Helpful hints and rules to reading the 12-lead EKGs...

• Always be sure to check for an inverted or negative QRS complex in AVR. This will ensure that
the lead were correctly connected appropriately and your recordings should be accurate.
• Analyze and evaluate the right chest leads. V1 & V2 will reveal more than any other two
contiguous leads. This is where you check for a Bundle Branch Block, Anterior and Posterior
wall infarctions, and "R" wave progression, etcetera...
• When checking your axis, always focus on Leads I & AVF. Be sure to check for Bundle Branch
Block. Axis vectors are inaccurate in their presence.
• When checking for signs of infarct, omit AVR. It is of no diagnostic value due to the fact that it
misrepresents pathological Q waves and obscures them.
• Acute Myocardial Infarction cannot be positively identified in the presence of LBBB!!!
It is prudent to suspect it per the patients presentation: however, serum enzyme tests among
other things are needed to make the diagnosis.
• As a rule, standard criteria for diagnosing AMI dictates that ST elevation of 1 mm. or more in
the presence of pathological Q waves in 2 or more contiguous leads is sufficient.
•

• Normal EKG parameters

•
 A normal 12 Lead EKG

Standard Limb Leads

• Lead I: The positive lead is above the left breast or on the left arm and the negative lead is on the right
arm.
Records the difference of potential between the Left arm and Right arm.
• Lead II: The positive lead is on the left abdomen or left thigh and the negative lead is also on the right
arm.
Records the difference of potential between the left leg and the right arm.
• Lead III: The positive lead is also on the left abdomen or left lower lateral leg but the negative lead is on
the left arm.
Records the difference of potential between the left leg and the right arm.
Vectors and Axis
• Vector: A quantity of electrical force that has a known magnitude and direction.
• Axis: A hypothetical line which joins the poles of a lead which measure electrical force.
• Mean Cardiac Vector: The average of all the instantaneous vectors. ( AKA mean
electrical axis ).
The position of the mean cardiac vector provides information about the electrical
"position" of the heart, and is influenced by the relationship of the heart within the
chest, as well as by the anatomy of the heart itself.
For pre-hospital purposes, the axis is either "normal" or "not normal."
• Normal Deviation:
The QRS deflection is upright or positive in I and either aVF or Lead II.
A normal axis means the QRS axis falls between 30 and 90 degrees in the chest. The heart is
lying in an angle between these parameters.
• Left Axis Deviation:
The QRS deflection is upright or positive in I and negative in aVF or Lead II.
The heart is lying in an angle greater than 90 degrees in the chest.
Can be normal in the presence of ascites, abdominal tumors, pregnancy or obesity.
Abnormalities are due to Left Ventricular enlargement or a Left anterior hemiblock.
Pathology: Left ventricular enlargement, and hypertrophy, Hypertension, Aortic Stenosis.
Ischemic Heart Disease. Inferior wall MI.
• Right Axis Deviation:
The QRS is downward or negatively deflected in I and positive in aVF or Lead II.
The heart is lying in an angle lower the 30 dgress in the chest.
Can be normal in young adults or "thin people."
May be abnormal in people who have a block in the posterior division of the left bundle.
Can imply delayed activation of the right ventricle ( as seen in RBBB ) or Right Ventricular
enlargement.
Pathology: Right Ventricular enlargement and hypertrophy. C.O.P.D. Pulmonary Embolism,
Congenital heart Disease, Inferior wall MI.
Abnormalities in the QRS Axis:
• Left Axis Deviation (LAD): > -30o (i.e., lead II is mostly 'negative')
• Left Anterior Fascicular Block (LAFB): rS complex in leads II, III, aVF, small q in leads I
• and/or aVL, and axis -45o to -90o
Some cases of inferior MI with Qr complex in lead II (making lead II
• 'negative')
Inferior MI + LAFB in same patient (QS or qrS complex in lead II)
Some cases of LVH
Some cases of LBBB
Ostium primum ASD and other endocardial cushion defects
Some cases of WPW syndrome (large negative delta wave in lead II)
• Right Axis Deviation (RAD): > +90o (i.e., lead I is mostly 'negative')
• Left Posterior Fascicular Block (LPFB): rS complex in lead I, qR in leads II,
• III, aVF (however, must first exclude, on clinical basis, causes of right
• heart overload; these will also give same ECG picture of LPFB)
Many causes of right heart overload and pulmonary hypertension
High lateral wall MI with Qr or QS complex in leads I and aVL
Some cases of RBBB
Some cases of WPW syndrome
Children, teenagers, and some young adults
•
Bizarre QRS axis: +150o to -90o (i.e., lead I and lead II are both negative)
• Consider limb lead error (usually right and left arm reversal)
Dextrocardia
 Some cases of complex congenital heart disease (e.g., transposition)
Some cases of ventricular tachycardia

Lead Groups
INFARCT LOCATION: ST ELEVATION FOUND IN:
Anterior - Septal V1, V2, V3, and V4 -- 0.2mV or more in leads
Posterior V1, and V2 -- 0.2mV or more in leads
Inferior II, III, and aVF -- 0.1mV or more in 2 leads
High Lateral I, and aVL -- 0.1mV or more in 2 leads
Low Lateral V5, and V6 -- 0.1mV or more in 2 leads

"ST Depression indicates Angina"

Diagrams below indicate which part the heart is being affected and what lead would show the
changes.
 12 lead rapid interpretation
Common ECG Formation
Ischemia=Inverted T waves

• Inverted T wave is symmetrical

• T waves are usually upright in leads I, II, and V2-V6

Injury=Elevated ST segment

• Signifies an acute process; ST returns to baseline with time

• If ST elevation is diffuse and unassociated with Q waves or reciprocal ST
depression, consider pericarditis
• Location of injury can be determined in same manner as infarct location

• Usually associated with reciprocal ST depression in other leads

Infarction=Q wave

• Small Qs may be normal in V5, V6, I and aVL

• Abnormal Q must be one small square (0.04 sec) wide

• Also abnormal if Q-wave depth is greater than one-third of QRS height in lead
III

Infarctions=
Anterior Infarction
• ST elevation without abnormal Q wave

• Usually associated with occlusion of the left anterior descending branch of the
left coronary artery (LCA)

Lateral Infarction
• ST elevation with/without abnormal Q wave
• May be a component of a multiple-site infarction

• Usually associated with obstruction of the left circumflex artery

Inferior Infarction
• ST elevation with/without abnormal Q wave

• Usually associated with right coronary artery (RCA) occlusion

Infarctions (cont)=
Right Ventricular Infarction
• Usually accompanies inferior MI due to proximal occlusion of the RCA
• Best diagnosed by 1 - 2 mm ST elevation in lead V4R
• An important cause of hypotension in inferior MI recognized by jugular venous
distension with clear lung fields

• Aggressive therapy is indicated, including: reperfusion, adequate IV fluids for

right heart filling, and pacing to maintain A-V synchrony if necessary

Posterior Infarction
• Tall, broad (>0.04 sec) R wave and ST depression in V1 and V2 (reciprocal
changes)
• Frequently associated with inferior MI

• Usually associated with obstruction of RCA and or left circumflex coronary

artery

RBBB= Right Bundle Branch Block

Close examination of QRS complex in various leads reveals
that the terminal forces (i.e., 2 half of QRS) are oriented
nd

rightward and anteriorly because the right ventricle is

depolarized after the left ventricle. This means the following:
Terminal R' wave in lead V1 (usually see rSR' complex)
indicating late anterior forces
Terminal S waves in leads I, aVL, V6 indicating late
rightward forces
Terminal R wave in lead aVR indicating late rightward forces
LBBB= Left Bundle Branch Block
Close examination of QRS complex in various leads reveals
that the terminal forces (i.e., 2 half of QRS) are oriented
nd

leftward and posteriorly because the left ventricle is depolarized

after the right ventricle.
Terminal S waves in lead V1 indicating late posterior forces

Terminal R waves in lead I, aVL, V6 indicating late leftward

forces; usually broad, monophasic R waves are seen in these
leads as illustrated in the ECG below; in addition, poor R
progression from V1 to V3 is common.
ECG criteria for LVH
There are several sets of criteria used to diagnose LVH via electrocardiography.[3] None of them are perfect,
though by using multiple criteria sets, the sensitivity and specificity are increased.

The Sokolow-Lyon index[4][5]:

• S in V1 + R in V5 or V6 (whichever is larger) ≥ 35 mm
• R in aVL ≥ 11 mm

The Cornell voltage criteria[6] for the ECG diagnosis of LVH involves measurement of the sum of the R wave in
lead aVL and the S wave in lead V3. The Cornell criteria for LVH are:

• S in V3 + R in aVL > 28 mm (men)

• S in V3 + R in aVL > 20 mm (women)
•

Other Voltage Criteria for LVH

Limb-lead voltage criteria:
R in aVL >11 mm or, if left axis deviation, R in aVL >13 mm plus S in III >15 mm

R in I + S in III >25 mm

Chest-lead voltage criteria:

S in V1 + R in V5 or V6 > 35 mm
Right Ventricular Hypertrophy
General ECG features 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)
May see incomplete RBBB pattern or qR pattern in V1
Evidence of right atrial enlargement (RAE) (lessonVII)

Specific ECG features (assumes normal calibration of 1 mV = 10 mm):

Any one or more of the following (if QRS duration <0.12 sec):

Right axis deviation (>90 degrees) in presence of disease capable of causing RVH
R in aVR > 5 mm, or
R in aVR > Q in aVR

Any one of the following in lead V1:

R/S ratio > 1 and negative T wave

qR pattern
R > 6 mm, or S < 2mm, or rSR' with R' >10 mm

Other chest lead criteria:

R in V1 + S in V5 (or V6) 10 mm
R/S ratio in V5 or V6 < 1
R in V5 or V6 < 5 mm
S in V5 or V6 > 7 mm
Wolff-Parkinson-White Preexcitation
Although not a true IVCD, this condition causes widening of QRS complex and, therefore,
deserves to be considered here
QRS complex represents a fusion between two ventricular activation fronts:
Early ventricular activation in region of the accessory AV pathway (Bundle of Kent)
Ventricular activation through the normal AV junction, bundle branch system
ECG criteria include all of the following:

• Short PR interval (<0.12s)

• Initial slurring of QRS complex (delta wave) representing early ventricular activation through
normal ventricular muscle in region of the accessory pathway
• Prolonged QRS duration (usually >0.10s)
• Secondary ST-T changes due to the altered ventricular activation sequence