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Explain me 10 common heart diseases with ecg changes and ecg images of those diseases

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ECG electrocardiogram myocardial infarction ST elevation

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atrial fibrillation ECG irregularly irregular rhythm no P waves

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complete heart block third degree AV block ECG

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ventricular tachycardia ECG wide QRS complex

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Wolff-Parkinson-White WPW syndrome ECG delta wave short PR interval

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left ventricular hypertrophy ECG high voltage Sokolow criteria

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hypertrophic cardiomyopathy ECG deep Q waves LVH

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pulmonary embolism ECG right heart strain S1Q3T3 pattern

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pericarditis ECG saddle-shaped ST elevation PR depression

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Brugada syndrome ECG coved ST elevation V1 V2 V3

Here is a comprehensive overview of 10 common heart diseases, their ECG changes, and representative ECG images from the medical literature.

10 Common Heart Diseases: ECG Changes & Images

1. 🫀 ST-Elevation Myocardial Infarction (STEMI)

ECG Changes

  • Hyperacute T waves — earliest sign; tall, broad, peaked T waves in ischemic territory
  • ST-segment elevation ≥1 mm in ≥2 contiguous leads (≥2 mm in V1–V3); convex ("tombstone") morphology in severe cases
  • Reciprocal ST depression in opposing leads (e.g., inferior STEMI → reciprocal changes in aVL)
  • Pathological Q waves — develop within hours as necrosis progresses; width >40 ms, depth >25% of R wave
  • T-wave inversion in evolving phase
  • R-wave loss in anterior STEMI
Lead Localization:
TerritoryLeads with ST ElevationCulprit Artery
AnteriorV1–V4LAD
InferiorII, III, aVFRCA
LateralI, aVL, V5–V6LCx
PosteriorReciprocal tall R + ST depression in V1–V3RCA/LCx
Anterior STEMI ECG showing ST elevation V1-V4
Acute anterior STEMI — prominent ST elevation across V1–V6 with hyperacute T waves, consistent with LAD occlusion
Inferior STEMI ECG
Inferolateral STEMI — ST elevation in II, III, aVF, V4–V6 with reciprocal depression in I and aVL
Source: Harrison's Principles of Internal Medicine 22E, Fig. 247-13; Tintinalli's Emergency Medicine

2. 🫀 Non-ST-Elevation Myocardial Infarction / Unstable Angina (NSTEMI/UA)

ECG Changes

  • ST-segment depression (horizontal or downsloping) ≥0.5–1 mm in ≥2 contiguous leads
  • Deep symmetrical T-wave inversions in precordial leads (especially V1–V4 in LAD disease)
  • Wellens' T wave sign — deep biphasic or inverted T waves in V2–V3 indicating critical LAD stenosis
  • No pathological Q waves (subendocardial pattern)
  • ECG may be normal in up to 6% of confirmed NSTEMI cases
  • Transient ST elevation may occur in Prinzmetal (vasospastic) angina
Wellens T-wave inversions anterior ischemia
Wellens pattern — deep T-wave inversions in precordial leads V1–V4, indicating severe LAD stenosis (Figs. 247-12 from Harrison's)
Source: Harrison's Principles of Internal Medicine 22E; Tintinalli's Emergency Medicine

3. 🫀 Atrial Fibrillation (AF)

ECG Changes

  • Absent P waves — replaced by continuous, chaotic fibrillatory (f) waves, best seen in V1 and lead II
  • Irregularly irregular R-R intervals — the hallmark
  • Narrow QRS complexes (unless aberrant conduction or bundle branch block)
  • Baseline may show fine (>350/min) or coarse (<350/min) fibrillation
  • Heart rate typically 100–180 bpm (uncontrolled)
  • Fibrillatory waves most prominent in lead V1
Atrial fibrillation 12-lead ECG
Coarse atrial fibrillation — absent organized P waves, irregularly irregular rhythm, prominent f waves in V1
Atrial fibrillation ECG fine fibrillation
Atrial fibrillation (Lead II) — visible QRS and T waves but no P waves, irregular spacing (Guyton & Hall Textbook, Fig. 13.20)
Source: Guyton & Hall Textbook of Medical Physiology; Tintinalli's Emergency Medicine

4. 🫀 Complete (Third-Degree) Heart Block

ECG Changes

  • Complete AV dissociation — P waves and QRS complexes are totally independent
  • P waves march through QRS complexes at their own regular rate (faster atrial rate)
  • Ventricular escape rhythm is slow and regular:
    • Junctional escape: narrow QRS, rate 40–60 bpm
    • Ventricular escape: wide QRS (>120 ms), rate 20–40 bpm
  • No fixed PR interval — PRs vary constantly
  • Secondary ST-T changes in ventricular leads
  • First-degree AV block: PR >200 ms; Second-degree (Mobitz I/II): progressive PR lengthening or dropped beats
Complete heart block 12-lead ECG
Third-degree heart block — wide QRS escape rhythm, P waves independent of QRS complexes, total AV dissociation
Complete heart block Lead II rhythm strip
Lead II rhythm strip — junctional escape rhythm, P waves present but unrelated to QRS (narrow complex), classic third-degree block
Source: Fuster & Hurst's The Heart; Ganong's Review of Medical Physiology

5. 🫀 Ventricular Tachycardia (VT)

ECG Changes

  • Wide QRS tachycardia (>120 ms), rate 100–250 bpm
  • Regular rhythm (monomorphic VT) or irregular morphology (polymorphic VT)
  • AV dissociation — P waves independent of QRS (pathognomonic when seen)
  • Fusion beats and capture beats (narrow QRS "interruptions") are diagnostic
  • Concordance in precordial leads (all QRS positive or all negative)
  • Northwest axis (negative in I and aVF) strongly suggests VT
  • Torsades de Pointes (polymorphic VT): twisting QRS axis around isoelectric line, associated with prolonged QT
Ventricular tachycardia wide-complex tachycardia ECG
Monomorphic VT — wide QRS complexes at ~170 bpm, positive concordance in precordial leads, consistent with ventricular origin
Source: Tintinalli's Emergency Medicine; Goldman-Cecil Medicine

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

ECG Changes

The ECG triad during sinus rhythm:
  1. Short PR interval (<120 ms) — accessory pathway bypasses AV node delay
  2. Delta wave — slurred upstroke at the onset of QRS
  3. Widened QRS complex (>120 ms) due to pre-excitation
During tachycardia:
  • Orthodromic AVRT (65%): narrow QRS, regular, rate 160–220 bpm — resembles SVT
  • Antidromic AVRT (5–10%): wide QRS, regular — resembles VT
  • AF with WPW (25%): wide irregular QRS with varying morphology, rate >200 bpm; life-threatening
WPW syndrome ECG with delta waves
Classic WPW pattern — short PR interval, prominent delta waves in II, III, aVF, V2–V6, widened QRS
Source: Tintinalli's Emergency Medicine, Tables 18-23 & 18-24; Pfenninger's Procedures for Primary Care

7. 🫀 Hypertrophic Cardiomyopathy (HCM)

ECG Changes

  • Left ventricular hypertrophy — high QRS voltage (Sokolow: SV1 + RV5 ≥35 mm)
  • Narrow septal Q waves in lateral leads (I, aVL, V5, V6) — due to septal hypertrophy
  • T-wave inversions — diffuse or precordial; giant T-wave inversions in apical HCM (Yamaguchi variant)
  • Left axis deviation
  • ST-segment depression (strain pattern) in lateral leads
  • Abnormal P waves if left atrial enlargement is present
  • May show atrial flutter or fibrillation
HCM ECG with LVH and septal Q waves
Hypertrophic cardiomyopathy — deep S wave in V3 (28 mm), narrow septal Q waves in V5–V6, atrial flutter with 2:1 block (Tintinalli's, Fig. 55-1)
Apical HCM with giant T-wave inversions
Apical HCM (Yamaguchi) — high QRS voltage, giant symmetric T-wave inversions most prominent in V3, classic repolarization abnormality
Source: Tintinalli's Emergency Medicine, Fig. 55-1; Miller's Review of Orthopaedics

8. 🫀 Acute Pericarditis

ECG Changes (evolve through 4 stages):

  • Stage 1 (acute): Diffuse concave ("saddle-shaped") ST elevation in all leads except aVR and V1; PR segment depression (most sensitive sign); Spodick's sign (downsloping TP segment)
  • Stage 2: ST normalization, PR depression persists
  • Stage 3: T-wave inversions (diffuse)
  • Stage 4: ECG normalizes
Key distinguishing features from STEMI:
  • ST elevation is diffuse (not in a coronary territory)
  • No reciprocal ST depression (except aVR shows PR elevation + ST depression)
  • Concave not convex ST morphology
  • No Q waves
Acute pericarditis ECG saddle-shaped ST elevation PR depression
Acute pericarditis — diffuse concave ST elevation in I, II, III, aVF, V2–V6; PR depression in II; reciprocal ST depression and PR elevation in aVR; Spodick's sign visible
Source: Harrison's Principles of Internal Medicine 22E; Tintinalli's Emergency Medicine

9. 🫀 Pulmonary Embolism (PE)

ECG Changes

  • Sinus tachycardia — most common finding (>90% of cases)
  • S1Q3T3 pattern (McGinn-White sign): prominent S wave in lead I, Q wave in lead III, T-wave inversion in lead III
  • Right bundle branch block (complete or incomplete) — due to right ventricular strain
  • Right axis deviation
  • T-wave inversions in V1–V4 — right ventricular strain pattern
  • P pulmonale — peaked P waves >2.5 mm in lead II
  • Normal ECG does not exclude PE
PE ECG S1Q3T3 right heart strain
Pulmonary embolism — annotated S1Q3T3 pattern with prominent S in I, Q wave in III, T-wave inversion in III; sinus tachycardia
PE with RBBB and precordial T inversions
Acute PE — sinus tachycardia at 116 bpm, S1Q3T3, incomplete RBBB, T-wave inversions in V1–V3; signs of acute right ventricular strain
Source: Harrison's Principles of Internal Medicine 22E; Tintinalli's Emergency Medicine

10. 🫀 Brugada Syndrome

ECG Changes

A genetic sodium channelopathy (SCN5A mutation) causing characteristic ECG patterns in V1–V2:
Type 1 (diagnostic / "coved" pattern):
  • Coved ST elevation ≥2 mm with J-point elevation in V1–V2 (or V1–V3)
  • ST segment descends with a convex morphology into an inverted T wave
  • Complete or incomplete right bundle branch block appearance
Type 2 & 3 (saddle-back patterns):
  • Less diagnostic; require provocation with sodium channel blockers (flecainide, ajmaline) to unmask Type 1
Clinical significance: Associated with ventricular fibrillation and sudden cardiac death, often in young males at rest or during sleep.
Brugada syndrome Type 1 coved ECG V1 V2
Brugada Type 1 — classic "coved" pattern in V1–V3: J-point elevation ≥2 mm, convex ST descent into symmetric T-wave inversion
Brugada syndrome full 12-lead ECG
Brugada Type 1 on 12-lead ECG — isolated coved ST changes in V1–V2, normal morphology in all other leads
Source: Harrison's Principles of Internal Medicine 22E; Tintinalli's Emergency Medicine

Quick Reference Summary Table

#DiseaseKey ECG Features
1STEMIST elevation ≥1mm (contiguous leads), Q waves, reciprocal depression
2NSTEMI/UAST depression, T inversions, Wellens pattern; no Q waves
3Atrial FibrillationNo P waves, irregularly irregular rhythm, fibrillatory baseline
43rd Degree Heart BlockComplete AV dissociation, slow escape rhythm, P waves "march through"
5Ventricular TachycardiaWide QRS >120ms, AV dissociation, fusion/capture beats, concordance
6WPW SyndromeShort PR <120ms, delta wave, widened QRS
7Hypertrophic CMPHigh voltage LVH, narrow septal Q waves, T inversions (giant in apical)
8Acute PericarditisDiffuse concave ST elevation, PR depression, Spodick's sign
9Pulmonary EmbolismSinus tachycardia, S1Q3T3, RBBB, right axis, T inversions V1–V4
10Brugada SyndromeCoved ST elevation V1–V2, RBBB morphology, inverted T waves
Sources: Harrison's Principles of Internal Medicine 22E; Tintinalli's Emergency Medicine; Guyton & Hall Textbook of Medical Physiology; Ganong's Review of Medical Physiology 26E; Tintinalli's Emergency Medicine; ECG images from PMC Clinical VQA literature database.
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