Interpreting ECG

Rucira Ooi
What is an ECG?
• 12 leads – V1 – 6, I, II, III, aVR, aVL, aVF
Where to place an ECG?
ECG wave form
P wave
• First bump
• Atrial depolarization
• Small, rounded wave
Q wave
• Follows after a P wave
• Downward dip
• May or may not be present
R wave
• First upward peak after the
P wave
S wave
• Any dip below the baseline
following an R wave
T wave
• Upward deflection following QRS
Complex
• Large, rounded wave
PR Interval
• Measured from the beginning of the P wave
to the beginning of the QRS complex
• Normal value: 0.12 – 0.2 secs (3 – 5 small
squares)
QRS duration
• Measured from initial deflection of the
QRS from the isoelectric line to the
end of the QRS complex
• Normal value: < 0.12 secs (less than 3
small squares)
Systematic way of interpreting ECG
In the following order:
1. Heart rate
2. Heart rhythm
3. Cardiac axis
4. P waves
5. QRS complexes
6. ST segment
7. Q-T interval
8. T waves
Heart rate
• Usually runs on a standard rate
25mm/s
• Remember to check the paper
speed!
• Each small square represents
0.04 secs
• One large square = 5 small
squares -> 0.2 seconds
Measuring the R-R interval
• Ventricular rate is calculated by looking at the distance between
consecutive QRS complexes
• Usually the distance between R waves is analysed
• When there are a number of large square between each R wave, the
ventricular rate is most easily calculated by counting the number of
large squares between each R wave and dividing this number into 300
• Formula: 300 / Number of large squares (eg. 300 / 5 = 60bpm)

• When the ventricular rhythm is more rapid use number of small

squares
• Formula: 1500 / Number of small squares
• Bradycardia = Heart rate of < 60 bpm
• Tachycardia = Heart rate of > 100bpm

• If heart rhythm is irregular, calculate the rate using the number of

squares between several R waves. Divide the answer to obtain an
average R-R interval.
• Eg. If there are 40 large squares between the first and the eleventh R
wave, the average R-R interval is 4 large squares => 300 / 4 = 75bpm
Heart rhythm
• Look for P waves and their relationship to QRS complex
• Normally one P wave should be followed by one QRS complex
• Good leads to assess P wave are leads II, V1 and V2
Sinus rhythm
• Normal heart rhythm
• P wave followed by QRS complex
• In sinus arrhythmia, the heart rate Increases on Inspiration
• To diagnose sinus rhythm, all of the following criteria should be met:
1. P wave preceding every QRS complex
2. P-R interval is normal
3. P-R interval is constant
Atrial fibrillation
• No P waves
• ECG baseline shows irregularity
• QRS complexes are irregular
Atrial flutter
• Flutter waves
• Baseline adopts a ‘saw-toothed’
• Atrial flutter may occur with a fixed degree of atrio-ventricular block
(eg. 3-to-1 block)
• This means that, for every three flutter waves, there would be one
QRS complex
1 st degree heart block
• P wave precedes each QRS complex, but the P-R interval is prolonged
(> 5 small squares )
• P-R interval remains constant from beat to beat
2 nd degree heart block
• Conduction problem more severe than 1st degree, but less severe
than 3rd degree heart block
• Has 3 main types
1. Mobitz Type 1 (Wenckebach phenomenon)
• Rhythm runs in cycles
• First P-R interval is often normal
• With each successive heart beat, the P-R interval lengthens
• Eventually, there will be a P wave with no following QRS complex
2. Mobitz Type 2
• P-R interval is constant
• Duration may be normal or prolonged
• Periodically there will be no conduction between the atria and
ventricles, and there will be a P wave with no associated QRS complex
3. Fixed degrees of AV block
• Two-to-one, three-to-one, four-to-one block
3 rd degree heart block
• No functioning conduction between atria and ventricles
• No constant relationship between P and QRS waves
 Cardiac axis
Axis Lead I Lead II Lead III
Normal Upgoing Upgoing Upgoing (or
downgoing)
Right axis Downgoing Upgoing Upgoing
deviation
Left axis Upgoing Downgoing Downgoing
deviation
P waves
• Tall, peaked P waves => P
pulmonale
• Sign of right atrium
enlargement
• Wide P waves, often bifid
=> P mitrale
• Sign of left atrium
enlargement
QRS duration
• A normal QRS complex should be less
than 3 small squares wide
• Problems in the conducting tissue
result in widening of QRS complexes
• Right BBB and Left BBB
• Important to identify LBBB, because
its able to develop into MI
• Do not attempt to comment on the
ST segment when LBBB is present
ST segment
• Normally, isoelectric
• Lies between QRS complex
and T wave
• ST elevation = MI (specific
to location of damaged
parts) and pericarditis (in all
leads)
• STEMI -> Convex upwards
• Pericarditis -> Saddle-
shaped
• ST elevation that persists over weeks and months after a MI
commonly signifies the presence of a ventricular aneurysm
• Horizontal ST depression can represent cardiac ischaemia, and may be
seen during episodes of angina pectoris
• ST depression may also indicate a NSTEMI which can be distinguished
from ischaemia only by measuring TnI
• ST depression in lateral chest leads => LVH (strain on the left ventricle)
• Down-sloping ST depression (reverse-tick) ST depression – Patients on
digoxin
Q-T interval
• Start of QRS complex to the end of the T wave
• Long Q-T intervals = cardiac dysrhythmias
• Q-T interval varies with heart rate, but should in general not be more
than 2 large squares in duration
• QT interval increases with bradycardia
T wave
• Final stage in ECG interpretation
• Can be upright or inverted
• Generally less than two-thirds of the height of their neighbouring R
wave, and should not be more than 2 large squares tall
• Inverted T waves are normally seen in leads aVR and III
• May also be seen in lead V1 and V2 but not V2 alone
• T wave inversion = Often a sign of Cardiac ischaemia or NSTEMI
Hyperkalaemia Hypokalaemia
Tall, tented T waves Flat, broad T waves
Loss of P waves ST depression
QRS complex broadening Long Q-T interval
Sine-wave shaped ECG Ventricular dysrhythmia
Cardiac arrest rhythms
Cardiac arrest rhythms - Shockable
• Priority in treatment is to deliver electricity to the heart using a
defibrillator
• Ventricular fibrillation
• Erratic nature of electrical activity
• Random and unpredictable
• Classified as being fine or coarse depending on whether the electrical activity
is of small (fine) or large (coarse) amplitude
• Ventricular tachycardia
• Broad QRS complex tachycardia
• Distinctive appearance on ECG monitor
• Not always associated with cardiac arrest, but is always a significant
arrhythmia
• Tombstone sign
Non-shockable rhythms
• Defibrillation will not be helpful to patients with one of these rhythms
• CPR should be administered and attempts made to reverse the cause
of the cardiac arrest
• PEA (Pulseless electrical activity)
• Heart rhythm is indistinguishable from a heart rhythm normally compatible
with life
• Asystole
• No identifiable cardiac electrical activity
• Important to adjust the gain on the ECG monitor to ensure that ‘fine’
ventricular fibrillation is not missed
• P wave asystole
• Rhythm where only P waves are seen
• No ventricular activity
• Rhythm may respond to cardiac pacing
Example 1
Example 2