ECG interpretation

Maia
Gotsadze
 The ECG

An EKG, also called an ECG or

electrocardiogram, is a recording of the
heart's electrical activity
 ECG

An electrocardiogram is a painless, non invasive way with quick

results which to diagnose many spread heart problems in people
of all ages.
It's a common test and are often done in a doctor's office, a clinic
or a hospital room. They've become standard equipment in
operating rooms and ambulances.

An electrocardiogram is a safe procedure.

 ECG

No special preparations are necessary for a standard

electrocardiogram
ECG is needed for patients which experience any of the
following signs and symptoms:
Heart palpitations
Rapid pulse
Chest pain
Shortness of breath
Dizziness, lightheadedness or confusion
Weakness, fatigue or a decline in ability to exercise
How to take ECG

A standard ECG takes a few minutes

Electrodes — typically 10 — will
be attached to chest and to limbs.
The electrodes are sticky patches applied to record the
electrical activity of heart.
Each one has a wire attached to a monitor.
If the patient has hair on the parts of body where the
electrodes will be placed, the technician may shave the
hair so that the patches stick.
Patient can breathe normally during the
electrocardiogram.
Moving, talking or shivering may distort the test results.
ECG

An electrocardiogram records the electrical

signals in a heart.

The impulses are recorded by a computer

and displayed as waves on a monitor or
printed on paper.
ECG

An electrocardiogram is also
called a 12-lead ECG because
it gets information from 12
different areas of the heart.
These waves are created by
electrodes, placed on the
chest and limbs.
 EKG Leads

Leads are electrodes which measure the difference in electrical potential

between either:

1. Two different points on the body (bipolar leads)

2. One point on the body and a virtual reference point with zero electrical
potential, located in the center of the heart (unipolar leads)
 EKG Leads

3 Standard Leads
The standard EKG has 12 leads:
3 Augmented Leads
6 Precordial Leads
 Position of limb and chest leads

Four limb electrodes

Six chest leads -Precordial Leads
Position of limb and chest leads

Four limbs
Four limb leads lead
Precordial Leads

Six chest leads -

Precordial Leads
 Summary of Leads

Limb Leads Precordial Leads

Bipolar I, II, III -

(standard limb leads)

Unipolar aVR, aVL, aVF (augmented V1-V6

limb leads)
Right Sided EKG????

Right leads
“look” directly
at Right
Ventricle when
there is right
ventricle MI
Cardiac conduction system

The EKG is a representation of the

electrical events of the cardiac
cycle.
It records the wave of
depolarisation that spreads across
the heart.
The Normal Conduction System

EKGs captures a tracing of

cardiac electrical impulse as it
moves from the atrium to the
ventricles. These electrical
impulses cause the heart to
contract and pump blood
• Each beat of the heart is
triggered by an electrical
impulse normally generated
from special cells in the upper
right chamber of the heart
(pacemaker cells).
Waveforms and Intervals
 What types of pathology can we identify and
study from EKGs?

Arrhythmias
Myocardial ischemia and infarction
Pericarditis
Chamber hypertrophy
Electrolyte disturbances (i.e. hyperkalemia, hypokalemia)
Drug toxicity (i.e. digoxin and drugs which prolong the QT interval)
ECG interpretation

Rate
Rhythm
Axis
P wave
PR interval
QRS duration
QRS morphology
Abnormal Q waves
ST segment
T wave
QT interval
 ECG paper

There are many types of ECG machine, including 3, 6, and 12 channel

machines.
The ECG trace is printed out on paper composed of a number of 1 and 5 mm
squares.
The height of each complex represents the amount of electrical potential
involved in each complex and an impulse of 1 mV causes a deflection of 10
mm. Horizontally each millimetre represents 0.04 second and each 5 mm
represents 0.2 second.
 ECG paper

1 Small square = 0.04 second 1 Large square = 0.2 second 5 Large squares = 1 second

Time
2 Large squares = 1 cm
 ECG paper and timing

ECG paper speed = 25mm/sec

Voltage calibration 1 mV = 1cm

ECG paper - standard calibrations

• each small square = 1mm
• each large square = 5mm

Timings
• 1 small square = 0.04sec
• 1 large square = 0.2sec
• 25 small squares = 1sec
• 5 large squares = 1sec
 STANDARDISATION ECG amplitude scale

Normal amplitude Half amplitude Double amplitude

10 mm/mV 5 mm/mV 20 mm/mV
ECG WAVES
 P waves

During normal atrial depolarization the main electrical vector is directed

from the SA node towards the AV node, and spreads from the right
atrium to the left atrium

This turns into the P waves on the ECG

So, P waves represents atrial depolarization

P wave height 2 and half small squares ,width
also 2 and half small square
 P-wave

Normal values Abnormalities

1. Inverted P-wave
• Junctional rhythm
2. Wide P-wave (P- mitrale)
1. up in all leads except
• LAE
AVR.
3. Peaked P-wave (P-pulmonale)
2. Duration.
• RAE
< 2.5 mm.
4. Saw-tooth appearance
3. Amplitude.
• Atrial flutter
< 2.5 mm. 5. Absent normal P wave
• Atrial fibrillation
P waves best seen in lead 2 and V1.
PR interval

Is a time from onset of atrial activation to onset of

ventricular activation

Start of P wave to start of QRS complex

Normal = 0.12 - 0.2 seconds (3-5 small squares)

Decreased = can indicate an accessory pathway

Increased = indicates AV block (1st/2nd/3rd)

 PR interval

Slide 17
Normal Q wave
 Q WAVES

Q waves < 0.04 second.

That’s is less than one small square duration.

Height < 25% or < 1/4 of R wave height

If the tooth is deep or wide, it is called a pathologic and indicates to

the myocardium injury
 Pathologic Q waves

Pathologic Q waves are a sign of previous myocardial infarction.

Pathologic Q waves are not a early sign of MI. Generally it takes
several hours or days to develop pathologic Q waves.
Once pathologic Q waves have developed they rarely go away.
However, if the MI is reperfused early (e.g. as a result of
percutaneous coronary intervention) stunned myocardial
tissue can recover and pathologic Q waves disappear.
In all other situations they usually persist indefinitely.
Pathologic Q waves
Q wave in septal hypertrophy
QRS COMPLEX

The QRS complex reflects the rapid

depolarization of the right and left
ventricles

They have a large muscle mass compared to

the atria and so the QRS complex usually
has a much larger amplitude than the P
wave.
QRS complex

Normal ≤ 0.12 seconds

> 0.12 seconds = Bundle Branch

Block
 Small voltage QRS

Defined as < 5 mm peak-to-peak in all limb leads or <10 mm in precordial

chest leads.

Causes : pulmonary disease, hypothyroidism, obesity, cardiomyopathy

Acute causes : pleural and/or pericardial effusions

Normal upward progression of R wave from
V1 to V6
V5 V6
V4
V3
V2
V1

The R wave in the precordial leads must grow from V1 to at least V5

QRS complex

Is there LVH?
Sum of the Q or S wave in V1 and
the tallest R wave in V5 or V6
>35mm is suggestive of LVH
 LVH-Voltage Criteria

In adult with normal chest wall

SV1+RV5 >35 mm
or
SV1 >20 mm
or
RV6 >20 mm
LEFT VENTRICULAR HYPERTROPHY
 Right ventricular hypertrophy

Upward R wave in V1 it is suggestive of RVH

Right ventricular hypertrophy (RVH) increases the height of the R wave in
V1.
And R wave in V1 greater than 7 boxes in height, or larger
than the S wave, is suspicious for RVH.
 Right Ventricular Hypertrophy

Other findings in RVH include right axis deviation - taller R waves in the
right precordial leads (V1-V3), and deeper S waves in the left
precordial (V4-V6).

The T wave is inverted in V1 (and often in V2).

Right Ventricular Hypertrophy
NORMAL ST- SEGMENT

It's isoelectric
[i.e. at same level of PR or PQ
segment at least in the
beginning]
 Abnormalities ST- SEGMENT

ST elevation: ST depression:
More than one small More than one small square
square Ischemia
Acute MI Ventricular strain
Prinzmetal angina BBB
Acute pericarditis Hypokalemia
Early repolarization Digoxin effect
ST elevation
ST depression
Abnormalities of ST- segment
ST segment
ST segment
 T wave

T waves represents the repolarization (or recovery)

of the ventricles.
 T-wave
.
Normal values
amplitude: T- inversion:
< 10mm in the chest leads
• Ischemia
• Myocardial infarction
Abnormalities: • Myocarditis
Peaked T-wave: • Ventricular strain
• Hyper-acute MI • BBB
• Hyperkalemia • Hypokalemia
• Normal variant • Digoxin effect
 T wave

Small = hypokalaemia

Tall = hyperkalaemia

Inverted/biphasic = ischemia/ previous infarct

T wave
T wave
T wave
QT- interval

Time interval between beginning

of QRS complex to the end
of T wave.
QT ≤ 11mm (0.44 sec)
Abnormalities:
Prolonged QT interval:
hypocalcemia and congenital
long QT syndrome.
Short QT interval: hypercalcemia.
 QT Interval
- Should be < 1/2 preceding R to R interval -

R R

QT interval
U waves

The U wave probably represents “ after

depolarizations” in the ventricles.
The U waves is hypothesized to be caused by
the repolarization of the interventricular
septum
They normally have a low amplitude and even
more often completely absent
They always follow the T wave
The electrical signals in a heart

When cardiac impulse moves towards the

positive contact- on the ECG is produced
upward line.
As the impulse moves away from the
electrode, a downward deflection is seen.
If there is no electrical activity - the ECG
shows a isoelectric line.
Simplified normal Position of leads on ECG graph

Lead 1 upward PQRS

Lead 2 upward PQRS
Lead 3 upward PQRS
Lead AVR downward or
negative PQRS
Lead AVL upward PQRS
Lead AVF upwards PQRS
 Simplified normal Position of leads on ECG graph

V1 V3 V4 V5 V6 Chest lead V1 –V2 negative or downward

V2 PQRS

Chest leads V3-V4-V5-V6 all are upright from

base line

The R wave slowly increasing in height from

V1 to V6.

So in normal ECG you see only AVR and V1,V2

as negative or downward deflections
Normal ECG
 Determining the Heart Rate

Rule of 300
10 Second Rule

HR 60-100 normal
< 60 => bradycardia
> 100 => tachycardia
 Basic of Heart Rate

Heart rate can be easily calculated from the ECG strip.

When the rhythm is regular, the heart rate is 300 divided by the number of
large squares between the QRS complexes. (or 1500 divided by the
number of small squares between the QRS complexes)
For example, if there are 2.5 large boxes between regular QRS complexes,
the heart rate is 120
( 300/2.5= 120)
What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm
 The Rule of 300

It may be easiest to memorize the following table:

# of big boxes Rate

1 300
2 150
3 100
4 75
5 60
6 50
 10 Second Rule

As most EKGs record 10 seconds of rhythm per page, one can

simply count the number of beats present on the EKG and multiply
by 6 to get the number of beats per 60 seconds

This method works well for irregular rhythms

 What is the heart rate?

33 x 6 = 198 bpm
The QRS Axis

The QRS axis represents the net

overall direction of the heart’s
electrical activity

Abnormalities of axis can hint at:

Ventricular enlargement
Conduction blocks (i.e.
hemiblocks)
 The QRS Axis

By near-consensus, the normal QRS axis

is defined as ranging from -30° to +90°.

-30° to -90° is referred to as a left axis

deviation (LAD)

+90° to +180° is referred to as a right

axis deviation (RAD)
Axis

Positive in I and II =
NORMAL

Positive in I and negative

in II = LAD

Negative in I and positive

in II = RAD
 Quadrant Approach: Example 1

The Alan E. Lindsay ECG

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Negative in I, positive in aVF  RAD

 Quadrant Approach: Example 2

The Alan E. Lindsay ECG

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Positive in I, negative in aVF  Predominantly positive in II 

 Basic of Heart Rhythm

Sinus rhythm is the normal rhythm

So, you need to be able to distinguish this from all

others

The impulse begins from the SA node and travel

through the AV junction and bundle of His into the
ventricles
 Basic of Heart Rhythm

When looking at rhythm we need to look at 5 components that enable us to

interpret an ECG strip

Rate (regular: 300 method@ irregular 6 sec method)

Regularity ( Tachy or brady @ regular or irregular)

 Basic of Heart Rhythm
P waves (should always come before the QRS complexes @ represent
atrial activity)

PR interval (duration)

QRS complex (shape, size, duration@ represents ventricular activity)

QT interval (duration)
Explaining strips
 Normal Sinus Rhythm

P waves (uniform shape) before each QRS complex

PRI: 0.12-.0.20 seconds and constant
The R-R intervals are constant; Rhythm is regular
QRS: .0.04 to 0.12 seconds
QT interval < 0.4 sec
Rate: 60-100 beats per minute
 Sinus Bradycardia

P waves (uniform shape) before each QRS complex

PRI: 0.12-.20 seconds and constant
The R-R intervals are constant; Rhythm is regular
QRS: .0.04 to 0.12 seconds
QT interval < 0.4 sec
Rate: Atrial and Ventricular rates are equal; heart rate less than 60
 Sinus Tachycardia

If the rates is between 100 to 150 beats per minute with the
same intervals it is a sinus tachycardia

PRI: 0.12-.20 seconds and constant

QRS: .0.04 to 0.12 seconds
QT interval < 0.4 sec
Sinus arrhythmia
Sinus arrhythmia
Supraventricular Dysrhythmias
Supraventricular Tachycardia
 Atrial fibrillation

AF describes as a condition in which the atria tissue randomly

generates action potentials from many different regions.
Physically, the atrial muscle appears to quiver.
There are no noticeable P waves, and the overall rhythm is
irregularly irregular
The duration of R-R interval varies
The amplitude of R-R varies
The key to recognizing A-fib are the narrow QRS’s and the
irregularly irregular rhythm
Atrial fibrillation
 Atrial Flutter

A single irritable focus within the atria issues an impulse that is

conducted in a rapid, repetitive fashion.

To protect the ventricles from receiving too many impulses, the AV

node blocks some of the impulses from being conducted through to
the ventricles.
 Atrial Flutter

Atrial fibrillation

Regularity: Atrial rhythm is regular. Ventricular rhythm will be regular if the AV

node conducts impulses through in a consistent pattern. If the pattern varies, the
ventricular rate will be irregular

Rate: Atrial rate is between 250-350 beats per minute. Ventricular rate will
depend on the ratio of impulses conducted through to the ventricles.
 Atrial Flutter

P Wave: When the atria flutter they produce a series of well defined P waves.
When seen together, these "Flutter" waves have a sawtooth appearance.
PRI: Because of the unusual "Flutter" configuration of the P wave and the
proximity of the wave to the QRS complexes, it is often impossible to
determine a PRI in the arrhythmia. Therefore, the PRI is not measured in Atrial
Flutter.
QRS: s less than 12 seconds; measurement can be difficult if one or more
flutter waves is concealed within the QRS complex.
Ventricular conduction abnormalities
 Ventricular Tachycardia

An irritable focus in the ventricles fires regularly at a rate of 150-250 beats per minute to
override higher sites for control of the heart.
Regularity: This rhythm is usually regular, although it can be slightly irregular.
Rate: Atrial rate cannot be determined.
The ventricular rate range is 150-250 beats per minute.
If the rate is below 150 bpm, it is considered a slow VT.
If the rate exceeds 250 bpm, its called Ventricular Flutter.
 Ventricular Tachycardia

P Wave: None of the QRS complexes will be preceded by P waves;

QRS: will be wide and bizarre, measuring at least 0.12 seconds.
It is often difficult to differentiate between the QRS and the T wave.
 Ventricular Fibrillation

Multiple foci in the ventricles become irritable and generate uncoordinated, chaotic
impulses that cause the heart to fibrillate rather than contract.
There are no waves or complexes that can be analyzed to determine regularity. The
baseline is totally chaotic.
There is no measurable rate
P Wave: There are no P waves present
QRS: There are no QRS complexes present
 Ventricular Fibrillation

A patients maybe unconscious as blood is not pumped to the

brain

Immediate treatment by defibrillation is indicated

This condition may occur during or after a MI (Defibrillate quickly)

 A sinoatrial block

A sinoatrial block is a disorder in the normal rhythm of

the heart, known as a heart block, that is initiated in
the sinoatrial node:
SA blok
Sinus arest
SSS
 Atrioventricular (AV) Heart Block

Degree AV Conduction Pattern

1St Degree Block Uniformly prolonged PR interval

2nd Degree, Mobitz Type I Progressive PR interval prolongation

2nd Degree, Mobitz Type II Sudden conduction failure

3rd Degree Block No AV conduction

 First Degree Block

• Prolongation of the PR interval > 0.20 seconds or 5

small squares, which is constant
Usually does not require treatment
 Second-Degree AV Block

There is intermittent failure of the supraventricular impulse to be

conducted to the ventricles.

Some of the P waves are not followed by a QRS complex.

The conduction ratio (P/QRS ratio) may be set at 2:1,3:1,3:2,4:3,and so

forth
 2nd degree AV Block (“Mobitz I” also called
“Wenckebach”):

ECG findings:
Progressive lengthening of the PR interval until a P wave is
blocked

PRI = .24 sec PRI = .36 sec PRI = .40 sec QRS is “dropped”

Pause

4:3 Wenckebach (conduction ratio may not be constant) Pattern Repeats………….

 Type II Second-Degree AV
Block:
Mobitz Type II

ECG findings
Intermittent or unexpected blocked P waves you don’t know when
QRS drops
P-R intervals may be normal or prolonged ,but they remain
constant
A long rhythm strip may help
 Second Degree AV Block

• Mobitz type I or Winckebach

• Mobitz type II
 Advanced Second-Degree AV Block

Two or more consecutive nonconducted sinus P waves

 3rd degree AV Block (“Complete Heart Block”):
Irregular Rhythm
QRS complexes may be narrow or broad depending on the level of the block
Atria and ventricles beat independent of one another (AV dissociation)
QRS’s have their own rhythm, P-waves have their own rhythm
May be caused by inferior MI and it’s presence worsens the prognosis
Treatment: usually requires pacemaker

QRS intervals

P-wave intervals – note how the P-waves sometimes distort QRS complexes or T-waves
Third-Degree (Complete) AV Block
 Asystole

The heart has lost its electrical activity. There is no electrical pacemaker to initiate
electrical flow.
Regularity: Not measurable; there is no electrical activity.
Rate: Not measurable; there is no electrical activity.
P Waves: Not measurable; there is no electrical activity.
PRI: Not measurable; there is no electrical activity.
QRS: Not measurable; there is no electrical activity.
Experience is a
wonderful thing.
It enables you to
recognize a mistake
when you make it
again.
PRIORITIES?
understand is still
something else,
But to act on what you
learn is all that really
matters!”
Quiz
Name the Rhythm # 1:
Answer:

Atrial Flutter
Name the Rhythm #2:
Sinus Bradycardia
Name the Rhythm #3:
Third Degree Heart Block
• Name the rhythm # 4:
Ventricular Fibrillation
• Name the rhythm #5:
Normal Sinus
• Name the rhythm #6:
AV Block 2 First Degree
• Name the rhythm # 7:
Atrial Fibrillation
• Name the rhythm # 8:
Ventricular Tachycardia
• Name the rhythm # 9:
Asystole
• Name the rhythm # 10:
AV Block 2 Second degree
• Name the rhythm # 11:
Sinus Tachycardia
1) A 45 yr old black man is noted to have a BP of 150/100. He has
been hypertensive the last 10 years. What is the abnormality on the
EKG?
2) What is the cause of the patients’s rapid
irregular pulse?
3) What is the cause of the wide QRS
complex?
4) The patient complains of “extra” beats.
What is the arrhythmia? Tx?
5) What is the arrhythmia?
6) A patient complains of palpatations. What
is the arrhythmia?
7) The following EKG is obtained during a
cardiac arrest. What is the arrhythmia?
8) What is the cause of the patient’s rapid
irregular pulse?
9) How does the rhythm change abruptly in
this patient?
10) What arrhythmia and conduction disturbance
are present on this V1 rhythm strip?
11) What conduction disturbance is present?
12) A patient has recurrent syncope. What is
the diagnosis?
13) What arrhythmia and conduction
disturbance are present?
Myocardial Infarction
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
A 63 yr.-old woman had severe chest pain 6
hours ago. What does the EKG show?
A 53 yr old man presents with crushing chest pain. He is
hypotensive with jugular venous distention. What is the EKG
diagnosis?
A 62 year old women presents with the sudden onset of
acute crushing chest pain. What is the diagnosis?
 “To look is one thing;
To see what you look at is another,
To understand what you see is a third;
To learn from what you understand is
still something else,
But to act on what you learn is all that
really matters!”
THANK YOU!!
For Your
Valuable Time