INTERPRETION OF ECG

STEP 1: CLINICAL HISTORY

a. Check brief history.
b. Compare traces with old records (If available)
c. First look (Lay of the Land)

NORMAL ECG PATTERNS

INTERVAL SPEED (mm/s)

QRS Interval 0.08 – 0.12s
QT Segment 0.35 – 0.44s
PR Segment 0.12 - 0.20s
ST Segment 0.12 -0.20s

STEP 2: CALIBRATION AND VALIDATION

a. Check Quality of Paper.
b. Check Speed of Paper (25 mm/s or not?)
c. Check Calibration (10 mm/mv or not?)
STEP 3: PARTS OF ECG
a. The standard ECG has 12 leads.
b. Six of the leads are considered “Limb Leads” while other six leads are considered “Precordial
Leads”

LIMB LEADS PERICORDIAL LEADS

Placed on Arms/Legs of an Individual Placed on Torso (Precordium)
Have following Leads : Have following Leads:
a. Lead I a. Lead V1
b. Lead II b. Lead V2
c. Lead III c. Lead V3
d. aVL d. Lead V4
e. aVR e. Lead V5
f. aVF f. Lead V6

The letter “a” stands for “augmented,” as these

leads are calculated as a combination of leads I, II
and III.
THE NORMAL ECG
A normal ECG contains waves, intervals, segments and one complex, as defined below.

WAVES INTERVALS SEGMENTS COMPLEX

A positive or negative The time between two The length between two The combination of
deflection from specific ECG events. specific points on an multiple waves grouped
baseline that indicates ECG that are supposed together.
a specific electrical to be at the baseline
event. amplitude (not negative
or positive).

The waves on an ECG The intervals The segments on an The only main complex
include the commonly measured on ECG include the on an ECG is the QRS
a. P wave an ECG include the a. PR segment complex
b. Q wave a. PR interval b. ST segment
c. R wave b. QRS interval c. TP segment.
d. S wave c. QT interval
e. T wave d. RR interval.
f. U wave.
MAIN PART OF AN ECG
The main part of an ECG contains a P wave, QRS complex and T wave.

WAVE/COMPLES DESCRIPTION
P Wave Indicates Atrial Depolarization

QRS Complex The QRS complex consists of a Q wave, R wave and S wave and represents
ventricular depolarization

T Wave The T wave comes after the QRS complex and indicates ventricular
repolarization.
STEP 3: RATE AND RHYTHM

RATE DESCRIPTION
Slow  Known as Bradycardia
 Speed is <60 beats per minute
 Indicates:
a. Sinus Bradycardia
b. Escape rhythm
c. AV Block

Normal  Known as “Normal Sinus Rhythm”

 Speed is 60 to 100 beats per minute
 Mostly regular
 Sinus arrhythmia
 P wave is
a. negative in aVR
b. positive in II,III and aVF

Fast  Known as Tachycardia

 Speed is >100 beats per minute
 Indicates:
a. Supra ventric tachycardia
b. Ventricular tachycardia
c. Sinus tachycardia

 Examine if rhythm is “Regular” or “Irregular”.

a. AFib represent “Irregular rhythm”
b. AFI represents “Occasionally Irregular”
c. AV block (Irregular or Partial AV Block)

 Examine if P wave is “Present or Absent”

a. If P wave is present it represents “Normal sinus rhythm”
b. I P wave is absent it represents “Flutter” or “AFib”
STEP 4: DETERMINE QRS AXIS IN FRONTAL PLANE

Lead I Lead II Quick and Easy Way

Positive Positive Normal Axis between -30º and +90º

Positive Negative Look at Lead II
Lead II Negative Left Axis deviation
Lead II Equiphasic Axis is -30º
Lead II Positive Normal Axis
Negative Positive Right Axis deviation from +90º to +180º
Negative Negative Right superior from -90º to -180º
STEP 5-A: MEASURMENT OF PR INTERVAL

PR INTERVAL DESCRIPTION
Short PR interval <0.12s
Represents:
a. Low atrial rhythm
b. Upper AV junctional rhythm
Normal PR interval 0.12 to 0.2s

Prolonged PR interval >0.2s

Represents:
a. No dropped beats
b. Dropped beats
c. No AV conduction
Very Long P wave Pushes the P wave into T wave therefore it can’t be
identified easily

STEP 5-B: MEASURMENT OF QRS COMPLEX (DURATION)

QRS COMPLEX DESCRIPTION

QRSD Normal <0.10s
QRSD Between 0.10 to 0.12s
Consider:
a. Incomplete Bundle Branch Block
b. Intraventricular Conduction Disorder

QRSD Wide >0.2s

Consider:
a. Sinus rhythm with “Right Bundle Branch Block (RBBB)” or “Left
Bundle Branch Block (LBBB)’
b. No Sinus rhythm with “Ventricular rhythm”
STEP 5-C: MEASURMENT OF QRS COMPLEX (VOLTAGE)

QRS COMPLEX VOLTAGE DESCRIPTION

HIGH QRS VOLATGE LOW QRS VOLTAGE

SV1 + RV6 > 35mm Amplitude in all QRS complex in Limb Leads is >
R in Lead I > 15mm 5mm and <10mm in Precordial Leads.
R > aVL > 11mm

LEFT VENTRICULAR HYPERTROPHY Consider:

(LVH) a. Pericardial Effusion.
b. Pleural Effusion
c. Emphysema (COPD)
Do Not Consider: d. Pneumothorax
a. Ventricular pacing looking for e. Marked Obesity
Pacemaker stimuli f. Previous massive Heart Failure
b. Hyperkalemia in case of Prolonged g. End stage dilated Cardiomyopathy
QRS Complex h. Hypothyroidism
c. Looking for Delta wave
STEP 6-A: LOOK FOR R WAVE PROGRESSION IN PRECORDIAL LEADS
CAUSE OF SLOW R WAVE PROGRESSION
a. Anterior Myocardial Infarction
b. Incorrect Lead Placement in Obese women
c. LVH(Left Ventricular Hypertrophy) , LBBB (Left Bundle Branch Block) , WPW (Wolff-
Parkinson-White)
d. Tension Pneumothorax
e. Congenital Heart disease

REVERSE R WAVE PROGRESSION

 It describes Abnormal R wave in Lead V1 that “Progressively decreases in Amplitude” in case of

Narrow QRS.
 Reverse R wave progression may occur due to:
a. Right Ventricular Hypertrophy(RVH)
b. Posterior or Posterior-Lateral Myocardial Infarction
c. Dextrocardia
d. Misplaced leads
(If QRS is wide there would be “Dominant R wave” that might be due to Right Bundle Branch Block or
Wolff-Parkinson-White Syndrome)
STEP 7: QT INTERVAL
QTc = Corrected QT Interval [Normal QTc is 440ms and value can slightly differ in women)
𝑄𝑇 𝐼𝑛𝑡𝑒𝑟𝑣𝑎𝑙 (𝑠)
QTc (s) =
√𝑅𝑅𝐼𝑛𝑡𝑒𝑟𝑣𝑎𝑙 (𝑠)

SHORT QT INTERVAL LONG QT INTERVAL

Time is <330ms Time is > 460ms

Increased Risk of “Atrial Fibrillation” and Increased Risk of “Early After Depolarization
“Ventricular Fibrillation” (EAD” and “Torsade de pointess (TdP)

STEP-8: U WAVE

 Small deflection of 0.5mm, immediately following T wave

 Have “Same Polarity as T wave”
 Possibly originating from “Purkinje Network”
 Best seen in Lead V2 and V3 in Slow Rates.
STEP-9: P WAVE

 P wave are best seen in Lead II and V1

 Normal P wave is observed when:
a. Lead II is <0.12s
b. Lead V1 is “Biphasic”
P wave Occurs when:
“Too Wide” a. Lead II is >0.12s
b. Lead II Is prominently notched with
Negative Terminal forces with V1
c. Represent “Left atrial abnormality”

P wave Occurs when:

“Too Tall” a. P is Peaked at Lead II
b. P is >2.5mm in Inferior Leads
c. P is >1.5mm in Lead V1

P wave is Occurs when P wave is negative in:

“Negative” a. Lead II
b. Lead III
c. Lead aVF
STEP 10: T WAVE
Normal a. Has same “Polarity as in QRS complex”
T wave b. T wave is “Upright” in I,II and V3 to v6
c. T wave is “Always inverted in “aVR”

T wave a. Commonly found in children and adolescent

inversion in b. Not found in healthy individuals
v1 and v3

High “Hyper acute T wave” “Hyperkalemia”

amplitude T
waves

a. “Broad based” T wave a. Best seen in “Precordial Leads”

b. May be seen 15-30 minutes after b. “Narrow based” T wave
Myocardial Infarction c. Represents as “Tenting of wave”
c. Represents as “Round Summit”
Abnormal T “Inverted T waves” “Biphasic T waves” “Flattened T waves”
waves

Camel “Severe Hypokalemia” “Hidden P waves”

hump T
wave

Prominent U wave fused with T wave a. Embedded in T wave

b. Represents “Sinus Tachycardia”
or “Various forms of Myocardial
Infarction”
STEP 11: ST SEGMENT
a. Duration of typical ST Segment is around 0.8s
b. It is usually “Flat” and “Isoelectric” and should Level essentially with PR and TP Segments.
c. “Ventricles remains De-polarized” in ST Segment
d. It is difficult to evaluate exactly where ST segments end and T wave begins therefore
Relationship of both ST Segment and T wave should be considered.
e. “Abnormal ST Segment (Elevation or Depression) Represents:
 Ischemia
 Infarction
f. “Diagnosis of Myocardial Ischemia or Infarction” depends on “Careful evaluation of ST
Segment”.

ST SEGMENT DEPRESSION ST SEGMENT ELEVATION

a. Most commonly represents “Myocardial
Ischemia”
b. Represents “Sub-endocardial infarction”
c. Represents “Reciprocal changes
associated with Acute Myocardial
Infarction”
d. May be elevated with “Drug effect like as
in Digitalis”
Ischemia or Early Myocardial Infarction
a. Represents “Acute Myocardial Infarction
(Convex ST segment Elevation)”
b. Represents “Transmural Infarction”
c. Represents “Pericarditis”
d.
Acute Myocardial Infarction

Effect of Digitalis Pericarditis

 VARIOUS ECG’S

“Normal
ECG”

“Bradycardia”

“Tachycardia”

“Acute
Myocardial
Infarction”

“Second
Degree Partial
Block”

“Atrial
Fibrillation”
“Ventricular
Tachycardia”

“Ventricular
Fibrillation”

“3rd Degree
Block”

“Wolff-
Parkinson-
White
Syndrome”

“Heart
attack/Heart
Block”

“Ischemic
Heart
Disease”
“Coronary
Heart
Disease”

“ST And NON- ANTERIOR STEMI

ST Elevated
Myocardial
Infarction”

POSTERIOR STEMI

INFERIOR STEMI
 NON STEMI

“Stable
Angina
Pectoris”

“Unstable
Angina
Pectoris”