tachycardia | Most common finding (~44%) |
| S1Q3T3 | S wave in lead I + Q wave in III + T inversion in III |
| New RBBB | Right ventricular pressure overload |
| Right axis deviation | Acute cor pulmonale |
| P pulmonale | Tall P in II (>2.5 mm) - right atrial strain |
| T-wave inversion V1-V4 | Right ventricular strain |
| ST elevation aVR | Severe RV ischemia |
- S1Q3T3 pattern is classic but only present in ~20% of cases - not sensitive
- Sinus tachycardia is the most common ECG finding
- Normal ECG does not rule out PE
- Creasy & Resnik's Maternal-Fetal Medicine, block 14
8. Complete Heart Block (Third-Degree AV Block)
| Feature | Finding |
|---|---|
| P waves | Present at their own rate (atrial rate, e.g. 70-90 bpm) |
| QRS | Present at slower rate (escape rate 30-60 bpm) |
| PR interval | Completely variable - no relationship between P and QRS |
| QRS morphology | Wide (if ventricular escape) or narrow (if junctional escape) |
- Complete AV dissociation: atria and ventricles beat independently
- Atrial rate always faster than ventricular rate
- Escape QRS morphology indicates the escape pacemaker site:
- Junctional (narrow) escape ~40-60 bpm
- Ventricular (wide) escape ~20-40 bpm - less reliable
- Clinical presentation: bradycardia, syncope, heart failure, hypotension
- Braunwald's Heart Disease, block 8; Goldman-Cecil Medicine, block 6
9. Acute Pericarditis
ECG evolves through 4 classic stages:
| Stage | Timing | ECG Change |
|---|---|---|
| Stage 1 | Days 1-2 | Diffuse concave ST elevation (saddle-shaped) + PR depression - all leads except aVR, V1 |
| Stage 2 | 1-2 weeks | ST returns to baseline; T waves flatten |
| Stage 3 | Weeks | T-wave inversion (diffuse) |
| Stage 4 | Weeks-months | Normalization |
Key distinguishing features from STEMI:
- ST elevation is concave (saddle-shaped) in pericarditis vs. convex in STEMI
- PR segment depression (pathognomonic when present) - best seen in II, V5-V6
- Diffuse (multi-lead, multi-territory) elevation rather than territorial
- No reciprocal ST depression (except aVR and V1 show ST elevation + PR depression)
- No Q waves
- Rosen's Emergency Medicine, block 12
10. Long QT Syndrome
QTc measurement:
- QTc = QT / √RR interval (Bazett's formula)
- Normal QTc: <440 ms (men), <460 ms (women)
- Prolonged: >450 ms (men), >470 ms (women)
- High risk for TdP: >500 ms
| Type | Cause | T-wave morphology |
|---|---|---|
| LQT1 (KCNQ1) | Congenital (autosomal dominant) | Broad-based T wave |
| LQT2 (HERG) | Congenital / drug-induced | Notched / bifid T wave |
| LQT3 (SCN5A) | Congenital | Long isoelectric ST, late peaked T |
| Acquired | Drugs, electrolytes | Variable |
Common causes of acquired long QT:
- Drugs: antiarrhythmics (quinidine, sotalol, amiodarone), antibiotics (azithromycin, fluoroquinolones), antipsychotics (haloperidol, quetiapine), antihistamines
- Electrolytes: hypokalaemia, hypomagnesaemia, hypocalcaemia
- Bradycardia, hypothyroidism, myocarditis
Life-threatening complication: Torsades de Pointes (TdP) - polymorphic VT with twisting QRS axis around the baseline
Quick Reference Summary Table
| Disease | Rate | Rhythm | P Wave | PR | QRS | ST/T |
|---|---|---|---|---|---|---|
| STEMI | Normal | Regular | Normal | Normal | Normal (or with BBB) | ST elevation (convex) ± Q waves |
| LBBB | Any | Regular | Normal | Normal/prolonged | Wide >120ms, M in V5-V6 | Discordant ST-T |
| Atrial Fibrillation | Variable | Irregularly irregular | Absent (fibrillatory) | None | Narrow (usually) | Variable |
| WPW | Any | Regular (sinus) | Normal | Short <120ms | Wide (delta wave) | Secondary changes |
| Hyperkalaemia | Slow-normal | Variable | Absent (severe) | Prolonged | Wide (severe) | Peaked T waves |
| LVH | Normal | Regular | Normal | Normal | Wide/voltage | Lateral strain pattern |
| PE | Tachycardia | Regular | Normal/P pulmonale | Normal | RBBB possible | S1Q3T3, T inv V1-V4 |
| Complete Heart Block | Slow (escape) | Regular (escape) | Present (faster rate) | Completely variable | Wide or narrow | Variable |
| Pericarditis | Normal | Regular | Normal | PR depression | Normal | Diffuse concave STE |
| Long QT | Variable | Regular | Normal | Normal | Normal | Prolonged QT |
Sources: Rosen's Emergency Medicine | Harrison's Principles of Internal Medicine 22E (2025) | Goldman-Cecil Medicine | Braunwald's Heart Disease | Tintinalli's Emergency Medicine | Morgan & Mikhail's Clinical Anesthesiology
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