An Easy Approach to
Interpret ECG
DR. D.P Khaitan
M.D (Medicine) F.C.G.P(IND) F.I.A.M.S (Medicine) FICP FICCMD
ESSENTIALS :
ECG interpretation is a knowledge based skill
3A
• A concept of normal ECG and abnormal ECGs based on a basic
book with special emphasis on illustrated ECGs explanation
• A regular revision
• A step-by-step methodical approach in collaboration with the
clinical history
Normal ECG
11 Steps interpretation of ECG
Positive wave towards the flow
of current
Negative wave away from the 1. A Bird’s eye view
flow of current 2. Heart rate (A rate – V rate)
3. Rhythm
LA 4. Electrical axis
SAN
AVN S 5. P-wave
RA
1
q
LV
6. PR interval
RV 2 7. QRS morphology
3
R V6 8. ST segment
V1
9. T changes
R 10. QTc interval
11. U wave
T
P U
Q English
nd
alphabets
S 2 half P Q R S T U
Step 1 : A Bird’s Eye View
Paper Seed = 25 mm/sec
1 mm width = .04 sec
0.5 mv
1 mV
standardization
1 mV = 10 mm ht
NB : Any gross abnormality on ECG : Rhythm regular or irregular , Tachycardia
/Bradycardia , Low voltage /Poor R-wave progression , etc.
Step 2 : Heart rate (A rate – V rate)
1 sec = 25 small sq Number of small
60 sec (1 min) = squares in
25x60 = 1500 small sq
Rate = 1500 between two
R-R interval corresponding RR
(small square )
When the rhythm
is regular A practical approach
• < 3 big squares =
A Tachycardia
Speed : 25 mm/sec >5 big squares =
Bradycardia
1500/15 = 100 bpm
• Accurate rate
calculation by the
given formula
B Count QRS in 10 second rhythm strip x 6 → use this method to
determine rate when rhythm is irregular (e.g., atrial fibrillation)
Step 3 : Rhythm
Tachy-rhythm Pre-
excitation
Sinus AF
Tachycardia AV node
AV node
Junctional
Atrial P Positive
Ectopic
Tachycardia tachycardia
P Negative P
Ventricle
MAT FP
AVN
AVNRT P
(Slow-Fast)
AF
SP
Atrial flutter :
cavo-tricuspid
Isthmus AV
circuit
TV
Bix Rule orthodromic AV
Node
Ventricle
Ventricular tachycardia - VT AV dissociation with faster ventricular rate (ventricular origin)
Josephson’s
Capture beat Fusion beat Sign
Left ear rabbit sign
North-west axis QRS > 0.14 sec
Brugada’s sign > 100 ms
QS pattern
NB : +Ve or –Ve concordance throughout the chest lead , i.e. with leads V1-6 so entirely
positive (R) or entirely negative ( QRS complexes) , with no RS complexes seen
Step 4 : Electrical Axis (Frontal plane)
NWA
+ 1800
Look at lead I and II
QRS Positive in leads I and II Normal Axis -300 to +900
QRS complex is positive in lead I but negative Left Axis Deviation - 300 to -900
in lead II
QRS Negative in lead I but positive in lead II Right Axis Deviation +900 to +1800
Step 5 : P-wave
P wave pattern usually best seen in lead II RAE
Inverted P-waves in inferior leads (II, III &
aVF) suggest retrograde activation of the
atria : RAE
• AV nodal rhythm
• Low left atrial site
• AVNRT or AVRT
Inverted P wave wave in standard lead I : LAE
• Incorrect electrode placement
(in between right arm and left arm) RAE
• Mirror image dextrocardia +
LAE
Step 6 : PR interval (0.12 to 0.20 Sec)
PR > : constant or gradual prolongation till QRS drop
First degree AV block Second degree – Mobitz type I
Shortened PR interval , LGL syndrome or WPW pattern
LGL syndrome
WPW pattern
Step 7 : QRS (on horizonatal plane ) morphology
QRS voltage < 5 mm in limb leads
<10 mm in chest leads
Transition zone & R-wave progression
LA
SAN R
AVN S V6
RA q septal wave
q q
1 LV
2 Electrical flow
R Thicker LV V5 , V6 =
r septal wave RV
V5 L. Ventricle
3
Ventricular dominance : RVH/LVH
V4 In bundle branch block :
V1 no simulataneous ventricular
V2 V3 activation but one after the other
r (Biphasic R)
• RBBB with RV pattern dominance
• LBBB with LV pattern dominance
S
Pathological Q wave : dead / inert
V1 -V2 = R. Ventricle Transitional zone myocardium
Diagnostic Approach to STEMI
T • 1 2 R 3 R
ST elevation R ST T
Myocardial infarction
Q ST T
Endocardium Epicardium Q ST
Potential difference Hyperacute mts-few hrs few hrs-few few days –
T days few weeks
• New ST-segment elevation at
J-point in at least two
anatomical continuous leads
of > 2 mm in a male or > 1.5
mm in a female over leads V2-
Fully Evolved Myocardial Infarction V3 and/or at least 1 mm in
T - ST = Current of Injury other continuous leads or
Q = Necrosis limb leads
T = Myocardial Ischemia (other ST causes excluded)
Epicardium • A wide Q wave (>0.04 sec) that
exceeds 25% of the R wave in
the leads with necrosis.
STEMI pattern on ECG
Q ST seg T
V1
II III
V2
V3
aVF R ST seg T
V3
Inferior STEMI Posterior wall MI
Reciprocal change is defined as ST-
segment depression > 1 mm in at least
2 leads in a single anatomic segment ,
occurring onto the contralateral side ,
as a mirror-image effect of ST-
segment elevation associated with
STEMI.
This supports the diagnosis of STEMI with
specificity and positive predictive value of
93%.
Wellens’ syndrome anterior STEMI
A Wellens’ Syndrome B Anterior STEMI with ‘’Shark Fin’’ sign formed
by fusion of QRS , ST-seg and T wave
Step 8 : ST segment - Phase 2
Coronary aretery disease is suggested by horizontal
plane or down sloping ST segment
The strain pattern – depressed convex – upward ST
segment with inverted T-wave
Digitalis effect : a mirror image correction mark
shape of the ST segment
Hyperacute phase of myocardial infarction and
prinzmetal’s angina is reflected by slope eelvation of
the ST segment associated with the Tall and widened
T -wave
ST in myocardial ischemia
Subendocardial Injury
The flow of current is away from the Horizontal or downsloping ST
exploring electrode (Potential difference) segment depression
ST segment depression
> 0.5 mm > 2 in two contiguous leads
myocardial ischemia
ST depression > 1 mm a worse
prognosis.
ST depression > 2 mm in > 3 leads
possibility of Non-ST elevation
myocardial infarction (NSTEMI) + T
inversions or flat T
T
Downsloping ST segment depression
Step 9 : T –wave – Phase 3
Low or inverted T waves in most leads may be
Ventricular action potential
associated with coronary heart disease
Low or inverted T waves associated with generalized
low voltage of the QRS complex suggest pericardial
effusion or myxoedema.
Tall , peaked T waves in the precordial leads may be
due to :
• ST elevation MI (broad based hyperacute T-wave)
• de Winter T-wave • Early repolarization syndrome
de Winter T-wave ERS T-wave
• Hyperkalaemia (narrow based Tall T-wave)
Step 10 : QTc interval
QTc estimation (use scientific calculator)
https://play.google.com/store/apps/details?id=com.scientificCalculator
• Bazett formula : QT / RR (useful with HR 60-100 bpm)
• Framingham formula : QT + 0.154 (1-RR) (At heart rate outside of the
range 60-100 bpm)
• A useful rule of thumb is that a normal QT is less than half the
preceding PR interval
QRS QRS
T T
P P U
QT interval QT interval
Normal QTc values
• QTc prolonged if > 440 ms in male or > 460 ms in women
• QTc is abnormally short if < 350 ms
• QTc > 500 ms is illustrated with an increased risk of Torsades de
pointes
QTc (continued)
Prolonged QTc in hypokalemia , hypocalcaemia , myocardial disease
, congenital long QT syndrome
Shortened QT interval : In Hyperkalemia , Hypercalcaemia ,
Vagotonia , Digoxin toxicity , congential short QT syndrome
Illustration by ECGs
QTc interval = 520 ms
Prolonged QT by rule of thumb Hypokalemia (A young male with
Quadriparesis and respiratory arrest)
Hypercalcaemia : with 340 ms with Congenital short QT syndrome
virtual absence of ST segment and a • QT and QTc intervals respectively : 0.32 and 0.32
ms both are equal and unchanged.
widening of T-wave • Tall / peaked T , best seen over precordial leads
V1-V4.
Step 11 : U wave
A predominant U wave in the midprecordial leads – V3 to V5 –
commonly due to hypokalemia
An inverted U wave in standard leads leads I and II and leads
and V6 is usually due to one of the following :
• Coronary heart disease
• Hypertensive heart disease
Normally Synchronized repolarization of
cardiac myocytes and Purkinje fibres
In hypokalemia dichotomized repolarization :
delayed and prolonged repolarization through T U
purkinje fibres T-U complex
fusion of T with U QT prolongation
Prominent • ST depression
U wave • Fusion of T with U
Concluding remark
Again to remind
ESSENTIALS :
ECG interpretation is a knowledge based skill
3A
• A concept of normal ECG and abnormal ECGs based on a basic
book with special emphasis on illustrated ECGs explanation
• A regular revision
• A step-by-step methodical approach in collaboration with the
clinical history
