BASIC ECG-

INTERPRETATION
 ECG - Introduction

 The electrocardiogram (ECG) is one of the simplest and

oldest cardiac investigations available, yet it can provide a
wealth of useful information and remains an essential part
of the assessment of cardiac patients.

 With modern machines, surface ECGs are quick and easy to

obtain at the bedside and are based on relatively simple
electrophysiological concepts

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 ECG - Introduction

 An ECG is simply a representation of the electrical activity

of the heart muscle as it changes with time, usually printed
on paper for easier analysis.

 Like other muscles, cardiac muscle contracts in response to

electrical de-polarization of the muscle cells.

 It is the sum of this electrical activity, when amplified and

recorded for just a few seconds that we know as an ECG.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Electrophysiology of the
Heart
 The normal cardiac cycle begins with spontaneous
depolarization of the sinus node, an area of specialised
tissue situated in the high right atrium (RA).
 A wave of electrical depolarization then spreads through the
RA and across the inter-atrial septum into the left atrium
(LA).

 The atria are separated from the ventricles by an electrically

inert fibrous ring, so that in the normal heart the only route
of transmission of electrical depolarization from atria to
ventricles is through the atrioventricular (AV) node.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Electrophysiology of the
Heart
 The AV node delays the electrical signal for a short time,
and then the wave of depolarization spreads down the inter-
ventricular septum (IVS), via the bundle of His and the right
and left bundle branches, into the right (RV) and left (LV)
ventricles.
 Hence with normal conduction the two ventricles contract
simultaneously, which is important in maximizing cardiac
efficiency.
 After complete depolarization of the heart, the myocardium
must then repolarize, before it can be ready to depolarize
again for the next cardiac cycle.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Voltage and Timing
intervals
 It is conventional to record the ECG using standard measures
for amplitude of the electrical signal and for the speed at
which the paper moves during the recording. This allows:
 Easy appreciation of heart rates and cardiac intervals and
 Meaningful comparison to be made between ECGs recorded on
different occasions or by different ECG machines.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Voltage and Timing
intervals
 The amplitude, or voltage, of the recorded electrical signal is
expressed on an ECG in the vertical dimension and is
measured in milli volts (mV).

 On standard ECG paper 1mV is represented by a deflection of

10 mm.

 An increase in the amount of muscle mass, such as with left

ventricular hypertrophy (LVH), usually results in a larger
electrical depolarization signal, and so a larger amplitude of
vertical deflection on the ECG.
(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Sample of standard ECG paper showing the scale of voltage,
measured on the vertical axis, against time on the horizontal
axis.

Each small square represents 40 milliseconds (ms) in time

along the horizontal axis and each larger square contains 5
small squares, thus representing 200 ms

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Voltage and Timing
intervals
 An essential feature of the ECG is that the electrical activity
of the heart is shown as it varies with time.

 In other words plotting electrical activity on the vertical axis

against time on the horizontal axis.

 Standard ECG paper moves at 25 mm per second during

real-time recording.

 This means that when looking at the printed ECG a distance

of 25 mm along the horizontal axis represents 1 second in
time.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
The Normal ECG
 ECG

The major waves of a single normal ECG

(www.ni.com) pattern
 The P- Wave

 The first structure to be depolarized during normal sinus

rhythm is the right atrium, closely followed by the left
atrium.

 So the first electrical signal on a normal ECG originates from

the atria and is known as the P wave.

 Although there is usually only one P wave in most leads of

an ECG, the P wave is in fact the sum of the electrical
signals from the two atria, which are usually superimposed.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 The P- Wave

 There is then a short, physiological delay as the

atrioventricular (AV) node slows the electrical
depolarization before it proceeds to the ventricles.

 This delay is responsible for the PR interval, a short

period where no electrical activity is seen on the ECG,
represented by a straight horizontal or ‘isoelectric’ line.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 The QRS complex

 Depolarization of the ventricles results in usually the largest

part of the ECG signal (because of the greater muscle mass
in the ventricles) and this is known as the QRS complex.
 The Q wave is the first initial downward or ‘negative’ deflection.

 The R wave is then the next upward deflection (provided it

crosses the isoelectric line and becomes ‘positive’).

 The S wave is then the next deflection downwards, provided it

crosses the isoelectric line to become briefly negative before
returning to the isoelectric baseline.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 ST segment and the T-
wave
 In the case of the ventricles, there is also an electrical
signal reflecting repolarization of the myocardium.

 This is shown as the ST segment and the T wave.

 The ST segment is normally isoelectric, and the T wave in

most leads is an upright deflection of variable amplitude
and duration

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Normal Intervals

 The recording of an ECG on standard paper allows the

time taken for the various phases of electrical
depolarization to be measured, usually in milliseconds.
There is a recognized normal range for such ‘intervals’:

 PR interval (measured from the beginning of the P wave

to the first deflection of the QRS complex). Normal range
120 – 200 ms (3 – 5 small squares on ECG paper).

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Normal Intervals
 QRS duration
 Measured from first deflection of QRS complex to end of QRS
complex at isoelectric line.

 Normal range up to 120 ms (3 small squares on ECG paper).

 QT interval
 Measured from first deflection of QRS complex to end of T
wave at isoelectric line.

 Normal range up to 440 ms (though varies with heart rate and

may be slightly longer in females).

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 Heart rate estimation
from the ECG
 Standard ECG paper allows an approximate estimation of
the heart rate (HR) from an ECG recording.
 Each second of time is represented by 250 mm (5 large
squares) along the horizontal axis.
 So if the number of large squares between each QRS
complex is:
 5 - the HR is 60 beats per minute.
 3 - the HR is 100 per minute.
 2 - the HR is 150 per minute.

(Dr Dallas Price; South Sudan Medical Journal; Consultant Cardiologist, St Mary's Hospital, Isle of Wight,
 ECG Electrodes
 Two arrangements, bipolar and Uni -polar leads.

 Bipolar Lead
 One in which the electrical activity at one electrode is
compared with that of another.

 By convention, a positive electrode is one in which the ECG

records a positive (upward) deflection when the electrical
impulse flows toward it and a negative (downward) deflection
when it flows away from it.

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 ECG Electrodes

 Uni -polar Lead

 One in which the electrical potential at an exploring electrode is
compared to a reference point that averages electrical activity,
rather than to that of another electrode.

 This single electrode, termed the exploring electrode, is the

positive electrode.

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 Limb Leads
 I, II, III, aVR, aVL, aVF explore the electrical activity in the
heart in a frontal plane; i.e., the orientation of the heart
seen when looking directly at the anterior chest.
 Standard Limb Leads: I, II, III; bipolar, form a set of
axes 60° apart
 Lead I: Composed of negative electrode on the right arm
and positive electrode on the left arm.
 Lead II: Composed of negative electrode on the right arm
and positive electrode on the left leg.
 Lead III: Composed of negative electrode on the left arm
and positive electrode on the left leg.

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 Augmented Voltage
Leads
 aVR, aVL aVF; unipolar ; form a set of axes 60°
apart but are rotated 30° from the axes of the
standard limb leads.
 aVR: Exploring electrode located at the right shoulder.

 aVL: Exploring electrode located at the left shoulder.

 aVF: Exploring electrode located at the left foot.

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 Reference Point for Chest
Leads
 The point obtained by connecting the left arm,
right arm, and left leg electrodes together.
 Vl: Positioned in the 4th intercostal space just to
the right of the sternum.
 V2: Positioned in the 4th intercostal space just to
the left of the sternum.
 V3: Positioned halfway between V2 and V4.
 V4: Positioned at the 5th intercostal space in the
mid- clavicular line.
 V5: Positioned in the anterior axillary line at the
same level as V4.
 V6: Positioned in the mid axillary line at the same
level as V4 and V5.

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 Reference Point for Chest
Leads
 Vl and V2: Monitor electrical activity of the
heart from the anterior aspect, septum, and
right ventricle.

 V3 and V4: Monitor electrical activity of the

heart from the anterior aspect.

 V5 and V6: Monitor electrical activity of the

heart from the left ventricle and lateral aspect.

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 Axis Deviation
 Interpretation of the ECG relies on the
idea that different leads (meaning the
ECG leads I, II, III, aVR, aVL, aVF and the
chest leads) "view" the heart from
different angles. This has two benefits:
 Firstly, leads which are showing problems (for example ST segment
elevation) can be used to infer which region of the heart is affected.
 Secondly, the overall direction of travel of the wave of
depolarization can also be inferred which can reveal other
problems. This is termed the cardiac axis.

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 Axis Deviation
Normal −30° to 90° Normal Normal
Left axis
deviation is
May indicate left
considered
anterior
Left axis normal in
−30° to −90° fascicular block
deviation pregnant women
or Q waves from
and those
inferior MI.
with emphysema
.
May indicate left
posterior Right deviation is
fascicular block, considered
Right axis Q waves from normal in
+90° to +180°
deviation high lateral MI, or children and is a
a right standard effect
ventricular strain of dextrocardia.
pattern
Is rare, and
Extreme right considered an
+180° to −90°
axis deviation 'electrical no-
man's land'
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Sinus Rhythm
Disturbances
 Sinus Tachycardia
 Sinus rhythm with a rate >100 beats per minute.
 With fast rates, P waves may merge with preceding T
waves and be indistinct.
 Can originate from the sino - atrial node, atrial muscle,
or atrioventricular junction. Often referred to as supra -
ventricular tachycardia without specifying site of origin.

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 Sinus Bradycardia
 Sinus rhythm with a rate <60 beats per minute.

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 Sino - Atrial Block
 Refers to failure of the sinus node to function for one or
more beats. In this condition, there are simply one or
more missing beats; i. e., there are no P waves or QRS
complexes seen.

 Fortunately, when the sinus fails to function for a

significant period of time (sinus arrest), another part of
the conduction system usually assumes the role of
pacemaker.

 These pacing beats are referred to as escape beats and

may come from the atria, the atrioventricular junction,
or the ventricles.
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(Sick-Sinus-Syndrome.pngwww.richacls.com)
 Sick Sinus Syndrome
 In elderly people, the sinus node may undergo degenerative
changes and fail to function effectively.

 Periods of sinus arrest, sinus tachycardia, or sinus

bradycardia may occur.

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 Atrial Arrhythmias
 Include premature atrial beats, paroxysmal
atrial tachycardia, multi-focal atrial
tachycardia, atrial flutter, and atrial
fibrillation.
 Because the stimuli arise above the level
of the ventricles, the QRS pattern usually is
normal.
 Premature Atrial
Contraction
 An ectopic beat arising somewhere in either atrium but not
in the sinoatrial node.

 Occurs before the next normal beat is due, and a slight

pause usually follows.

 The P wave may have a configuration different from the

normal P wave and may even be of opposite polarity.

 Occasionally, the P wave will not be seen because it is lost

in the preceding T wave.

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 Premature Atrial
Contraction
 The P-R interval may be shorter then the normal.
 If the premature atrial depolarization wave reaches the AV
node before the node has had a chance to repolarize, it may
not be conducted, and what may be seen is an abnormal P
wave without a subsequent QRS complex.
 These premature atrial depolarization waves may be
conducted to ventricular tissue before complete
repolarization has occurred, and in such cases, the
subsequent ventricular depolarization may take place by an
abnormal pathway, generating a wide, bizarre QRS complex.

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Premature Atrial
Contraction
 Paroxysmal Atrial
Tachycardia
 Defined as three or more consecutive PACs.
 PAT usually occurs at a regular rate, most commonly
between 150 and 250 beats per minute.
 P waves may or may not be seen and may be difficult to
differentiate from sinus tachycardia.

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Paroxysmal Atrial
Tachycardia
 Multifocal Atrial
Tachycardia
 Results from the presence of multiple, different atrial
pacemaker foci.
 This rhythm disturbance is characterized by a tachycardia
with beat-to-beat variation of the P wave morphology.

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 Atrial Flutter
 An ectopic atrial rhythm.

 Instead of P waves, characteristic saw-tooth waves are seen.

 The atrial rate in atrial flutter is usually about 300 beats per
minute.

 However, the AV junction is unable to contract at this rapid

rate, so the ventricular rate is less-usually 150, 100, 75, and so
on, beats per minute.

 Atrial flutter with a ventricular rate of 150 beats per minute is

called a two-for-one flutter because of the ratio of the atrial
rate (300) to the ventricular rate (150)
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 Atrial Fibrillation
 Here the atria are depolarized at an extremely rapid rate, greater
then 400 beats per minute.

 This produces a characteristic wavy baseline pattern instead of

normal P waves.

 Because the AV junction is refractory to most of the impulses

reaching it, it only allows a fraction of them to reach the
ventricles.

 The ventricular rate, therefore, is only 110-180 beats per minute.

 Also characteristic of atrial fibrillation is a haphazardly irregular

ventricular rhythm.

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 Junctional Rhythms
 The three types of junctional rhythms are premature
junctional contractions, junctional tachycardia,
and junctional escape rhythms.
 Junctional rhythms arise in the AV junction.
 P waves, when seen, are opposite their normal
polarity. They are called retrograde P waves.
 These p waves may precede, be buried in, or follow
the QRS complex. Since the stimulus arises above the
level of the ventricles, the QRS complex is usually of
normal configuration.
 Premature Junctional
Contractions
 Can occur since the AV junction may also serve as an
ectopic pacemaker.
 These are similar to PACs, in that they occur before the
next beat is due and a slight pause follows the premature
beat.

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(www.rinceus.com)
 Atrioventricular
Junctional Tachycardia
A run of 3 or more premature junctional
beats.
 Has about the same rate as PAT and
often cannot be distinguished from it.
 The difference is not clinically
significant.
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AV Junctional Tachycardia
LBBB
 Atrioventricular Escape
Beat
 An escape beat that occurs after a pause in the normal
sinus rhythm.

 Atrial pacing usually resumes after the junctional beat.

 A junctional escape rhythm, defined as a consecutive run of

atrioventricular junctional beats, may develop if the SA
node does not resume the pacemaker role.

 Junctional escape rhythm has a rate between 40 and 60

beats per minute.

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 Atrioventricular Heart
Block
Heart block occurs in 3 forms:
 first degree.
 Second degree and

 third degree.

Second degree heart block is divided into two types:

 mobitz type 1 and
 mobitz type 2
 First Degree heart block

 The ECG abnormality is simply a prolonged P-

R interval to greater than 0.2 seconds.

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 Second Degree Heart Block, Mobitz Type 1

 The characteristic ECG is progressive lengthening

of the P-R interval until finally a beat is dropped.

 The dropped beat is seen as a P wave that is not

followed by a QRS complex.

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 Second Degree Heart Block, Mobitz Type
2

 A more severe form of second degree block, since

it often progresses to complete heart block.

 The characteristic ECG picture is that of a series of

non-conducted P waves; e.g., 2:1, 3:1, 4:1, block.

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 Third Degree Heart
block

 Also known as: Complete Heart Block. The

atrioventricular junction does not conduct any
stimuli from the atria to the ventricles.

 Instead, the atria and the ventricles are paced

independently.
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 Third Degree Heart
block
 The characteristic ECG picture is
 (1) P waves are present and occur at a rate faster than the
ventricular rate;
 (2) QRS complexes are present and occur at a regular rate,
usually <60 beats per minute;
 (3) the P waves bear no relationship to the QRS complexes.
 Thus, the P-R intervals are completely variable.
 The QRS complex may be of normal or abnormal width,
depending on the location of the blockage in the AV junction.

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Left Ventricular
Hypertrophy
 The electro-cardiogram demonstrates several changes.

 The QRS complex is widened due to an intra-ventricular

conduction delay.

 There is left axis deviation.

 ST depression is observed along with inverted T-waves

noted in several leads.

 Several voltage criteria are met including an R-wave in aVL

lead which is greater than 18mm.
 Left Ventricular
Hypertrophy

cmbi.bjmu.edu.cn)
 Right ventricular
hypertrophy
 If conditions occur which decrease pulmonary circulation,
meaning blood does not flow well from the heart to the
lungs, extra stress can be placed on the right ventricle. This
can lead to right ventricular hypertrophy. The ECG changes
include.
 Right axis deviation (>90 degrees)
 Tall R-waves in RV leads; deep S-waves in LV leads.
 Slight increase in QRS duration.
 ST-T changes directed opposite to QRS direction (i.e., wide
QRS/T angle).
 Evidence of right atrial enlargement (RAE).

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 Right ventricular
hypertrophy

cmbi.bjmu.edu.cn)
Ventricular
Arrhythmias
 Premature Ventricular
Contractions (PVC)
 PVCs are premature beats arising from the ventricles, and are
analogous to premature atrial contractions and premature
junctional contractions.
 PVCs have two major characteristics: (1) they are premature and
arise before the next normal beat is expected (a P wave is not seen
before a PVC), and (2) they are aberrant in appearance.
 The QRS complex always is abnormally wide; the T wave and the
QRS complex usually point in opposite directions.
 The PVC usually is followed by a compensatory pause. PVCs may
be unifocal or multifocal.
 Unifocal PVCs arise from the same ventricular site, and as a result
have the same appearance on a given ECG lead. Multifocal PVCs
arise from different foci and give rise to different QRS patterns.

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 Ventricular Tachycardia
 This is defined as a run of 3 or more PVCs and may
occur in bursts or paroxysmally.
 They may be persistent until stopped by intervention.
The heart rate is usually 120 to 200 beats per minute.
Ventricular tachycardia is a life-threatening
arrhythmia.

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 Ventricular Fibrillation

 This occurs when ventricles fail to beat in a coordinated

fashion and, instead, twitch asynchronously.
 The beats are sometimes divided into coarse and fine
rhythms.

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 Ventricular Escape Beats
 A ventricular focus may initiate depolarization when a faster
pacemaker does not control the rate.

 They occur after a pause in the regular rhythm. If a higher focus

fails to pick up the rhythm, ventricular escape beats may continue.

 When this occurs, the rhythm is called idioventricular and has a

rate usually less than 100 beats per minute.

 The QRS complex is wide and bizarre; P waves will not be present.

 Idioventricular rhythms are usually of short duration and require no

intervention.

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 Aberrant Ventricular
Depolarization
 Here the depolarization wave is initiated above the ventricular
level and, because it is premature, reaches the ventricles when
they are in a partially depolarized state, resulting in a wide
QRS complex.
 The following rules can be used to determine aberrant
ventricular depolarization:
 (1) the beat is aberrant if a P wave precedes the wide QRS
complex.
 (2) the preceding R-R interval usually is longer than the other ones.
 (3) most aberrant beats are conducted via the left bundle branch,
giving the appearance of right bundle branch block in lead V1.
 (4) the initial deflection of the wide QRS is in the same direction as
that of the normal QRS complex.

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Myocardial Infarction
ECG Changes in some
Electrolyte imbalances
Summary
 Pulse rate lies between 60 and 100 beats/minute
 Rhythm is regular except for minor variations
with respiration.
 P-R interval is the time required for completion of
aerial depolarization; conduction through the AV
note, bundle of His, and bundle branches; and
arrival at the ventricular myocardial cells.
 The normal P-R interval is 0 12 to 0.20 seconds.
 The QRS interval represents the time required for
ventricular cells to depolarize.
 The normal duration is 0.06 to 0.10 seconds.
Summary

 The Q-T interval is the time required for

depolarization and repolarization of the ventricles.
 The time required is proportional to the heart rate.
 The faster the heart rate, the faster the
repolarization, and therefore the shorter the Q-T
interval.
 With slow heart rates, the Q-T interval is longer.
 The Q-T interval represents about 40% of the total
time between the QRS complexes (the R-R
interval).
 In most cases, the Q-T interval lasts between 0.34
and 0.42 seconds.
Thank You