ECG INTERPRETATION

An Electrocardiogram(ECG) is a diagram that depicts the electrical activity of the heart. A

12 Lead system uses 10 electrodes and measures the electrical activity of the heart from 12
various positions, as shown in Figure 1 below.

Figure 1: (a) Electrode placement in 12 lead system; (b) 12 lead ECG; (c) Einthoven’s triangle
(Goldberg et al., 2018)
 1. Normal ECG

Key features of a 12 Lead ECG are the various waves, summarized in figure 2.

Heartrate can be calculated by simply dividing 300 (the total number of large squares at 1
minute of paper speed 25mm/sec) by the number of squares occupied by the R-R wave. A
regular rhythm is denoted if the heartrate is the same along the strip.

Figure 2: Normal ECG with parts labelled.

Table 1: ECG segments with normal durations recorded

Table 2: ECG wave with associated heart function.

Figure 3: (Top) ECG diagrammatic with concomitant heart movements. (Bottom) Normal ECG
with regular sinus rhythm.
Normal cardiac axis is usually located downward and slightly to the left. (QRS between -30
and 90) as shown in the figure below.

Figure 4: The relationship between QRS axis and limb leads of the ECG

Figure 5: ECG with normal axis deviation

 2. ECG changes during myocardial infarction

A. ST-Elevation Myocardial Infarction (STEMI)

Figure 6:ECG depicting a STEMI

ST segment elevation in specific leads may clue one in on what is occurring in the specific
myocardial area as well as what vessel is likely occluded. There is usually reciprocal ST
depression in the electrically opposite leads. The table below summarizes this.
Fig depicting ST elevation and reciprocal depression in various leads

ST elevation and Q waves in lead II, III and avF with reciprocal ST depression in lead I, aVL,
V5 and V6 which indicates Acute inferior wall STEMI. Presence of elevated ST segments, tall
T waves and absence of T wave inversion points towards the acuteness of ischemia. There is
an abnormal Q in II, III, aVF diagnostic and specific for an inferior infarct of indeterminate
age.
 B. Non-ST-elevation myocardial infarction (NSTEMI)

Two ECG changes occur commonly in this condition: ST-segment depression and T-wave
flattening/inversion. Dynamic ST segment and T wave changes suggest MI.

Examples of ST segment morphology in MI

Figures below depict ST depression and T wave inversion respectively.

Fig: subendocardial ischemia with ST depression

Fig: Widespread T wave inversion

Fig: widespread ST depression in Leads V5-6. Subtle ST elevation in V1-V2 and AVR with
small Q waves
 3. Atrial Fibrillation (AF)

ECG illustrating atrial fibrillation depicts irregularly irregular rhythm, absent P waves,
fibrillatory waves (which may mimic P waves leading to misdiagnosis), absence of an
isoelectric line, variable ventricular rate, QRS complexes usually >120ms.

The figures below depict AF:

Fig: Irregular ventricular response with coarse fibrillatory waves seen in V1

 4. Atrial Flutter:
ECG depicts a narrow complex tachycardia (atrial activity 300bpm), loss of the isoelectric line,
saw-tooth flutter waves, inverted flutter waves in leads II,III, aVF, upright flutter waves in V1
that may resemble P waves, regular rhythm, typically 2:1 block.

Fig with AF with 2:1 block: anticlockwise flutter. Inverted flutter waves in II, III + aVF at a
rate of 300 bpm. Upright flutter waves in V1 simulating P waves. 2:1 AV block resulting in a
ventricular rate of 150 bpm. Note the occasional irregularity, with a 3:1 cycle seen in V1-3

Fig with AF of variable block. Inverted flutter waves in II, III + aVF with atrial rate ~ 300
bpm, Positive flutter waves in V1 resembling P waves, AV block varies from 2:1-4:1
 5. Ventricular Tachycardia (VT):
ECG depicts broad, uniform QRS complexes, regular rhythm, no discernible P waves.

Fig 1: Classic monomorphic VT with uniform QRS complexes, indeterminate axis, very broad
QRS

Fig 2: Very broad complexes: NW axis, Brugada’s sign — the distance from the onset of the
QRS complex to the nadir of the S-wave is > 100ms; Josephson’s sign — notching near the
nadir of the S wave is seen in leads II, III, aVF
 6. Ventricular Fibrillation (VF)
ECG depicts chaotic, irregular waves, no identifiable P waves, no organized QRS complexes,
no T waves. It is an important shockable rhythm.

VF is rarely diagnosed using a 12 Lead ECG.

 7. First-Degree AV Block:
ECG depicts a prolonged PR interval (>200 ms), regular rhythm, due to a delay in conduction
from the atria to the ventricles.

The ECG examples are as follows:

Fig: Sinus bradycardia with 1st degree heart block, PR interval >300ms

Fig: normal sinus rhythm with 1st degree AV block, PR interval 260ms
 8. Second-Degree AV Block:
a. Mobitz I (Wenckebach):
ECG shows progressive PR prolongation until a QRS is dropped. The greatest increase in PR
interval duration is typically between the first and second beats of the cycle.

The figure below shows an example of the phenomenon.

b. Mobitz II:
ECG shows intermittent non-conducted P waves without PR prolongation. The PR interval in
the conducted beats remains constant.
 9. Third-Degree AV Block (Complete Heart Block):
ECG shows no relationship between P waves and QRS complexes, atrial rate faster than
ventricular rate.

The ECGs below illustrate this.

Fig: Atrial rate is 85bpm, ventricular rate is 38bpm, lack of atrial impulses conducted to
ventricles, marked inferior ST elevation
 10. Bundle Branch Blocks:
a. Left Bundle Branch Block (RBBB)
ECG depicts wide QRS>120ms, dominant S wave in V1, broad monophasic notched R wave
in lateral leads(I, aVL, V5-56), absence of Q waves in lateral leads, prolonged R wave peak
time. May be associated with left axis deviation.

For example:

Fig: Broad notched R waves in aVL and I.

 b. Right Bundle Branch Block (RBBB):
ECG depicts a wide QRS, RSR’ pattern in V1-3 (“M-shaped” QRS complex), wide, slurred S
wave in lateral leads (I, aVL, V5-V6). May also have discordance with ST depression and/or
T-wave inversion in right precordial leads(V1-V3)

The examples below of the ECG:

Fig: Isolated RBBB. Typical RSR’ pattern in V1-V2. Widened S waves again demonstrated in
lateral leads, especially V4-V6; Discordance in leads V1-V2.
 11. Supraventricular Tachycardia (SVT):
ECG depicts narrow QRS complexes, regular rapid rhythm, P waves often buried in preceding
T waves. It also depicts NW axis deviation.

An example is shown below:

Fig: narrow complex tachycardia with retrograde P waves visible preceding each QRS
complex.
 12. Pericarditis
Pericarditis on an ECG shows diffuse concave ST elevation and PR depression throughout
most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6), reciprocal ST
depression and PR elevation in lead aVR (± V1).
ECG changes may occur in 4 stages:

• Stage 1 – widespread STE and PR depression with reciprocal changes in aVR (occurs
during the first two weeks)
• Stage 2 – normalisation of ST changes; generalised T wave flattening (1 to 3 weeks)
• Stage 3 – flattened T waves become inverted (3 to several weeks)
• Stage 4 – ECG returns to normal (several weeks onwards)

The figures below are ECG examples

Fig showing ECG with widespread concave ST elevation and PR depression is present
throughout the precordial (V2-6) and limb leads (I, II, aVL, aVF).There is reciprocal ST
depression and PR elevation in aVR.

Fig showing sinus tachycardia, Widespread concave STE and PR depression (I, II, III,
aVF, V4-6) Reciprocal ST depression and PR elevation in V1 and aVR. Spodick’s
sign best visualised in lead II
 13. Hyperkalemia

Hyperkalemia results in peaked T waves, widened QRS, flattened P waves and sine wave
pattern in severe cases. The table below summarizes these changes.

The ECGs below depict this as well.

Fig: Prolonged PR interval, broad bizzare QRS, peaked T waves

Fig: Huge peaked T waves and sine wave appearance
 14. Hypokalemia

Hypokalemia (K<2.7mmol/L) results in increased P wave amplitude, prolonged PR interval,

widespread ST depression and inversion/flattened T waves, prominent U waves(best seen in
leads V2-V3) and apparently long QT interval due to fusion of T and U wave. With worsening
hypokalemia, supraventricular tachyarrhythmias may occur.

Fig depicting U waves

The ECGs below exemplify this.

Fig showing widespread ST depression, T wave inversion. There are also prominent U waves
and long QU interval. K+= 4.7mmol/L
Fig depicting ST depression and T wave inversion best noted in inferior leads. Prominent U
waves and long QU interval. Serum K+= 1.9mmol/L
 15. Hypocalcemia:

Hypocalcemia (normal Ca2+= 2.2-2.6mmol/L)causes QTc prolongation, usually due to ST

segment prolongation. Torsades De Pointes may occur.

The figures below depict this.

Fig representing QTc prolongation

 16. Hypercalcemia:

The main ECG change seen in hypercalcemia is shortening of the QT interval. In severe cases,
Osborn waves(J waves) may appear. Normal Ca2+ levels (2.1-2.6 mmol/L)

The figures below depict this.

Figure: Osborn waves in severe hypercalcemia.

Figure depicting Bizarre-looking QRS complexes: Very short QT interval: J waves =
notching of the terminal QRS, best seen in lead V1
 17. Pulmonary Embolism

The most frequent finding on ECG is sinus tachycardia, occurring in nearly half of pulmonary
embolism cases. Other ECG changes often seen include:
• Right heart strain: This manifests as T wave inversions in the right precordial leads
(V1-4) and sometimes the inferior leads (II, III, aVF). This pattern suggests high
pressure in the pulmonary artery.
• Rightward axis shift: The electrical impulse may travel through the heart in a more
rightward direction than normal. In extreme cases, it can even mimic a leftward axis
shift.
• Dominant R wave in V1: This suggests acute right ventricular enlargement.
• Right atrial enlargement: A tall P wave in lead II can indicate this.
• SI QIII TIII pattern: This is a combination of deep S wave in lead I, Q wave in lead
III, and inverted T wave in lead III. While often seen in PE, it's not a reliable indicator.
• Clockwise rotation: The electrical impulse activation pattern appears shifted,
suggesting rotation of the heart due to right ventricular enlargement.
• Non-specific ST and T wave changes: These can include both elevation and
depression, but hold little diagnostic value for PE on their own.

The figures below show 2 examples of pulmonary embolism.

Figure depicting patient with massive pulmonary embolism, with ECG changes consistent with
Right bundle branch block, extreme right axis deviation (+180 degrees), S1Q3T3, T waves
inversions in V1-4 and lead III, clockwise rotation with persistent S wave in V6
Figure depicting deep S1Q2T3 wave, possibly due to right ventricular enlargement and
possible ischemia