4. ECG Graph Paper X- Axis time in seconds Y- Axis Amplitude in mill volts

6. ECG Complex P wave PR Interval QRS complex ST segment T Wave QT Interval RR Interval

8. Identify the ECG Complex 1 2 3 4 5 6 7 8

10. Let us Identify the waves 1 2 3 4 5 6 7 8

13. Normal ECG

15. Pediatric ECG

17. Juvenile ECG

21. Pseudo Normalization Before Chest pain During Chest pain Chest pain Relieved T ↓ T ↓ T ↑

22. Rate Determination Next QRS QRS

23. Rate Determination BRADY T ACHY NORMA L No. of Big Boxes R – R Interval Rate Cal. Rate One 0.2 sec 60 ÷ 0.2 300 Two 0.4 sec 60 ÷ 0.4 150 Three 0.6 sec 60 ÷ 0.6 100 Four 0.8 sec 60 ÷ 0.8 75 Five 1.0 sec 60 ÷ 1.0 60 Six 1.2 sec 60 ÷ 1.2 50 Seven 1.4 sec 60 ÷ 1.4 43 Eight 1.6 sec 60 ÷ 1.6 37

24. What is the Heart Rate ? Answer on next slide

26. What is the Heart Rate ? Answer on next slide

28. What is the Heart Rate ? Answer on next slide

30. + + + - - - ECG Bipolar Limb Leads R L F R F L

32. ECG Unipolar Limb Leads + + + Lead aVR Lead aVL Lead aVF R L F

34. ECG Chest Leads

36. Atrial Ectopics APC APC APC APC

38. Atrial Fibrillation

40. Look at this ECG

41. Atrial Flutter Heart rate Rhythm P wave PR interval QRS in sec

43. Ventricular Ectopics VPC VPC VPC VPC

45. Ventricular Tachycardia

47. The Six Limb Leads INFERIOR LEFT RIGHT FRONTAL PLANE

49. The Six Chest Leads TRANSVERSE PLANE

51. Cardiac Impulse

53. QRS Axis SE NE NW SW

55. Axis Determination NORMAL RIGHT LEFT MEET LEAVE ALL UPRIGHT

56. Axis Determination Axis L I L III or aVF TIP Normal Positive Positive Both Up Right Negative Positive Meet Left Positive Negative Leave Indeterminate Negative Positive Meet

57. What is the Axis ? LEAD 1 LEAD 2 LEAD 3 aVR aVL aVF

59. LEAD 1 LEAD 2 LEAD 3 What is the Axis ?

61. LEAD 1 LEAD 2 LEAD 3 aVR aVL aVF What is the Axis ?

63. Atrial Waves

64. Right Atrial Enlargement

65. Right Atrial Enlargement P wave voltage is 4 boxes or 4 mm

67. Atrial Enlargements RIGHT ATRIAL ENLARGEMENT LEFT ATRIAL ENLARGEMENT

68. Left Atrial Enlargement

69. Left Atrial Enlargement P wave duration is 4 boxes-0.04 x 4 = 0.16

72. Right Ventricular Hypertrophy

74. Is there any hypertrophy ?

76. What is in this ECG ?

78. Left Ventricular Hypertrophy

80. What is in this ECG ?

82. LVH Types Volume Over Load Pressure Over Load

84. Cardiac Conduction

86. Complete RBBB

88. Interpret this ECG

89. Complete LBBB

91. Interpret This ECG

92. Rate Dependent LBBB

94. Blood Supply of Heart LCA RCA LAD LCX RCA

97. Ischemia and Infarction TRANSMURAL Injury ST Elevation

98. Ischemic Heart Disease (IHD) Blood supply Sub-endocardial Transmural Ischemia Transient loss Stable Angina Variant Angina Infarction Persistent loss NSTEMI ACS STEMI ACS ST Segment Depressed Elevated

99. Types of Angina CHRONIC STABLE ANGINA

101. Micro Vascular Angina

105. T wave inversion

107. Acute Coronary Syndromes Minor Plaque Disruption Non-Occlusive Thrombus Occlusive Thrombus Myocardial Infarction or Sudden Cardiac Death Asymptomatic Unstable Angina or Non-Q-MI Major Plaque Disruption Occlusive Thrombus Non-Vulnerable Atherosclerotic Plaque Vulnerable Atherosclerotic Plaque

108. ACUTE CORONARY SYNDROMES No ST Elevation ST Elevation Unstable Angina NQMI QWMI Myocardial Infarction NSTEMI

109. The Plaque – Clinical Effects Nature of the Plaque Clinical Presentation Picture Stable Plaque Silent or Stable Angina Vulnerable Plaque Stable Angina A Minor Plaque Disruption Unstable Angina B Major Plaque Rupture USA / NSTEMI C Non Occlusive Thrombus NSTEMI or STEMI D Occlusive Thrombus STEMI or Sudden Death

111. ACS Pathophysiology Plaque Rupture, Thrombosis, and Microembolization Quiescent plaque Platelet-thrombin micro-emboli Plaque rupture Process Plaque formation Inflammation Multiple factors ? Infection Plaque Rupture ? Macrophages Metalloproteinases Thrombosis Platelet Activation Thrombin Marker Cholesterol LDL, LP (a), HCy C-Reactive Protein sICAM Interleukin 6, TNF  sCD-40 ligand, SAA MDA Modified LDL, MMP-9, sICAM, D-dimer, Neopterin Complement, Fibrinogen, Troponin, CRP, CD40L Vulnerable plaque Macrophages Foam Cells Collagen  platelet activation TF  Clotting Cascade Lipid core Metalloproteinases Inflammation

112. QMI Thrombus Formation and ACS UA NQMI STE-MI Plaque Disruption/Fissure/Erosion Thrombus Formation Non-ST-Segment Elevation Acute Coronary Syndrome (ACS) ST-Segment Elevation Acute Coronary Syndrome (ACS) Old Terminology: New Terminology:

113. Management of ACS A = Aspirin, B = Beta-blocker, C = Clopidogrel, G = GPIIb/IIIa Inhibitor IHD type Drug Rx. Hep. /LMH ICU Care Lytic Rx P PTCA Stable Angina A+B No No No No Unstable Angina A+B+C Heparin No / Yes No No NSTEMI A+B+C+G LMH YES No No STEMI or QWMI A+B+C+G LMH YES YES YES

115. Lipid Profile Report We have 2 types of fats in our body – the cholesterol and the triglyceride LIPID TYPE LIPOPROTEIN Remarks Treatment TC = 250 HDL = 30 Abnormal Exercise LDL = 170 Abnormal STATINS VLDL = 50 Abnormal Diet TG = 350 VLDL = 235 Abnormal FIBRATE Chylomicron= 85 Abnormal Diet

117. Complications of Acute MI Arrhythmia Extension / Ischemia Acute MI Heart Failure Expansion / Aneurysm RV Infarct Pericarditis Mechanical Mural Thrombus

119. What is in this ECG

121. Look at This ECG

123. Interpret this ECG

125. What are these ECGs

128. Critical Narrowing of LAD

129. Holter & TMT in CAD

131. Normal Q waves Notice the small Normal Q in Lead I

133. Pathological Q wave Notice the deep & wide Infarction Q in Lead I

135. Q wave of Cardiomyopathy

137. Serial ECG changes of MI

139. Blood Supply - MI - Leads ANTERIOR LATERAL INFERIOR POSTERIOR LAD LAD or LCx RCA RCA + LCx V1, V2, V3, V4 V5, V6, L1, aVL L2, L3, aVF V1, V2 Mirror

141. Acute Anterior MI

143. Very Striking

146. Acute Anterio-Lateral MI

148. Severe Chest Pain – Why ?

150. What changes we see ?

152. Why Acute changes disappeared ? r TPA

154. Guess How Old is this MI !

156. Acute Inferior wall MI

158. Which wall MI ?

160. What is striking ? Acute Inf Post

162. Where are the ST ↑ ? Inf Lysed

164. What Can We Infer ?

166. Acute True Posterior MI

168. Decipher V1, V2, V3

170. Identify the Double wall MI

172. New or Old – What MI ?

174. Look at the Right Chest Leads R R R R R R

176. Will Right Ventricular MI occur ?

178. Electrical Alternans

180. Ventricular Bigeminy Normal VPC VPC Normal

182. Myxedema 50 Heart rate Rhythm P wave PR interval QRS in sec

184. S.A.H. ECG changes

186. Hyperkalemia

188. Hypokalemia