20 heart diseases and their specific ECG findings with ECGs
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I now have excellent textbook content and ECG images from authoritative sources. Let me compile a comprehensive response covering 20 heart diseases with their specific ECG findings and images.
20 Heart Diseases and Their Specific ECG Findings
1. ST-Elevation Myocardial Infarction (STEMI) - Anterolateral
ECG Findings:
- ST elevation in V1-V4 (anterior leads) and I, aVL, V5, V6 (lateral leads)
- Reciprocal ST depression in leads III, aVF
- Development of Q waves in infarcted territory
- Hyperacute (peaked) T waves in early phase
- Proximal LAD occlusion with thrombus
Anterolateral STEMI: ST elevation in V1-V4 (anterior) and I, aVL, V5, V6 (lateral). Proximal LAD lesion confirmed at emergent PCI. - Rosen's Emergency Medicine
2. Inferior STEMI
ECG Findings:
- ST elevation in II, III, aVF (inferior leads) - ≥2 contiguous inferior leads required
- Reciprocal ST depression in leads I and aVL
- ST elevation greater in III than II = 90% sensitive for RCA occlusion
- ST elevation in V1 with inferior STEMI suggests concomitant right ventricular infarction
- Left circumflex occlusion: III elevation NOT > II, aVL isoelectric or elevated
Inferior STEMI: Marked ST elevation inferiorly (II, III, aVF). Classic reciprocal ST depression in I and aVL. - Rosen's Emergency Medicine
3. Posterior Myocardial Infarction
ECG Findings:
- No direct ST elevation on standard 12-lead (no posterior electrodes)
- Reciprocal changes in V1-V3: horizontal ST depression + upright T wave
- Tall, wide R wave in V1-V2 (mirror image of posterior Q wave)
- R:S ratio >1 in V1-V2
- Posterior leads V8-V9: direct ST elevation (increases sensitivity)
- Occurs in ~15-20% of all AMIs, usually with inferior or inferolateral MI
Posterior MI: V8 and V9 posterior leads showing subtle ST elevation (arrows), consistent with acute posterior wall MI. Horizontal ST depression and tall R waves in V1-V2 are the mirror-image findings. - Rosen's Emergency Medicine
4. de Winter Pattern (Proximal LAD Occlusion)
ECG Findings:
- J-point depression with upsloping ST depression in anterior leads (V1-V6)
- Prominent, hyperacute (tall, peaked) T waves in anterior leads
- ST elevation in aVR
- No classic ST elevation - this pattern is a "STEMI equivalent"
- Indicates proximal LAD obstruction
"The de Winter electrocardiographic finding, a pattern associated with proximal left anterior descending coronary artery obstruction. In the anterior leads, ST segment depression with depression of the J point is noted along with prominent, hyperacute T wave. In addition, ST segment elevation is also seen in lead aVR." - Rosen's Emergency Medicine
5. High Lateral STEMI
ECG Findings:
- ST elevation in leads I and aVL
- Reciprocal ST depression in III, aVF, and V1
- ST elevation in V2 may also be seen
- Indicates obstruction of left circumflex or first diagonal (D1) artery
6. Wolff-Parkinson-White (WPW) Syndrome
ECG Findings (classic triad during sinus rhythm):
- Short PR interval (<120 ms) - due to pre-excitation via accessory pathway
- Delta wave - slurred upstroke at the beginning of the QRS complex
- Widened QRS complex (>120 ms) - from ventricular pre-excitation
- Secondary ST/T wave changes (discordant to QRS)
- During tachycardia: narrow complex (orthodromic AVRT) or wide complex (antidromic AVRT)
- Associated with ventricular fibrillation if atrial fibrillation occurs through the accessory pathway
Top right: WPW - delta wave (slurred QRS upstroke) with short PR interval. Bottom left: Brugada - dome-shaped ST elevation in V1-V3. Bottom right: Ventricular fibrillation. - Miller's Review of Orthopaedics
7. Brugada Syndrome
ECG Findings (Type 1 - diagnostic):
- Coved-type (dome-shaped) ST elevation ≥2 mm in V1-V2 (sometimes V3), followed by a negative T wave
- Right bundle branch block (RBBB) pattern
- Type 2: "Saddle-back" ST elevation (≥2 mm J-wave, ≥1 mm ST elevation above baseline)
- Pattern may be dynamic - can appear normal between episodes
- Associated with syncope and sudden cardiac death from VF/VT
- Triggered/unmasked by fever, sodium channel blockers, vagotonic states
8. Long QT Syndrome (LQTS)
ECG Findings:
- Prolonged QT interval - corrected QTc >450 ms in males, >460 ms in females
- T wave morphology abnormalities: broad, notched, or biphasic T waves
- Predisposes to Torsades de Pointes (polymorphic VT)
- Associated with sudden cardiac death
- Each LQTS genetic subtype has characteristic T-wave morphology
Long QT Syndrome: The dotted line shows prolonged QT interval extending beyond the normal QT endpoint. Prolonged QTc >450 ms is a risk factor for torsades de pointes and sudden cardiac death. - Miller's Review of Orthopaedics
9. Ventricular Fibrillation (VF)
ECG Findings:
- Completely chaotic, irregular electrical activity
- No discernible P waves, QRS complexes, or T waves
- Irregular, rapid undulations of varying amplitude and frequency
- Rate: 300-600 "depolarizations" per minute
- Immediately life-threatening - no organized cardiac output
- Often preceded by VT or preceded by R-on-T phenomenon
Ventricular fibrillation: Completely disorganized electrical activity with no identifiable waveforms. - Miller's Review of Orthopaedics
10. Hypertrophic Cardiomyopathy (HCM)
ECG Findings:
- Left ventricular hypertrophy (LVH) - deep S waves in V1-V3 (often >25-30 mm)
- Narrow septal Q waves in lateral leads (V5, V6, I, aVL) - from septal hypertrophy
- Upright T waves in leads with septal Q waves (V3, V6) - characteristic pattern
- Left atrial enlargement (broad, notched P waves)
- May show atrial fibrillation or atrial flutter
- Deep T-wave inversions in lateral leads if ischemic component
HCM: Deep S-wave (28 mm) in V3 (LVH, large arrow). Narrow septal Q waves in V5-V6 (arrowheads). Upright T waves in V3 and V6, typical of HCM. Atrial flutter with 2:1 block - extra P waves visible in ST segments (small arrows). - Tintinalli's Emergency Medicine
11. Acute Pericarditis
ECG Findings (4 phases):
- Phase 1 (days 1-2): Diffuse ST elevation (saddle-shaped, concave up) in most leads; PR depression in most leads (PR elevation in aVR); no Q waves; no reciprocal ST depression (key differentiator from STEMI)
- Phase 2 (days 3-7): ST returns to baseline; T-wave amplitude decreases and flattens
- Phase 3 (weeks 1-3): T-wave inversions; ST isoelectric
- Phase 4: Complete resolution
- Spitzberg sign: ST/T ratio >0.25 in V6
- Low voltage in all leads if large pericardial effusion present
Classic pericarditis ECG progression: Phase 1 (7/11) - diffuse ST elevation. Phase 2 (7/18) - ST normalizes, T-wave flattening. Phase 3 (7/23) - T-wave inversions. Phase 4 (12/19) - complete resolution. - Rosen's Emergency Medicine
12. Atrial Fibrillation (AF)
ECG Findings:
- Absent P waves - replaced by fibrillatory (f) waves (irregular, chaotic baseline) at 350-600/min
- Irregularly irregular R-R intervals - hallmark finding
- Narrow QRS (unless pre-existing bundle branch block or aberrant conduction)
- Ventricular rate usually 100-180/min if untreated (AV node limits conduction)
- "Coarse AF" - prominent f waves; "Fine AF" - barely visible baseline oscillations
- WPW + AF = wide irregular tachycardia (dangerous - irregular pre-excited beats, can degenerate to VF)
13. Atrial Flutter
ECG Findings:
- Sawtooth flutter waves (F waves) at ~300/min in inferior leads (II, III, aVF)
- Regular atrial activity, usually with 2:1 AV block → ventricular rate ~150/min
- Flutter waves best seen in leads II, III, aVF (negative) and V1 (positive)
- Narrow QRS (unless aberrancy or pre-excitation)
- PR appears constant within a given conduction ratio
- QRS may obscure flutter waves - look carefully in II and V1
14. Complete (Third-Degree) Heart Block
ECG Findings:
- Complete AV dissociation - P waves and QRS complexes march independently
- P waves at a faster rate than QRS (e.g., P rate 80/min, QRS rate 30-45/min)
- Narrow QRS if junctional escape rhythm (40-60/min)
- Wide QRS if ventricular escape rhythm (20-40/min) - more dangerous
- Regular P-P and R-R intervals, but P-R intervals vary randomly
- Associated with syncope (Stokes-Adams attacks), hemodynamic compromise
15. First-Degree AV Block
ECG Findings:
- Prolonged PR interval >200 ms (one large box) - constant, every P conducts to QRS
- Normal P wave morphology
- Every P wave followed by a QRS (1:1 conduction maintained)
- QRS typically narrow
- Often benign; seen in athletes, elderly, inferior MI, digoxin toxicity, Lyme disease
16. Second-Degree AV Block - Mobitz Type II (Wenckebach)
ECG Findings:
- Progressive PR prolongation with each beat until a P wave is not conducted (dropped QRS)
- After the dropped beat, PR resets to shortest interval and cycle repeats
- RR intervals progressively shorten before the dropped beat
- Usually narrow QRS; block is at AV node level
- Grouped beating pattern (e.g., 3:2, 4:3 patterns)
17. Left Bundle Branch Block (LBBB)
ECG Findings:
- QRS duration ≥120 ms (wide, slurred)
- Broad, notched R wave in lateral leads (I, aVL, V5-V6) - "M-shaped" or "rabbit-ears"
- Deep S wave or QS pattern in V1 (rS or QS)
- ST and T waves discordant to QRS (ST depression and T inversion in leads with tall R)
- New LBBB in the right clinical context = STEMI equivalent
- Left axis deviation
18. Right Ventricular Hypertrophy / Cor Pulmonale
ECG Findings (Pulmonary Hypertension/Cor Pulmonale):
- Right axis deviation (axis >+100°)
- Dominant R wave in V1 (R/S > 1 in V1)
- S1Q3T3 pattern (in acute PE): S wave in lead I, Q wave in lead III, T-wave inversion in III
- ST depressions in V1-V3 (right ventricular strain)
- Sinus tachycardia
- P-pulmonale (tall peaked P waves in II, III, aVF >2.5 mm)
- Right bundle branch block (RBBB) pattern may develop
19. Mitral Stenosis
ECG Findings:
- P-mitrale (bifid P waves in II, III; duration >120 ms) - left atrial enlargement
- Broad, notched P waves (lead II) and biphasic P waves in V1 (negative terminal component)
- Right axis deviation (from RV pressure overload)
- RVH patterns if pulmonary hypertension develops
- Atrial fibrillation - very common complication (dilated LA becomes arrhythmogenic)
"Abnormalities in the ECG may include atrial fibrillation, left atrial enlargement, or right axis deviation." - Schwartz's Principles of Surgery
20. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
ECG Findings:
- Epsilon wave - small positive deflection at the end of the QRS in V1-V3 (pathognomonic)
- T-wave inversions in right precordial leads V1-V3 (most common finding; present in >85%)
- Right bundle branch block (RBBB) - complete or incomplete
- Prolonged S-wave upstroke in V1-V3 (≥55 ms)
- QRS duration in V1-V3 ≥110 ms
- Ventricular tachycardia with LBBB morphology (origin in RV)
- Right precordial late potentials on signal-averaged ECG
Summary Table
| # | Disease | Key ECG Finding | Leads Affected |
|---|---|---|---|
| 1 | Anterolateral STEMI | ST elevation + Q waves | V1-V6, I, aVL |
| 2 | Inferior STEMI | ST elevation + reciprocal depression | II, III, aVF; reciprocal I, aVL |
| 3 | Posterior MI | Tall R, ST depression (mirror image) | V1-V3 (reciprocal); V8-V9 direct |
| 4 | de Winter Pattern | J-point depression, hyperacute T | V1-V6, ST elevation aVR |
| 5 | High Lateral STEMI | ST elevation I, aVL | I, aVL; reciprocal III, aVF, V1 |
| 6 | WPW | Short PR + delta wave + wide QRS | All leads |
| 7 | Brugada | Coved ST elevation, RBBB pattern | V1-V3 |
| 8 | Long QT Syndrome | Prolonged QTc | All leads |
| 9 | Ventricular Fibrillation | Chaotic, no organized complexes | All leads |
| 10 | HCM | LVH voltage + narrow septal Q waves | V2-V6, I, aVL |
| 11 | Acute Pericarditis | Diffuse ST elevation + PR depression | All leads except aVR, V1 |
| 12 | Atrial Fibrillation | Absent P waves, irregular RR | All leads |
| 13 | Atrial Flutter | Sawtooth flutter waves 300/min | II, III, aVF, V1 |
| 14 | Complete Heart Block | AV dissociation, escape rhythm | All leads |
| 15 | First-Degree AVB | PR >200 ms | All leads |
| 16 | Mobitz I (Wenckebach) | Progressive PR prolongation, dropped QRS | All leads |
| 17 | LBBB | Wide QRS, broad R in lateral leads | I, aVL, V5-V6; QS in V1 |
| 18 | Cor Pulmonale/RVH | Right axis deviation, dominant R in V1 | V1, I, III |
| 19 | Mitral Stenosis | P-mitrale, right axis deviation, AF | II, V1 |
| 20 | ARVC | Epsilon wave, T inversions V1-V3 | V1-V3 |
Sources:
- Rosen's Emergency Medicine, 10e (Coronary artery disease ECG atlas)
- Tintinalli's Emergency Medicine, 9e (HCM, WPW, AV blocks, ARVC)
- Fuster and Hurst's The Heart, 15e (Arrhythmias, channelopathies)
- Miller's Review of Orthopaedics, 9e (WPW, Brugada, Long QT, VF - sudden death in athletes)
- Goldman-Cecil Medicine (VT, LBBB, AV blocks)
- Braunwald's Heart Disease, 2 Vol Set (VT, inherited cardiomyopathies)
- Schwartz's Principles of Surgery, 11e (Valvular disease ECG)
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