Most common ecg findings in the cvs cases and along with are images features compared with normal ecg
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common ECG findings cardiovascular diseases compared to normal ECG
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Common ECG Findings in Cardiovascular Cases - With Images Compared to Normal
The Normal ECG - Baseline Reference
Before examining pathological ECGs, understanding normal ECG components is essential.
Normal ECG inscription showing P wave (atrial depolarization), PR interval (AV conduction delay), QRS complex (ventricular depolarization), ST segment + T wave (ventricular repolarization), J point, and QT interval. Paper speed: 25 mm/sec; 1 small box = 0.04 sec; 1 mm vertical = 0.1 mV. - Goldman-Cecil Medicine, Fig. 42-2
Normal values at a glance:
| Component | Normal Value |
|---|---|
| Heart rate | 60-100 bpm |
| P wave | Upright in I, II, aVF; duration <0.12 s |
| PR interval | 0.12-0.20 s (3-5 small boxes) |
| QRS duration | <0.12 s (3 small boxes) |
| QT interval | <0.44 s (corrected for rate) |
| ST segment | Isoelectric (at the TP segment baseline) |
| T wave | Upright in I, II, V3-V6; inverted in aVR; variable in III, aVL, aVF |
1. ST Segment Elevation - STEMI (Acute MI)
What changes vs. normal:
- Normal: ST segment sits flat at the isoelectric baseline
- STEMI: ST segment rises above the isoelectric line in at least 2 contiguous leads
- Diagnostic cut-offs (per Fourth Universal Definition of MI):
- Men >40 years: ≥2 mm in V2-V3, ≥1 mm in all other leads
- Men <40 years: ≥2.5 mm in V2-V3
- Women: ≥1.5 mm in V2-V3, ≥1 mm in all other leads
Evolution of STEMI on ECG (earliest to latest):
- Hyperacute T waves - tall, broad, peaked T waves appearing within minutes of infarction onset
- ST elevation - J-point elevation with flat/convex/tombstone morphology
- Q waves - pathologic Q waves develop at 8-12 hours (irreversible necrosis marker)
- T wave inversion - as ST segments return to baseline
- Persistent Q waves - permanent markers of prior infarction
Fig. 64.1: (A) Hyperacute broad tall T waves in V3-V4 with early ST rise. (B) Same patient 30 minutes later showing frank ST elevation in V1-V4. - Rosen's Emergency Medicine
Regional localization by lead:
| Location | Leads with ST elevation | Artery |
|---|---|---|
| Anterior | V1-V4 | LAD |
| Anterolateral | V1-V6, I, aVL | LAD (proximal) |
| Inferior | II, III, aVF | RCA or LCx |
| Lateral | I, aVL, V5-V6 | LCx |
| Posterior | ST depression V1-V3 (mirror) | RCA/LCx |
| Right ventricular | V1, V3R-V4R | RCA (proximal) |
2. ST Segment Morphology - AMI vs. Mimics
Fig. 64.2: (A) STEMI - flat/convex (domed) ST elevation. (B) Non-AMI causes: concave ST elevation of benign early repolarization (BER) and pericarditis. (C) STEMI can occasionally also show concavity - serial ECGs help resolve this. - Rosen's Emergency Medicine
Key morphologic distinctions:
| Condition | ST morphology | Key differentiator |
|---|---|---|
| STEMI | Flat, convex ("domed"), or "tombstone" | Dynamic - changes with symptoms; reciprocal depression |
| Benign early repolarization | Concave ("smiley face"), V4-V6 | Static, young males, J-point notching |
| Acute pericarditis | Concave, diffuse (all leads except aVR/V1) | PR depression in II, PR elevation in aVR |
| LVH | Concave in V5-V6 with deep S waves | Voltage criteria (Sokolow-Lyon) |
3. ST Segment Depression - NSTEMI / Subendocardial Ischemia
Fig. 64.3: (A) Horizontal ST depression - unstable angina. (B) Horizontal ST depression - NSTEMI. (C) Downsloping ST depression - unstable angina. (D) Upsloping ST depression - less ischemia-specific. (E) Reciprocal ST depression in lead III with anterior STEMI. - Rosen's Emergency Medicine
ST depression patterns compared to normal:
- Normal: ST segment is isoelectric (at baseline)
- Horizontal depression: Most specific for subendocardial ischemia - measures ≥1 mm below isoelectric line at J+60-80 ms
- Downsloping depression: More ominous, strongly associated with ischemia
- Upsloping depression: Less specific, also seen in sinus tachycardia
- Reciprocal depression: Mirror image of ST elevation in the opposite wall - increases specificity for STEMI and predicts larger infarction
4. T Wave Abnormalities
T Wave Inversion (TWI)
Normal vs. abnormal:
- Normal: T waves upright in I, II, V3-V6; inverted only in aVR, V1
- Ischemic TWI: Narrow, deep, symmetrical inversions in the precordial or limb leads
Wellens Syndrome - a specific and critical pattern:
Fig. 64.5: (A) Type I Wellens: deeply inverted T waves in V2 (seen in ~75% of cases). (B) Type II Wellens: biphasic T waves in V2 (seen in ~25%). (C) Patient with Wellens pattern (pain-free). (D) Same patient 6 hours later with return of pain showing full anterolateral STEMI - proximal LAD occlusion confirmed. - Rosen's Emergency Medicine
- Clinical significance: Indicates critical proximal LAD stenosis; natural history is progression to anterior STEMI
- Characteristic features: Deep symmetric TWI or biphasic T waves in V2-V3; minimal ST elevation (<1 mm); no Q waves; often occurs when patient is pain-free
5. Left Bundle Branch Block (LBBB)
Normal vs. LBBB:
- Normal: QRS <0.12 s; upright R waves in lateral leads; concordant ST-T with QRS
- LBBB: QRS ≥0.12 s; broad notched R in I, aVL, V5-V6; QS pattern in V1-V3; discordant ST-T segments (ST and T opposite to QRS direction)
Rule of appropriate discordance: In LBBB, ST elevation in V1-V3 and ST depression with TWI in V5-V6 are normal findings (not ischemia). Ischemia is suspected when this rule is violated (Sgarbossa criteria):
- Concordant ST elevation ≥1 mm in any lead (5 points)
- Concordant ST depression ≥1 mm in V1-V3 (3 points)
- Excessively discordant ST elevation ≥5 mm (2 points)
- Score ≥3 = highly specific for acute MI in LBBB
6. Atrial Fibrillation (AF)
Normal vs. AF:
| Feature | Normal Sinus Rhythm | Atrial Fibrillation |
|---|---|---|
| P waves | Distinct, upright in II, one per QRS | Absent; replaced by chaotic f-waves (fine or coarse) |
| RR intervals | Regular | Irregularly irregular |
| Rate | 60-100 | Ventricular rate typically 110-160 (uncontrolled) |
| QRS | Narrow (unless aberrant conduction) | Narrow (unless LBBB or WPW) |
Key visual feature: Absent P waves replaced by an undulating, chaotic baseline with completely irregular ventricular response.
7. Heart Block (AV Block)
Normal PR interval: 0.12-0.20 s
| Type | ECG Finding | vs. Normal |
|---|---|---|
| 1st degree | PR >0.20 s; all P waves conduct | PR prolonged but every P followed by QRS |
| 2nd degree Mobitz I (Wenckebach) | Progressive PR lengthening until a P is dropped | PR gets longer each beat, then a QRS is dropped |
| 2nd degree Mobitz II | Fixed PR; sudden non-conducted P waves | PR constant but some P waves don't have a QRS |
| 3rd degree (Complete) | P waves and QRS completely dissociated | No relationship between P waves and QRS; QRS rate <40 |
8. Left Ventricular Hypertrophy (LVH)
Normal vs. LVH:
- Normal: R wave height + S wave depth do not meet voltage criteria
- LVH: Increased voltage + ST-T strain pattern
Sokolow-Lyon voltage criteria:
- S in V1 + R in V5 or V6 ≥35 mm, OR
- R in aVL ≥11 mm
LVH strain pattern: ST depression with asymmetric T wave inversion in I, aVL, V5-V6 - similar to ischemia but in the context of voltage criteria.
9. Pulmonary Embolism (PE) - S1Q3T3 Pattern
Normal vs. acute PE:
- Normal: No prominent S in lead I, no Q or T inversion in lead III
- Acute PE: The classic "S1Q3T3" pattern - S wave in lead I + Q wave in lead III + T wave inversion in lead III
- Also: Sinus tachycardia (most common), right heart strain (right axis deviation), new RBBB, T inversion in V1-V4
10. Pericarditis
Normal vs. acute pericarditis:
- Normal: Isoelectric ST throughout; flat PR
- Pericarditis: Diffuse concave ST elevation (all leads except aVR and V1) + PR depression (pathognomonic, best in lead II) + PR elevation in aVR
Summary Comparison Table
| Condition | ST Segment | T Waves | QRS | P Waves | Rate/Rhythm |
|---|---|---|---|---|---|
| Normal | Isoelectric | Upright I, II, V3-V6 | <0.12 s | Regular, one/beat | 60-100, regular |
| STEMI | Elevated (convex), regional | Hyperacute early, inverted late | May have Q waves | Normal | Often tachycardia |
| NSTEMI/UA | Depressed (horizontal/down) | Inverted | Normal | Normal | Often tachycardia |
| Wellens | Minimal elevation | Deep symmetric inversion V2-V3 | Normal, no Q | Normal | Normal |
| AF | Normal | Normal | Normal (may be wide) | Absent (f-waves) | Irregular |
| 1st-degree HB | Normal | Normal | Normal | Normal | PR >0.20 s |
| 3rd-degree HB | Normal | Normal | Wide (escape) | Dissociated from QRS | Bradycardia <40 |
| LBBB | Discordant elevation V1-V3 | Discordant inversions V5-V6 | Broad ≥0.12 s, notched R | Normal | Normal |
| LVH | Strain (depression V5-V6) | Asymmetric inversion | Tall R lateral leads | Normal | Normal |
| Pericarditis | Diffuse concave elevation | Normal initially | Normal | Normal | Sinus tachycardia |
| PE | Variable | Inversion V1-V4 | RBBB pattern | Normal | Sinus tachycardia |
Sources:
- Rosen's Emergency Medicine, Chapter 64 (ACS/ECG in detail)
- Goldman-Cecil Medicine, Chapter 42 (ECG fundamentals)
- Harrison's Principles of Internal Medicine 22e
- Robbins & Kumar Basic Pathology (arrhythmia mechanisms)
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