Acute Cardiovascular Care Association

• - ase 18 noses I I I In 1ovascu ar enc1es Disclaimer: All shown ECGs are only examples of the typical diseases as they might be encountered in everyday clincal practice. Some patients might show different diseases although the ECG looks similar

First ECG must be done on first contact with interpretation on scene by trained emergency personal or via telemedicine. In all patients arriving at the emergency department with a suspect of the first ECG must be recorded within 10 minutes after patient arrival

ST Elevation Non-ST Elevation Myocardial (STEMI) Infarction (NSTEMI) > Most commonly presence of non-specific ST-segment and T-wave changes often with sinus ST-segment elevation in at least two contiguous leads > > No pathological ECG changes in 1/3 of patients and if > QRS/ QT prolongation and AV conduction defects >0.25/ >0.2mV in men <40/>40 years or 0.15mV in normal additional leads with V7 through V9 and V3r > Diffuse T-wave inversion or features of women in leads V2/V3 and/or 0.1mV in other leads. through V4r should be considered > Additional leads should always be included with V7 > Typical signs include ST-depression, T-wave inversion through V9 and V3r through V4r and transient ST-segment elevations Vl ---- Obtain additional ECGs during monitoring i.e. recurrent ...Jr-'r-+-• ...11 > ST-segment depression in V1-V3 and positive terminal > l T-Wave record leads V7-V9 to identify ST-segment symptoms II .,j,,__.,_},.-�__,_J"-'½� V2 __J[r-1�(1 elevation >=0.1mV > ECG confounders like left BBB or paced rhythm corrupt 111 V3 .JAJf---lA.J ..,.).,_.,) __ ___ }-._)--J.__; > In inferior (right coronary artery) myocardial infarction ECG based diagnosis I I I I record leads V3r and V4r to identify right ventricular a V R �,r--''i'-·'1..._,..,,�;"' 1 involvement aVL vs ...... , "\r--, -c, .. �,-.·-··-., . --�·c-• LJ > In left concordant ST elevation "'\,--i 1 (leads with positive QRS deflection) seems to be the V6 """11_____,LJ...,_, best indicator , - _, __ .,__ ------:--- > Presence of ST-depression in eight or more surface leads __ �,- - -- ,-

together with ST-elevation in aVR and/or V1 suggests """" '•""""· ''" .,,. '" """" '·" '"· ,,..,-�,-... left main disease Pericarditis/ > Widespread concave ST-elevation and PR-depression found in both the limb leads and chest leads 11 __},"1_.V\_J.11'------,ltLY\ ...... J,\_Vl_'-'L} V-f'Jl-,.,------s,..r--�,..r > Reciprocal ST-depression and PR-elevation in lead aVR 1 111 _L'\__,_J V\____JA ... \... J'LY \_}'\_V\._I -�('--('---•('� > S1Q3T3 sign indicate acute volume and/ or pressure and/or V1 I a V R �-,._,,,------,...,,...,-, ��,.---1,-,, ...... _...... 1� overload of the right ventricle > Presence of (due to pain or pericardia I > New complete or incomplete right BBB with rightward effusion) shift of the QRS axis > Low QRS voltage, sinus tachycardia and electrical > ST segment elevation in aVR and V1, T-wave inversion alternans suggest presence of pericardia! effusion . � ·- ....,J..,,..._._,__J.,,.-v,...... Jv<_;'• ::....,.,,_...,_,,_�..,,,. -r�\...... r'---..,...... ,,,.___,.,'-----,('\.-""-f- in leads V1-V4 ��.J _/L/L/,-/L../•-/L)L/L/t.J > Sinustachycardia or atrial / VI�

�,--v---..,...... ,._,.,...,�,.....,,,_, fl , r r , r r r r- r,.___r,_...... r ,,...... r --t----f -1--r--...r -+-1 � " !.../wL/,_,fwt) ...... J ,_/L)l.. ��,...... w,...... w,,_w,,..i 1: ---- I, l l-l i)l _,,,...,_..,,-,,r----1---t--+--+------1,,-+-+--r-l�,...... ,.,., ...... ,J r---"f----r-,,-.-r--...... _,...._,.---r-----•"', -ttJ;LVWILjlLJ/L...1/L.J/L,.JfL W...... J...... -l.-J�J, l-.J. L l J. ! V3� '.__. I I '· •. '· 1, ...J t � I, l, JI'· __J,H _,,___,...__..,.,,,__�-"---,,__..,'---"c.._,,,,"\• -L..J,..,.. l !_ _j..-....J..,...... l,..__.-J,___ r r r r f7---r-...,.-r r--r7·-r--n-----r--rJl ' I, I, ( l 1.-J,_J,...J '· i, .....J, ! 1,---(....l.J} � V4 � -���...,...... ,.J...r--lJ- ...... l.,...... ,...... J_l.,...... J�•_...... l.-- _.... lu 1a.•>.UU s:1.,..... U Uh "" l.t '1_1...J··� " •• I 11 I i ,.1 1 ¼> I 1, l•• J �J...J ,....J...... l.' ""' �,...... J,-J�� �. � I, ,�1 ______V5� , I I -I..J,....J, I I 1 1 I t l I 1 1 t .tJ1

Rare important diagnoses Bradyarrhythmias/ > Fast, broad and irregular are characterized •:::--.,,....,,...... ,-----,�-CJ!__..,_,r--' -· --- --·· ------·------··.._r-- --� ------.__r------by a wide QRS complex tachycardia, right-bundle > Complete (3rd degree AV Block) with branch block, right superior axis deviation and varying ECG has independent ventricular and atrial rates (AV RR intervals dissociation) Fast Broad Ventricular arrythmias/Cardiac > Irregular tachycardia are due to atrial > ECG shows a junctional or ventricular esape rhythm in fibrillation with antegrade conduction via left AV block 3 Arrest posterolateral pathway > tachycardia is a form of polymorphic > Irregular deflections of varying amplitude ventricular tachycardia occuring in the context of QT > No P-waves, QRS complexes or T-waves identifiable on prolongation the ECG Ventricular tachycarida: Regular, broad QRS complexes Pulseless electric activity/ > Pulseless electric activity is defined as any electrical cardiac activity expected to generate pulsatile circulation but the patient has signs of Fast Broad Irregular tachycardia and no palpable pulse > Asystole is characterized by an ECG without any electrical activity ESC European Society of Cardiology Torsades de pointes tachycardia