ECG Interpretation in One Page

Ryan Aycock, MD, MS (copyright 2009-2011)

Dept of Emergency Medicine, Staten Island University Hospital, NY
RATE AND INTERVALS

1500
1 mm = 0.1 mV Heart rate = = (# R peaks in 6 sec block) * 10
mm

300 150 100 75 60 50

250 136 94 71 58 48
214 125 88 68 56 47
188 115 83 65 54 45
167 107 79 63 52 44
1 mm = 0.04 sec

5 mm = 0.2 sec

NORMAL TIMING AND MORPHOLOGY AXIS

P wave: 0.08 - 0.11 sec, <2.5 mm, upright in I, II, aVF, V4-V6, negative
in aVR; can be biphasic in III, aVL, V1, V2 Left axis
PR segment: <0.8 mm deviation from baseline (some say <1 mm)
PR interval: 0.12 - 0.20 sec
Q wave: <0.03 sec, < of R height; can change with respiration. Extreme axis -90
o

Should not appear in V1-V3 o o

QRS complex: <0.1 sec, >5 mm in limb leads, >10 mm in precordial -120 -60
leads, transitions in V3-V4
Intrisicoid deflection: <0.035 sec in right leads, <0.045 sec in left leads o o
QT interval: < of R-R interval (QTc: <0.44 sec) aVR, -150 aVL, -30
QT
QTc = (Bazett formula), should be 0.3-0.44 sec
sqrt(60/HR)
o o
T wave: asymmetric, upstroke > downstroke, <6 mm in limb leads, 180 I, 0
<12 mm in precordials, <of R height (can be taller in V1 and V2),
can be biphasic or inverted in III, V1-V3 (called juvenile waves)

ABNORMALITIES o o
Left atrial abnormality: +150 +30
P wave in lead II: notched, >0.12 sec wide (“P-mitrale”)
P wave in lead V1: negative component >0.1 mV and >0.04 sec o o Normal axis
III, +120 II, +60
Right atrial abnormality: o
P wave in lead II: peaked, >0.25 mV (“P-pulmonale”) aVF, +90
Right axis
P wave in lead V1: positive deflection >0.15 mV or >V6
PR segment depression >0.8 mm is pericarditis or atrial infarct
PR interval <0.12 sec is junctional beat, Lown-Ganong-Levine
(benign), WPW, or normal variant
PR interval >0.20 sec is 1o AV block or hyperkalemia
Q waves tall and narrow in lateral leads with tall RS in V2/V3 is HOCM
Q wave >0.03 sec (unless in V1 only) or > of R height is MI Z-AXIS
QRS >0.12 sec is bundle branch block or intraventricular delay
Left ventricular hypertrophy:
R in aVL + S in V3 >28 mm (males), >20 mm (females) (most Normal or left axis
accurate, Cornell criteria)
S in V1 + R in V5/V6 >35 mm (use 40 mm for age < 40)
S in V2 + R in V5/V6 >45 mm V6, 80o P
R in aVL >12 mm (most specific) V5, 60o P
Minor criteria: R in I >14 mm, R in aVF >21 mm, S in aVR > 15 mm,
R in V5 > 26 mm, OR R in V6 > 20 mm V4, 40o P
Cannot make diagnosis in LBBB
Strain—There is a progression of elevated, concave upward ST with V1, 20o P V3, 20o P
asymmetric upright T in V1-V3 to depressed, concave downward
ST with asymmetric inverted T in V4-V6. A q in V6 with an upright
tall T signifies volume overload. V2, 0o A V2, 0o P
Ischemia presents with flat ST and symmetrical T waves
Right ventricular hypertrophy:
R > S in V1, S > R in V5/V6 V3, 20o A V1, 20o A
Usually associated with right axis deviation or RAE
Very difficult to make diagnosis in LBBB
Strain—depressed, concave downward ST with asymmetric inverted V4, 40o A
T in V1-V3. Can have S1Q3T3
HOCM: Deep, narrow Q’s in lateral leads, high voltage QRS V5, 60o A
QTc >0.44 sec is prolonged QT and can be due to hypokalemia, V6, 80o A
hypocalcemia, ischemia, hypothyroidism, hypothermia, or drugs
Potassium levels: Right or extreme
<3.0 mEq/L – U waves, QTc prolongation, minimal QRS Note: Z-axis cannot be
axis
prolongation, ST depression; can lead to atrial tach with block determined in WPW or RBBB
>5.5 mEq/L – peaked T waves, fascicular block
>6.5 mEq/L – QRS and QT intervals widen, first degree AV block
>7.0 mEq/L – PR interval widens and P waves decrease in V1 V1
amplitude
>7.5 mEq/L – P waves disappear, sine wave appears
Hypocalcemia: long ST segment → prolonged QT
Hypercalcemia: short ST segment → short QT
Digoxin: scooped ST segments, biphasic or inverted T, short QT,
prominent U. Can lead to atrial tach with block or junctional tach.
RVH with strain LVH with strain
ARRHYTHMIAS
Sinoatrial block: a missed beat that is a multiple of an R-R interval. The cycle
continues on same interval.
Sinus pause/arrest: a missed beat that is not a multiple of an R-R interval.
Premature atrial contraction: P wave comes sooner than expected, morphol-
ogy is different, PR interval may be longer than previous beats. Usually no
compensatory pause (i.e., the beat resets the SA node using previous
interval). The beat does not need to be conducted (no QRS complex).
PAC with aberrancy: wide QRS complex mimicking RBBB due to longer
refractory period of R bundle. More common in slow HR.
Focal ectopic atrial rhythms: a regular run of PAC’s. Ectopic P’s and PR’s are
similar. Atrial rhythm: 50-60 bpm, accelerated atrial rhythm: 60-99 bpm,
atrial tachycardia: >100 bpm. Block can occur with fast rates. Adenosine
and electrical alternans helps in diagnosis. Transient ST/T abnormalities.
Wondering atrial pacemaker: irregularly irregular rhythm, >3 different P’s and
PR’s, HR<100 bpm, found with excessive vagal tone (e.g., sleeping).
Multifocal atrial tachycardia is WAP >100 bpm with tall/deep P’s, usually
found in lung disease.
Atrial flutter: typically regular rhythm with 2:1 conduction or higher. Atrial rate
>250 bpm, ventricular rate is 125-175 bpm. Sawtooth appearance aids in
diagnosis.
Atrial fibrillation: irregularly irregular rhythm, no discernible P waves.
Premature junctional contraction: QRS comes sooner than expected and is
similar to previous QRS’s. P waves may appear as antegrade (with short
PR) or retrograde, and will be inverted. Can be aberrant. Usually no
compensatory pause.
Junctional escape beat: similar in appearance to PJC, but occurs after a
pause following normal rhythm.
Focal ectopic junctional rhythms: a regular run of escaped junctional beats,
similar to PJC’s. Junctional rhythm: 40-60 bpm, accelerated junctional
rhythm: 60-100, junctional tachycardia (rare): >100 bpm. Can be found in
complete AV dissociation—R-R interval will be shorter than P-P interval.
Premature ventricular contraction: wide QRS comes sooner than expected.
No P waves. Compensatory pause present (next beat is on time).
Ventricular escape beat: similar in appearance to PVC, but occurs late after a
pause following normal rhythm. No compensatory pause.
Idioventricular rhythm: a regular run of escaped ventricular beats, similar to
PVC’s. HR is 20-50 bpm. P waves present in AV dissociation. Accelerated
ventricular rhythm: 50-100 bpm.
Ventricular tachycardia: similar appearance to idioventricular rhythms, HR is
100-200 bpm, QRS >0.12 sec. Capture beats are normal sinus QRS
complexes. Fusion beats are in between a capture and ventricular beat.
Irregularities in QRS complexes are sinus beats. Brugada’s sign: interval
from R to bottom of S >0.10 sec. Josephson’s sign: notch near bottom of S.
Pathonomonic if V1-V6 are all negative or all positive.
Ventricular flutter: VTach >200 bpm. Torsade de Pointes is a twisting version
of VTach or VFlutter.
Ventricular fibrillation: cardiac chaos.
BLOCKS
First-degree AV block: PR >0.20 sec, otherwise normal ECG.
Mobitz I second-degree AV block (Wenckebach): increasing PR interval until
a beat is dropped.
Mobitz II second-degree AV block: dropped beats without a changing PR
interval.
Third-degree AV block: P’s and QRS’s are regular, but independent of each
other. QRS rate < P rate.
RBBB: QRS >0.12 sec, slurred S in I and V6, RSRˊ in V1 (Rˊ>R). QRˊ is
possible in anteroseptal MI if found in more than 2 leads. T waves are
discordant with the terminal QRS. An incomplete RBBB has the same
morphology with a QRS between 0.1-0.12 sec.
LBBB: wide QRS, large S in V1, large R in I and V6, no Q in I and V6. T
waves are discordant with the terminal QRS. Prolonged QT is usually not
clinically significant.
Left anterior fascicular block: left axis deviation not otherwise explained. r in
III aids in diagnosis. Poor R wave progression
Left posterior fascicular block: right axis deviation without RAE or RVH. s in I
and q in III aids in diagnosis. Might be confused with pulmonary embolus.
delta V1 I, V6 V1 I, V6
wave
Wolff-Parkinson-White Right bundle branch block Left bundle branch block
ST ELEVATION
STEMI timing
Hyperacute: tall T
Acute: ST elevation, Q is small or absent, T changes are minimal or
absent, reciprocal ST
Subacute: ST elevation minimal or absent, T inversion, pathological
Q’s
Old: pathological Q, ST is isoelectric, T may inverted or normal
Diagnosing AMI in LBBB (Sgarbossa’s Criteria): concordant ST
elevation >1 mm, ST depression >1 mm in V1-V3, discordant ST
elevation of >5 mm, presence of Q waves
Anterolateral MI: ST elevation in every lead but V1, poor R progress
Right ventricular infarct: inf MI, ST elevation in III > II, possible ST
elevation in V1, minimal or no ST elevation in V2 unless there is
infarct extension. If ST depression in V2 >  of ST elevation in aVF,
consider additional posterior wall infarct. Must get a right-sided ECG.
Posterior MI: wide R, depressed ST, and upright T in V1 or V2. Usually
associated with inf or high lateral MI. Must obtain a posterior ECG.
Aortic aneurysm: AMI in both L and R coronary systems
Ventricular aneurysm: pathologic Q’s and tombstone ST’s in V1-V3
that are chronic.
Brugada syndrome: incomplete right bundle branch block with ST
elevation and J point elevation in V1-V3. Type 1: gradually
descending (coved) ST segment and negative T. Type 2: saddle
back pattern with a positive or biphasic T. Type 3: saddle back
pattern with minor ST elevation, positive T. Class IC antiarrhythmics
aid in diagnosis.
Pericarditis: PR depression, diffuse ST elevation with upward concave
ST’s, terminal QRS notching. T waves invert before normalizing.
Wellens Syndrome: Normal ECG with chest pain. When pain-free,
precordial T’s are deep, inverted or biphasic. No pathologic Q’s.
Wolff-Parkinson-White syndrome: short PR, wide QRS, delta wave,
ST-T changes, tachycardia. Type A: positive QRS in V1 and V2,
possibly out to V6, mistaken for RBBB. Type B: negative QRS in V1
and V2, positive in all others, mistaken for LBBB. Type C: positive
QRS in V1-V4, negative in others. Q waves are pseudoinfarcts.
DIFFERENTIAL DIAGNOSES
R > S or ST depression in V1: posterior MI, WPW type A, RBBB, RVH,
normal variant in the young (only R > S applies)
Widened QRS: hyperkalemia, VTach, heart block, drug effects, WPW,
BBB, PVC’s, aberrancy
Symmetrical T waves: ischemia, electrolyte disturbances (hyperK),
and CNS problems—typically has broad T’s and prolonged QT
Right axis deviation: normal variant in the young, RVH, L post
hemiblock, dextrocardia, ventricular beats, COPD (without RVH),
high lateral MI with deep Q’s
Left axis deviation: LVH, LBBB, left anterior hemiblock, ventricular
beats, inferior MI with deep Q’s, COPD (occasionally)
ST elevation in I and II: pericarditis, apical MI, aortic root aneurysm
U wave: hypokalemia, bradycardia, LVH, CNS events, drugs
Notching at the end of QRS (or J point elevation) associated with ST
elevation is usually benign early repolarization or pericarditis. Do not
confuse with J waves, a sign of hypothermia that can also present
with bradycardia, ST depression, T inversion, and QT prolongation.
V2 II V2 V2
Brugada Early repolarization Ventricular
Syndrome aneurysm
OR
Subacute
anterior MI
V1 II V4R
Osborn/
J wave
Hypothermia Pericarditis Right
ventricular MI