Top 10 ecg changes with pictures

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ECG electrocardiogram changes patterns STEMI ST elevation

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atrial fibrillation ECG heart block bundle branch block

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hyperkalemia peaked T waves ECG ventricular tachycardia

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Wolff-Parkinson-White WPW delta wave PR interval short ECG long QT torsades de pointes

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long QT interval torsades de pointes ECG pericarditis diffuse ST elevation saddle

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left ventricular hypertrophy ECG voltage criteria complete heart block third degree

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Top 10 ECG Changes (with Images)

1. 🫀 ST-Elevation Myocardial Infarction (STEMI)

Key Features: ST elevation ≥1 mm in ≥2 contiguous leads, reciprocal ST depression, hyperacute T-waves, Q-wave development, tombstone morphology.

Lead patterns by territory:

Inferior STEMI (RCA/LCx): elevation in II, III, aVF + reciprocal depression in I, aVL
Anterior STEMI (LAD): elevation in V1–V4
Lateral STEMI: elevation in I, aVL, V5–V6

Inferior STEMI (RCA occlusion):

Inferior STEMI with tombstoning and reciprocal changes in aVL

Anterolateral STEMI (LAD occlusion):

Anterolateral STEMI with ST elevation V1-V6, I, aVL and reciprocal changes inferiorly

2. 🔥 Hyperkalemia

Key Features (progressive with rising K⁺):

Peaked, narrow-based (tented) T-waves — first sign
Prolonged PR interval, widening QRS
Loss of P-waves (sinoventricular rhythm)
Sine-wave pattern → ventricular fibrillation

Early hyperkalemia — peaked T-waves:

Peaked symmetrical T-waves in precordial leads — classic early hyperkalemia

Severe hyperkalemia — wide QRS, sine-wave, absent P-waves:

Severe hyperkalemia with wide QRS sine-wave morphology and absent P-waves

3. 💙 Atrial Fibrillation (AF)

Key Features:

Irregularly irregular rhythm — no two R-R intervals equal
Absent P-waves, replaced by fibrillatory (f) waves (best seen in V1)
Narrow QRS (unless aberrant conduction/BBB)
Ventricular rate variable (controlled: 60–100; rapid response: >100)

AF with Right Bundle Branch Block (RBBB):

Atrial fibrillation with rapid ventricular response and RBBB — absent P-waves, irregularly irregular, rsR' in V1

4. 🔵 Left Bundle Branch Block (LBBB)

Key Features (WiLLiaM — W in V1, M in V5/V6):

QRS duration >120 ms
Broad, notched R in I, aVL, V5–V6 (M pattern)
Deep QS in V1–V3 (W pattern)
Discordant ST-T changes (ST/T opposite to QRS)
New LBBB + chest pain = treat as STEMI equivalent (Sgarbossa criteria)

AF with LBBB:

AF with complete LBBB showing deep S-waves V1-V3 and broad monophasic R in V5-V6 with ST-T discordance

5. 🟠 Right Bundle Branch Block (RBBB)

Key Features (MaRRoW — M in V1, W in V5/V6):

QRS duration >120 ms
rsR' ("M" shape) or RSR' in V1–V2
Broad, slurred S-wave in I, aVL, V5–V6 (W pattern)
T-wave inversion in V1–V3 (normal secondary change)

AF with RBBB:

6. ⚡ Wolff-Parkinson-White (WPW) Syndrome

Key Features (Pre-excitation triad):

Short PR interval (<120 ms)
Delta wave (slurred upstroke of QRS)
Widened QRS (>120 ms)
Secondary ST-T changes
Risk: AF with rapid conduction → ventricular fibrillation (avoid AV nodal blockers!)

Classic WPW pattern:

Classic WPW with short PR interval and prominent delta waves in precordial and inferior leads

WPW with pseudoinfarction pattern (negative delta waves inferior leads):

WPW with negative delta waves in II, III, aVF mimicking inferior MI — left posteroseptal pathway

7. ⏱️ Long QT Syndrome / Torsades de Pointes

Key Features:

QTc >440 ms (men), >460 ms (women) — clinically significant >500 ms
T-wave broad and prominent
T-wave alternans = high-risk sign
Torsades de Pointes: twisting polymorphic VT around isoelectric line, triggered by R-on-T

Causes: Electrolyte disturbances (↓K⁺, ↓Mg²⁺, ↓Ca²⁺), drugs (quinidine, sotalol, haloperidol, macrolides, methadone), congenital LQTS

Prolonged QTc (QTc 632 ms):

Severely prolonged QT interval QTc 632ms with broad T-waves across leads

Torsades de Pointes initiation (short-long-short sequence + R-on-T):

Torsades de Pointes onset with short-long-short RR sequence twisting polymorphic VT

8. 🫁 Left Ventricular Hypertrophy (LVH)

Key Features:

Sokolow-Lyon criteria: S in V1 + R in V5 or V6 ≥35 mm (or R in aVL ≥11 mm)
Cornell criteria: R in aVL + S in V3 >28 mm (men) or >20 mm (women)
LV strain pattern: ST depression + asymmetric T-wave inversion in I, aVL, V5–V6
Left axis deviation
Associated with hypertension, aortic stenosis, HOCM

LVH with strain pattern + first-degree AV block:

LVH with high voltage in V5-V6 and strain pattern ST depression T-wave inversion lateral leads

9. 🚨 Complete (Third-Degree) AV Block

Key Features:

Complete AV dissociation — P-waves and QRS complexes occur independently
Atrial rate faster than ventricular rate
Escape rhythm: narrow QRS = junctional escape (~40–60 bpm); wide QRS = ventricular escape (~20–40 bpm)
Causes: inferior MI (usually transient), Lyme disease, medications, degenerative disease

Complete AV block with ventricular escape:

Third-degree complete AV block with AV dissociation P-waves and wide-complex ventricular escape rhythm

10. ❤️‍🔥 Inferolateral STEMI (Extensive / Wraparound LAD)

Key Features: ST elevation in both inferior (II, III, aVF) AND lateral (V4–V6) leads — characteristic of either a "wraparound" distal LAD or simultaneous RCA + LCx territory involvement.

Inferolateral STEMI — extensive territory:

Inferolateral STEMI with ST elevation in inferior and lateral leads simultaneous

Quick Reference Table

#	ECG Change	Key Finding	Clinical Pearl
1	Anterior STEMI	ST↑ V1–V4	LAD occlusion; cath-lab activation
2	Inferior STEMI	ST↑ II, III, aVF	Check right-sided leads for RV infarct
3	Hyperkalemia	Peaked T → wide QRS → sine wave	Emergent calcium gluconate
4	Atrial Fibrillation	Irregularly irregular, no P-waves	Rate vs. rhythm control decision
5	LBBB	Wide QRS, W in V1, M in V5-V6	New LBBB + pain = STEMI equivalent
6	RBBB	rsR' in V1, slurred S in V5-V6	May indicate acute PE if new
7	WPW	Short PR, delta wave	Avoid adenosine/digoxin in AF-WPW
8	Long QT/TdP	QTc >500 ms, twisting VT	IV magnesium sulfate for TdP
9	LVH	High voltage + strain pattern	Hypertension/valvular disease marker
10	Complete AV Block	AV dissociation, escape rhythm	Urgent pacing if hemodynamically unstable

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