Chapter A7: Atlas of Electrocardiography

Anterior wall ischemia (deep T-wave inversions and ST-segment depressions in I, aVL, V₃–V₆) in a patient with LVH (increased voltage in V₂–V₅).

Acute anterolateral wall ischemia with ST elevations in V₄–V₆. Probable prior inferior MI with Q waves in leads II, III, and aVF.

Acute lateral ischemia with ST elevations in I and aVL with probable reciprocal ST depressions inferiorly (II, III, and aVF). Ischemic ST depressions also in V₃ and V₄. Left atrial abnormality.

Sinus tachycardia. Marked ischemic ST-segment elevations in inferior limb leads (II, III, aVF) and laterally (V₆) suggestive of acute inferolateral MI, and prominent ST-segment depressions with upright T waves in V₁–V₄ are consistent with associated acute posterior MI.

Acute, extensive anterior MI with marked ST elevations in I, aVL, V₁–V₆, and low amplitude pathologic Q waves in V₃–V₆. Marked reciprocal ST-segment depressions in III and aVF.

Acute anterior wall MI with ST elevations and Q waves in V₁–V₄ and aVL and reciprocal inferior ST depressions.

Sinus rhythm with premature atrial complexes. RBBB; pathologic Q waves and ST elevation due to acute anterior/septal MI in V₁–V₃.

Acute anteroseptal MI (Q waves and ST elevations in V₁–V₄) with RBBB (note terminal R waves in V₁).

Extensive prior MI involving inferior-posterior-lateral wall (Q waves in leads II, III, aVF, tall R waves in V₁, V₂, and Q waves in V₅, V₆). T-wave abnormalities in leads I and aVL, V₅, and V₆.

Sinus rhythm with PR prolongation (“first-degree AV block”), left atrial abnormality, LVH, and RBBB. Pathologic Q waves in V₁–V₅ and aVL with ST elevations (a chronic finding in this patient). Findings compatible with prior anterolateral MI and left ventricular aneurysm.

Prior inferior-posterior MI. Wide (0.04 s) Q waves in the inferior leads (II, III, aVF); broad R wave in V₁ (a Q wave “equivalent” here). Absence of right-axis deviation and the presence of upright T waves in V₁–V₂ are also against RVH.

Sinus rhythm with RBBB (broad terminal R wave in V₁) and left anterior fascicular block (hemiblock) and pathologic anterior Q waves in V₁–V₃. Patient had severe multivessel coronary artery disease, with echocardiogram showing septal dyskinesis and apical akinesis.

Acute pericarditis with diffuse ST elevations in I, II, III, aVF, V₃–V₆, without T-wave inversions. Also note concomitant PR-segment elevation in aVR and PR depression in the inferolateral leads.

Sinus rhythm; diffuse ST elevations (I, II, aVL, aVF, V₂–V₆) with associated PR deviations (elevated PR in aVR; depressed in V₄–V₆); borderline low voltage. Q-wave and T-wave inversions in II, III, and aVF. Diagnosis: acute pericarditis with inferior Q-wave MI.

Sinus rhythm, prominent left atrial abnormality (see I, II, V₁), right-axis deviation, and RVH (tall, relatively narrow R wave in V₁) in a patient with mitral stenosis.

Sinus rhythm, left atrial abnormality, and LVH by voltage criteria with borderline right-axis deviation in a patient with mixed mitral stenosis (left atrial abnormality and right-axis deviation) and mitral regurgitation (LVH). Prominent precordial T-wave inversions and QT prolongation also present.

Coarse AF, tall R in V₂ with vertical QRS axis (positive R waves in II, III, and aVF) indicating RVH. Tall R in V₄ may be due to concomitant LVH. Patient had severe mitral stenosis with moderate mitral regurgitation.

Sinus rhythm; first-degree AV “block” (PR prolongation); LVH (tall R in aVL); RBBB (wide multiphasic R wave in V1) and left anterior fascicular block in a patient with HCM. Deep Q waves in I and aVL are consistent with septal hypertrophy.

LVH with deep T-wave inversions in limb leads and precordial leads. Striking, “spade-like” T-wave inversions in mid-precordial leads suggest apical HCM (Yamaguchi’s syndrome).

Sinus tachycardia with S1Q3T3 pattern (T-wave inversion in III), incomplete RBBB, and right precordial T-wave inversions consistent with acute RV overload in a patient with pulmonary emboli.

Sinus tachycardia, right-axis deviation, RVH with tall R in V₁ and deep S in V₆, and inverted T waves in II, III, aVF, and V₁–V₅ in a patient with atrial septal defect and severe pulmonary hypertension.

Signs of right atrial/RV overload in a patient with chronic obstructive lung disease: (1) peaked P waves in II; (2) QR in V₁ with narrow QRS; (3) delayed precordial transition, with terminal S waves in V₅/V₆; (4) superior axis deviation with an S₁-S₂-S₃ pattern.

(1) Low voltage; (2) incomplete RBBB (rSr′ in V₁–V₃); (3) borderline peaked P waves in lead II with vertical P-wave axis (probable right atrial overload); (4) slow R-wave progression in V₁–V₃; (5) prominent S waves in V₆; and (6) atrial premature beats. This combination is seen typically in severe chronic obstructive lung disease.

Prominent U waves (II, III, and V₄–V₆) with ventricular repolarization prolongation in a patient with severe hypokalemia.

Abbreviated ST segment such that the T wave looks like it takes off directly from QRS in some leads (I, V₄, aVL, and V₅) in a patient with severe hypercalcemia. Note also high takeoff of ST segment in V₂/V₃ simulating acute ischemia.

Sinus rhythm with LVH, left atrial abnormality, and tall peaked T waves in the precordial leads with inferolateral ST depressions (II, III, aVF, and V₆); left anterior fascicular block and borderline prolonged QT interval in a patient with renal failure, hypertension, and hyperkalemia; prolonged QT is secondary to associated hypocalcemia.

Normal ECG in an 11-year-old male. T-wave inversions in V₁–V₂. Vertical QRS axis (+90°) and early precordial transition between V₂ and V₃ are normal findings in children.

Left atrial abnormality and LVH in a patient with long-standing hypertension.

Normal variant ST-segment elevations in a healthy 21-year-old male (commonly referred to as benign early repolarization pattern). ST elevations exhibit upward concavity and are most apparent in V₃ and V₄, and less than 1 mm in the limb leads. Precordial QRS voltages are prominent, but within normal limits for a young adult. No evidence of left atrial abnormality or ST depression/T-wave inversions to go along with LVH.

Sinus rhythm with first-degree AV “block” (PR interval = 0.24 s) and complete LBBB. Left axis deviation.

Dextrocardia with: (1) inverted P waves in I and aVL; (2) negative QRS complex and T wave in I; and (3) progressively decreasing voltage across the precordium.

Sinus tachycardia; intraventricular conduction delay (IVCD) with a rightward QRS axis. QT interval is prolonged for the rate. The triad of sinus tachycardia, a wide QRS complex, and a long QT in appropriate clinical context suggests tricyclic antidepressant overdose. Terminal S wave (rS) in I and terminal R wave (qR) in aVR are also noted as part of this IVCD variant.

Borderline sinus bradycardia (59 beats/min), prolonged PR interval (250 ms), and RBBB are present with marked right-axis deviation (RAD), the latter consistent with left posterior fascicular block (LPFB). The latter is a diagnosis of exclusion, which requires ruling out lead reversal, normal variant, RV overload syndromes, or lateral MI, in particular, as causes of the RAD. This ECG also shows nondiagnostic Q waves in the inferior leads. In concert with RBBB, the LPFB indicates bifascicular block.