12 Lead ECG Interpretation

Learning Objectives

• Be able to explain a systematic approach

to interpreting a 12 lead ECG.

• Be able to identify common ECG

abnormalities.
 Recap: So what is a 12 lead
ECG?
Represents the heart`s electrical activity recorded
from electrodes on the body surface
 Sequence of Interpretation
1. Patient and ECG checks
2. Analyse rate and rhythm (PR interval, QRS
duration, etc.)
3. Analyse S-T segments & T waves
4. Cardiac axis
5. Check for bundle branch block (& fasicular block)
6. Check for chamber hypertrophy
7. Check for amplitude of complexes
8. Check Q-Tc interval
9. Possibly compare to previous recordings
 1. Patient & ECG Checks

• Name, DOB, time date

• Race
• Gender
• At rest or exercise
• In pain or no pain
• Check for calibration
• Check for lead transposition
• ECG checks….
 Visual confirmation of standard speed and amplitude

1mm = 1 small square Standard speed and amplitude settings

2. Analyse Rate and Rhythm (PR interval,
QRS duration, etc.)
https://www.youtube.com/watch?v=zVXBue-
2MFA&list=PLB1CqE-myy75-2BOrGXhCKDxRghciGnta
3. Analyse S-T Segment
S-T Segements
 Significance of ST changes
Causes of ST Segment Elevation
Acute myocardial infarction
Coronary vasospasm (Printzmetal’s
angina)
Pericarditis
Benign early repolarisation
Left bundle branch block
Left ventricular hypertrophy
Ventricular aneurysm
Brugada syndrome
Ventricular paced rhythm
Raised intracranial pressure
Reference: https://litfl.com/st-segment-ecg-library/
Causes of ST Segment Depression
Myocardial ischaemia / NSTEMI
Reciprocal change in STEMI posterior
MI
Digoxin effect
Hypokalaemia
Supraventricular tachycardia
Right bundle branch block
Right ventricular hypertrophy
Left bundle branch block
Left ventricular hypertrophy
Ventricular paced rhythm
 T wave
▪ Ventricular repolarization = no ventricular activity
▪ Resting phase of the cardiac cycle
Variations in T wave morphology

https://wikem.org/wiki/File:T_wave_morphology.png#filelinks
 Significance of T wave changes

Hyperacute Depression Biphasic Flattened

STEMI Normal in children Ischaemia Ischaemia
Angina MI Hypokalaemia Electrolyte
abnormality
Hyperkalaemia Ischaemia Wellens Syndrome
Bundle branch block
Stain patterns
Pulmonary embolism
Hypertrophic
cardiomyopathy
Raised ICP
Reference: https://litfl.com/t-wave-ecg-library/
 ECG evolution acute ST
elevation MI

http://epomedicine.com/wp-content/uploads/2017/10/ecg-evolution-mi.png
Accessed 23/07/2018
https://i1.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/07/ECG-Anatomy-LITFL.jpg?ssl=1. Accessed 17/04/2018
 12 lead ECG zones

Lateral
Septal /
Anterior
Lateral
Inferior
Areas of Infarction
Antero-lateral Infarction
Inferior and Posterior Infarction
Acute Inferior Infarction
 Q Waves
Normal Q Waves:
Small Q waves are normal in most leads
Normally Q waves are not seen in the right-sided leads
(V1-3)

Pathological Q Waves:
> 40 ms (1 mm) wide
> 2 mm deep
> 25% of depth of QRS complex
Q waves in right-sided leads (V1-3)
Pathological Q waves usually indicate current or prior MI
 ECG evolution acute ST
elevation MI

http://epomedicine.com/wp-content/uploads/2017/10/ecg-evolution-mi.png
Accessed 23/07/2018
Indeterminant age Infarct
 Pericarditis

Diffuse concave ST elevation with PR depression

Acute Pericarditis:
Hyperkalaemia:
Left Ventricular Hypertrophy
4. Cardiac Axis
 Cardiac Axis

University of Aberdeen: http://ajames131.wixsite.com/ecginterp/cardiac-axis (accessed 22/04/2018)

Normal Axis = QRS axis between -30° and +90°

Left Axis Deviation = QRS axis less than -30°

Right Axis Deviation = QRS axis greater than +90°

Left Axis Deviation (LAD)
 Causes of Left Axis Deviation
(LAD)

Left anterior fascicular block

Left bundle branch block
Left ventricular hypertrophy
Inferior MI
Ventricular ectopy
Paced rhythm
Wolff-Parkinson White syndrome
Right Axis Deviation (RAD)
 Causes of Right Axis Deviation
(RAD)
• Left posterior fascicular block
• Lateral myocardial infarction
• Right ventricular hypertrophy
• Acute lung disease (e.g. Pulmonary Embolus)
• Chronic lung disease (e.g. COPD)
• Ventricular ectopy
• Hyperkalaemia
• Sodium-channel blocker toxicity
• WPW syndrome
• Normal in children or thin adults with a horizontally
positioned heart
 5. Bundle Branch Blocks

Clinical ECG Interpretation: https://ecgwaves.com/wp-content/uploads/2016/09/x-

retledningsblodforsorjning-1.jpg. Accessed 13/04/2018
 Right Bundle Branch Block

Clinical ECG Interpretation: https://ecgwaves.com/wp-content/uploads/2016/09/x-

retledningsblodforsorjning-1.jpg. Accessed 13/04/2018
 1

2
3
 Normal quick Slower depolarisation RSR’ configuration
depolarisation of right ventricle in leads V1 & V2
of septum & then comes after
left ventricle
Slurred S wave in lateral leads(V6 and Lead 1, aVL)
Right Bundle Branch Block
Diagnostic Criteria of Right BBB:
• Broad QRS > 120ms

• RSR’ pattern in V1-3

• Wide, slurred S wave in the lateral leads (I, aVL,

V5-6)

Associated Features:
• ST depression and T wave inversion in the right
precordial leads (V1-3)
 Causes of Right BBB

• Right ventricular hypertrophy / cor pulmonale

• Pulmonary embolus
• Ischaemic heart disease
• Rheumatic heart disease
• Myocarditis or cardiomyopathy
• Degenerative disease of the conduction system
• Congenital heart disease (e.g. atrial septal
defect)
 Left Bundle Branch Block

Clinical ECG Interpretation: https://ecgwaves.com/wp-content/uploads/2016/09/x-

retledningsblodforsorjning-1.jpg. Accessed 13/04/2018
 2
1
 Left Bundle Branch Block

http://lifeinthefastlane.com/ecg-library/basics/left-bundle-branch-block/
Left Bundle Branch Block
 Diagnostic Criteria of Left BBB:
• QRS duration of > 120ms
• Dominant S wave in V1
• Broad monophasic R wave in lateral leads (I, aVL,
V5-V6)
• Absence of Q waves in lateral leads (I, V5-V6; small
Q waves are still allowed in aVL)
• Prolonged R wave peak time > 60ms in leads (V5-6)

Associated Features:
• Left axis deviation
 Causes of Left BBB
• Aortic stenosis
• Ischaemic heart disease
• Hypertension
• Dilated cardiomyopathy
• Anterior MI
• Primary degenerative disease (fibrosis) of the
conducting system (Lenegre disease)
• Hyperkalaemia
• Digoxin toxicity
 Fascicular Blocks

Clinical ECG Interpretation: https://ecgwaves.com/wp-content/uploads/2016/09/x-

retledningsblodforsorjning-1.jpg. Accessed 13/04/2018
6. Check for Chamber Enlargement

We can check for enlargement of each of

the 4 chambers of the heart….
A normal P wave is made up of first the right
and then the left atrium depolarizing:
Right Atrial Enlargement

https://www.youtube.com/watch?v=gGz0T_dw0Ho
Huge Right Atrial Enlargement
Right Atrial Enlargement
Left Atrial Enlargement
Leads I, II, or III
Left Atrial Enlargement

https://www.youtube.com/watch?v=gGz0T_dw0Ho
Notched P waves
(P Mitrale)
Biphasic P wave of LAE
By Mariana Ruiz Public Domain, https://commons.wikimedia.org/w/index.php?curid=860706
 Right Ventricular Hypertrophy
• Criteria
– Increased R:S ratio in V1
(R wave is bigger than the S wave in V1)
– Right axis deviation
– Rule out other causes of big R wave in V1
Posterior Infarction
Right Bundle Branch Block
Adolescents/Children
Right Ventricular Hypertrophy
http://www.nidaanhospital.com/diagnosis-causes-treatment-options-for-left-ventricular-hypertrophylvh/
 Left Ventricular Hypertrophy
• Results in ↑R wave in left-sided leads (I, aVL
and V4-6) & ↑ S wave in right-sided leads (III,
aVR, V1-3).

• Thickened LV wall leads to prolonged

depolarisation.
 Voltage Criteria for LVH

Most Common Criteria:

S wave in V1 + R wave in V5 or V6 > 35mm

 Other Individual Lead Voltage
Criteria

• Any one chest lead >45mm (R or S wave)

• aVL > 11mm

• Lead I > 12mm  L I F (E)
• aVF > 20mm 11 12 20
 Other Criteria for LVH
• ST segment depression and T wave
inversion in the left-sided leads:
=>AKA the left ventricular ‘strain’ pattern

• ST elevation in the right chest leads V1-3

• Left atrial enlargement
• Left axis deviation
 Left Ventricular Hypertrophy

>12

29
>11

32
What type of hypertrophy is revealed here?
What type of hypertrophy is revealed here?
 7. Amplitude of Complexes
The QRS is said to be low voltage when:

• The amplitudes of all the QRS complexes

in the limb leads are < 5 mm

OR

• The amplitudes of all the QRS complexes

in the chest leads are < 10 mm
 Low voltage is produced by…

• The “damping” effect of increased layers between

the heart and the electrode

fluid (pleural effusion, pericardial effusion)

fat (obesity)
air (pneumothorax, emphysema)

• Loss of viable myocardium

• Many other reasons…..

> 700ml Pericardial Effusion
Extensive myocardial loss from
a prior anterior MI.
8. Check QTc Interval
QTc is the QT interval corrected for a heart rate of
60bpm

QTc is prolonged if:

> 440ms in men
> 460ms in women

QTc > 500ms is associated with increased risk of

torsades de pointes (a type of ventricular tachycardia)

QTc is abnormally short if < 350ms

Causes of Prolonged QTc:
• Hypokalaemia
• Hypomagnesaemia
• Hypocalcaemia
• Hypothermia
• Myocardial ischemia
• Post-cardiac arrest
• Raised intracranial pressure
• Congenital long QT syndrome
• DRUGS
Long QT Interval (>500ms)

Reference: https://lifeinthefastlane.com/cicm-saq-2012-1-q23/
 References
32bravo711 (2012) Interpreting a rhythm strip Retreived from:
https://www.youtube.com/watch?v=zVXBue-2MFA&list=PLB1CqE-myy75-
2BOrGXhCKDxRghciGnta

Life in the Fast Lane (2019) Retrived from: https://litfl.com/st-segment-ecg-

library/

https://www.youtube.com/watch?v=URBREKIUALk
32bravo711
12 Lead Interpretation Part 1: Introduction to the 12 Lead EKG
https://www.youtube.com/watch?v=URBREKIUALk&t=989s
12 Lead Interpretation Part 2: The 6 Step 12-Lead Interpretation Process
https://www.youtube.com/watch?v=YsiNFaDtTYo&t=670s
12 Lead Interpretation Part 3: R-wave Progression, Electrical Vectors & Axis Deviations
https://www.youtube.com/watch?v=Mu71NqijEu0&t=691s
12 Lead Interpretation Part 4-1: Bundle Branch and Fascicular Blocks
https://www.youtube.com/watch?v=zObYyEQa9iA&t=987s
12 Lead Interpretation Part 4-2: Bundle Branch and Fascicular Blocks
https://www.youtube.com/watch?v=qVHwV9HheB4&t=582s
12 Lead Interpretation Part 5-1: Chamber Enlargements and Hypertrophies
https://www.youtube.com/watch?v=KbPADUplMPI
12 Lead Interpretation Part 5-2: Chamber Enlargements and Hypertrophies
https://www.youtube.com/watch?v=hl0Kjq_W_nM&t=6s
12 Lead Interpretation Part 6-1: Pathophysiolgoy of Myocardial Infarctions
https://www.youtube.com/watch?v=bKrsLQuCs88
12 Lead Interpretation Part 6-2: EKG Changes & Lead Localization of Myocardial
Infarctions https://www.youtube.com/watch?v=RQhn4srQdgQ
12 Lead Interpretation Part 7: Management of MI
https://www.youtube.com/watch?v=v0aJ67WkrAI
Now for some practice….