INTERPRETATION OF

NORMAL
ELECTROCARDIOGRAM
Dr. Amandeep Singh (Assistant professor)
NINE FEATURES TO BE MENTIONED
• RATE AND RHYTHM
• AXIS
• P WAVE MORPHOLOGY
• PR INTERVAL
• QRS COMPLEX MORPHOLOGY
• ST SEGMENT MORPHOLOGY
• T WAVE MORPHOLOGY
• U WAVE MORPHOLOGY
• QTc INTERVAL
STANDARD CALIBRATION
• STANDARD PAPER SPEED : 25 MM/S
• VOLTAGE : 10 MM PER MV
• ON HORIZONTAL AXIS EACH THICK LINE AT THE INTERVAL OF 0.2
SECONDS AND THIN LINE AT INTERVAL OF 0.04 SEC
• ON VERTICAL AXIS EACH THICK LINE AT INTERVAL OF 0.5MV AND
THIN LINES AT INTERVAL OF 0.1 MV
• HENCE EACH SMALL SQAURE IS 0.04X0.1 AND EACH LARGE SQUARE IS
0.2 X 0.5
RATE :
• We can calculate bpm by dividing 300 by the number of LARGE squares
between each R-R interval (space between two consecutive R waves = one
beat)

• 1500 is divided by the number of SMALL squares between consecutive R waves

• R wave method
• Rate = Number of R waves (rhythm strip) X 6
• The number of complexes (count R waves) on the rhythm strip gives the
average rate over a ten-second period. This is multiplied by 6 (10 seconds x 6 =
1 minute) to give the average beats per minute (bpm)
• Useful for slow and/or irregular rhythms
AXIS :
P WAVE
• The P wave represents depolarization of the atria. Atrial
depolarization spreads from the SA node towards the AV node, and
from the right atrium to the left atrium
• The P wave is typically upright in most leads except for aVR; an
unusual P wave axis (inverted in other leads) can indicate an ectopic
atrial pacemaker. If the P wave is of unusually long duration, it may
represent atrial enlargement. Typically a large right atrium gives a tall,
peaked P wave while a large left atrium gives a two-humped bifid P
wave.
• Normal duration: < 0.12 s (< 120ms or 3 small squares)
ATRIAL ENLARGEMENT ON ECG
P-R INTERVAL
• The PR interval is measured from the beginning of the P wave to the
beginning of the QRS complex. This interval reflects the time the electrical
impulse takes to travel from the sinus node through the AV node.
• A PR interval shorter than 120 ms suggests that the electrical impulse is
bypassing the AV node, as in Wolf-Parkinson-White syndrome. A PR
interval consistently longer than 200 ms diagnoses first degree
atrioventricular block. The PR segment (the portion of the tracing after
the P wave and before the QRS complex) is typically completely flat, but
may be depressed in pericarditis.
• The normal PR interval is between 120 – 200 ms (0.12-0.20s) in duration
(three to five small squares).
QRS COMPLEX :
• The QRS complex represents the rapid depolarization of the right and left
ventricles. The ventricles have a large muscle mass compared to the atria,
so the QRS complex usually has a much larger amplitude than the P wave.
• If the QRS complex is wide (longer than 120 ms) it suggests disruption of
the heart's conduction system, such as in LBBB, RBBB, or ventricular
rhythms such as ventricular tachycardia. Metabolic issues such as severe
hyperkalemia, or tricyclic antidepressant overdose can also widen the
QRS complex. An unusually tall QRS complex may represent left
ventricular hypertrophy while a very low-amplitude QRS complex may
represent a pericardial effusion or infiltrative myocardial disease.
• Normal QRS width is 70-100 ms
LBBB CRITERIA ON ECG :
• QRS duration > 120ms
• Dominant S wave in V1
• Broad monophasic R wave in lateral leads (I, aVL, V5-6)
• Absence of Q waves in lateral leads
• Prolonged R wave peak time > 60ms in leads V5-6
RBBB CRITERIA ON ECG
• QRS duration > 120ms
• RSR’ pattern in V1-3 (“M-shaped” QRS complex)
• Wide, slurred S wave in lateral leads (I, aVL, V5-6)
LVH CRITERIA ON ECG
• Voltage Criteria
• Limb Leads:
• R wave in lead I + S wave in lead III > 25 mm
• R wave in aVL > 11 mm
• R wave in aVF > 20 mm
• S wave in aVR > 14 mm
• Precordial Leads:
• R wave in V4, V5 or V6 > 26 mm
• R wave in V5 or V6 plus S wave in V1 > 35 mm
• Largest R wave plus largest S wave in precordial leads > 45 mm
• Non Voltage Criteria
• Increased R wave peak time > 50 ms in leads V5 or V6
• ST segment depression and T wave inversion in the left-sided leads:
AKA the left ventricular ‘strain’ pattern
• The most commonly used Criteria is the Sokolov-Lyon criteria: S wave
depth in V1 + tallest R wave height in V5-V6 > 35 mm
RVH CRITERIA ON ECG
• Diagnostic criteria
• Right axis deviation of +110° or more.
• Dominant R wave in V1 (> 7mm tall or R/S ratio > 1).
• Dominant S wave in V5 or V6 (> 7mm deep or R/S ratio < 1).
• QRS duration < 120ms (i.e. changes not due to RBBB).
J POINT
• The J-point is the point at which the QRS complex finishes and the ST
segment begins.
• The J-point may be elevated as a normal variant. The appearance of a
separate J wave or Osborn wave at the J-point is pathognomonic of
hypothermia or hypercalcemia.
ST SEGMENT
• The ST segment connects the QRS complex and the T wave; it
represents the period when the ventricles are depolarized.
• It is usually isoelectric, but may be depressed or elevated with
myocardial infarction or ischemia. ST depression can also be caused
by LVH or digoxin. ST elevation can also be caused by pericarditis,
Brugada syndrome, or can be a normal variant (J-point elevation).
T WAVE
• The T wave represents the repolarization of the ventricles. It is
generally upright in all leads except aVR and lead V1.
• Inverted T waves can be a sign of myocardial ischemia, left ventricular
hypertrophy, high intracranial pressure, or metabolic abnormalities.
Peaked T waves can be a sign of hyperkalemia or very early
myocardial infarction.
• Amplitude < 5mm in limb leads, < 10mm in precordial leads (10mm
males, 8mm females)
QTc INTERVAL
• The QT interval is measured from the beginning of the QRS complex
to the end of the T wave. Acceptable ranges vary with heart rate, so it
must be corrected to the QTc by dividing by the square root of the RR
interval.
• A prolonged QTc interval is a risk factor for ventricular
tachyarrhythmias and sudden death. Long QT can arise as a genetic
syndrome, or as a side effect of certain medications. An unusually
short QTc can be seen in severe hypercalcemia.
U WAVE
• The U wave is hypothesized to be caused by the repolarization of the
interventricular septum. It normally has a low amplitude, and even
more often is completely absent.
• U wave is usually in the same direction as the T wave.
• U wave is best seen in leads V2 and V3.
• A very prominent U wave can be a sign of hypokalemia,
hypercalcemia or hyperthyroidism.
• THANK YOU