Basic ECG Interpretation

Segments and Intervals

 PR segment
 Part of the PR interval
 Horizontal line between the end of the P wave and the
beginning of the QRS complex
 Normally isoelectric line(flat)
 Segments and Intervals
 TP segment
 Segments and Intervals
 ST segment
 The point at which the QRS complex and the ST segment
meet (i.e., the ST junction or J point)
ST-Segment Deviation
 ST-Segment Deviation
 Possible shapes of ST-segment elevation that may be
seen with acute myocardial infarction
Electrocardiography Intervals
Electrical Conduction and
Cardiac Anatomy
 Normal ECG Parameters
 NSR ------------------- 60 and 100 bpm
 SB ---------------------- <60 bpm
 ST ---------------------- >100 bpm
 SVT -------------------- >150 bpm
 QRS -------------------- 0.06 – 0.10
seconds
 PR Interval ----------- 0.12 – 0.20
seconds
 Atrial rate ------------ 60-100 bpm
 Junctional ----------- 40 – 60 bpm
 Ventricular ---------- 20 – 40 bpm
The Beating Heart - Electrophysiology
Electrical Stimulation And Contraction

BEFORE THE HEART CONTRACTS

IT MUST BE ELECTRICALLY STIMULATED

DEPOLARIZATION
Anatomy and Physiology of Cardiac Conduction
SINUS NODE
• The Heart’s ‘Natural Pacemaker’
Sinus Node - 60-100 BPM at rest
(SA Node)

LA
RA
LV
RV
 Anatomy and Physiology of
Cardiac Conduction

SINUS NODE

• The Heart’s ‘Natural Pacemaker’

Sinus Node
- 60-100 BPM at rest
(SA Node)

LA
RA
LV
RV
Impulse Formation
In SA Node
Atrial Depolarization
Delay @ AV Node
Conduction Through
Bundle Branches
Conduction Through Purkinje
Fibers
 Ventricular
Depolarization
Plateau Phase of Repolarization
Final Rapid (Phase 3) Repolarization
Normal ECG Activation
What is an ECG?

 ELECTROCARDIOGRAM
- Records electrical activity of the atria
and ventricles (Heart) as it is
depolarizes and repolarizes.
Bedside Cardiac Monitor
12 Lead ECG
Cables and Electrodes of
12 Lead ECG
Electrode Placement for
12 Lead ECG
RA LA
(-) (+)
LEAD I
RA (-) LEAD I (+) LA

(-) (-)
LEAD II
LEAD III

(+) LF
 R
6 Major Waves
or Deflections

T U
P

Q
S
MEASUREMENT
OF THE P & THE T
WAVES
 R

P T
U

Q
S
 DO’s

When
studying the p
wave, always
look at I, II,
avF & V1!
P WAVE Upright in: I, II, avF and
left precordial leads
How tall?
0.5 -2.5 mm

How wide?
0.10 sec. Biphasic in
V1
Distance
not >0.03 sec.
DO remember
Sinus Rhythm -
The p wave
must look the
same in any
given lead!
DO remember
The AV node is
the normal link
between the
atria &
ventricles!
PR INTERVAL

0.12 secs.

0.20 secs.
 PR INTERVAL

Where to
measure:
standard or uni-
polar limb lead
with the longest
PR interval
 DO remember

Short PR means
bypass of the AV
node; too long
means block!
 R

P T U

Q S
 DO Look

•Duration - width
•Height
•Progression of
the R wave
Measurement of the QRS
Complex
R

Q
S
 QRS
Duration

R
0.10 sec. -
Older children
And adults
 R

P T
U

Q S
 Q Wave

Lead II & aVF R

<0.04 sec. Wide
<2 mm. Deep
<25% of succeeding
R wave (<50% - aVL,
<15% - left of V3)
 ST Segment

•Isoelectric line
•Normally deviate
bet. -0.5 & +1mm
from the baseline
QT Interval
 QT Interval

Normal QT for
rates 60 -100
= 0.30 - 0.40 sec.
 The T Wave

For adults:
>30 years old:
normally inverted
only in V1
< 30 yrs. old:
normally inverted
in V1-3
 The T Wave

•T in V1 is taller
than T in V6
•Abnormal T waves
occur frequently in
healthy persons as
a variant pattern or as
a result of physiologic
stimuli
 The T Wave

•T is usually not
above 10 mm.
In any of the
precordial
leads
 The U Wave

•Prominent
in V3
•not >1 mm
amplitude
 DO NOT FORGET
P = 0.10 sec
= 0.5 - 2.5mm (Ht.)
PR = 0.12-0.20 sec
QRS = 0.10 sec]
QTc = 0.30-0.40 sec
Rate = 60-100/min
 ECG PAPER
 Each small box is measured 1 mm which corresponds to 0.04 sec
 One big box ( 5 small boxes ) is measured 5 mm which corresponds to
0.2 sec
 5 big boxes ( 25 small boxes ) are equivalent to 1 sec
 300 big boxes / 1,500 small boxes are equivalent to 1 minute
 Paper Speed : 25 mm/sec
 The vertical line measures the voltage of the complexes in millivolts
(mV)
 The horizontal line measures the duration of the complexes in seconds
Determination of Rate Regular Rhythm

1 2 3 4

1500 / 23 = 65/min
Determination of Rate
Regular Rhythm

150 75
300 100

1500 / 23 = 65/min
Determination of Rate Irregular Rhythm
3 second strip

Rate /min = Number of complexes x 20

Or if 6 second strip:
Rate/min = number or complexes x 10
6 second strip
 Normal Sinus Rhythm

Look at the p waves:

•same contour in same lead?
•upright in I, II, aVF & left precordial
leads
•followed by QRST?
Lead II
 Sinus Bradycardia

• Rate: Slow (<60 bpm)

• Rhythm: Regular
• P waves: Normal
• PR Interval: Normal (0.12-0.20
sec)
• QRS : Normal (0.06-0.10 sec)
 Sinus Tachycardia

Rate: Fast(>100 bpm)

Rhythm: Regular
P waves: Normal
PR Interval: Normal (0.12-0.20 sec)
QRS : Normal (0.06-0.10 sec)
 SINUS PAUSE
(SINUS ARREST)

Rate: Normal to Slow

Rhythm: Irregular whenever a pause (arrest) occurs
P Waves: Normal except in areas of pause
PR Interval: Normal (0.12-0.20 sec)
QRS: Normal (0.06-0.10 sec)
Sinus Exit Block

Sino-atrial exit block is due to failed propagation of pacemaker impulses beyond

the SA node.
However, some of the sinus impulses are “blocked” before they can leave the SA
node, leading to intermittent failure of atrial depolarisation (dropped P waves).
Premature Atrial
Contraction
Atrial Tachycardia

Atrial tachycardia has a more or less regular heart rate > 100 bpm, with
narrow QRS complexes but P-waves that do not originate from the sinus node
but from another site in the atria. The P-waves therefore have a different
configuration and their non-sinus origin can easily be recognized if the P
waves are negative in I and/or aVF.
Multifocal Atrial
Tachycardia

3 different P wave morphologies

Irregularly occurring QRS complexes
Paroxysmal Supraventricular
Tachycardia

Rate: 150-250 bpm

Rhythm:
P Waves: Frequently buried in preceding T waves
PR Interval: not possible to measure
QRS: Normal (0.06-0.10 sec)
 Atrial Flutter

Atrial rate = 250-350/min

( P as flutter waves )
Variable degree of AV block
( irregular RR interval )
 Atrial Fibrillation

Rate: Atrial >350

Venticular- variable
No discernible P waves
Irregular RR interval
Wolf Parkinson White
Syndrome

Supraventricular rhythm with wide

QRS complex because of pre-excitation
Short or no PR segment followed by a
delta wave (slurred upstroke of QRS)
 Junctional Rhythm

Impulses from the AV node

P wave inverted or buried w/in
QRS or follows the QRS
Rate slow (40-60 bpm)
QRS narrow
 Accelerated
Junctional Rhythm
Impulses from the AV node
P wave inverted or buried w/in
QRS or follows the QRS
Rate 60-100 bpm
QRS narrow
Idioventricular Rhythm

Impulse ventricular in origin

Absence of (N), upright P wave
associated with QRS complexes
QRS > 0.10 sec
T wave opposite in direction to
QRS
Rate < 40 / min
Rate < 40 / min
 Premature Ventricular Contraction
Prematurely occurring complex.
Wide, bizarre looking QRS complex.
Usually no preceding P wave.
T wave opposite in deflection to the QRS
complex.
Complete compensatory pause following
every premature beat.
Premature Ventricular Contraction

= Bigeminy

= Trigeminy

= Quadrigeminy
Premature Ventricular Contraction

= Multifocal PVC’s

= Couplet’s

= V-tach
 Ventricular
Tachycardia
Rate: 100-250 bpm
At least 3 consecutive PVC’s
Rapid, bizarre, wide QRS complexes
(> 0.10 sec)
No P wave (ventricular impulse
origin)

Rate > 100 / min

Torsades De Pointes

Rate: 200-250 bpm

Rhythm: Irregular
P wave: None
PR Interval: None
QRS: wide (>0.10 sec); bizarre appearance
Ventricular Fibrillation
Associated with coarse
or fine chaotic
undulations of the ECG
baseline
No P wave
No true QRS complexes
Indeterminate rate

Coarse Fibrillation Fine Fibrillation

 Asystole
(ventricular standstill)
Atrioventricular (AV) Blocks
FIRST DEGREE
AV BLOCK

Rate: depends
Rhythm: Regular
P wave: normal
PR interval > 0.20
sec
QRS: Normal

0.28 sec 0.28 sec 0.28 sec

SECOND DEGREE AV BLOCK
MOBITZ I or WENCKEBACH

Rate: depends
Rhythm: Atrial-regular; Vent-Irregular
Progressive lengthening
of PR interval w/ intermittent
dropped beats

0.20 sec 0.28 sec 0.20 sec

SECOND DEGREE
AV BLOCK BLOCK AT THE
MOBITZ II Bundle of His
Bilateral bundle
branches
Rate/ Rhythm: Trifascicle
Atrial: (60-100bpm)/ Regular
Ventricular (slower)/ regular or Irregular
Fixed PR interval w/ intermittent
dropped beats .

0.18 sec 0.18 sec 0.18 sec

 THIRD DEGREE
AV BLOCK
Complete atrioventricular block
Impulses originate at both SA node and at
the subsidiary pacemaker below the block
Do you have regularly occurring P waves and QRS complexes? Yes
Are the P waves related to the QRST complexes? No
Is the atrial rate < = > ventricular rate? greater

Ventricular rate = 43 BPM Ventricular rate = 43 BPM

Atrial rate = 80 BPM Atrial rate = 80 BPM

Atrial rate = 80 BPM
Third Degree (“Complete”)
Atrio-Ventricular Block

 No recognizable consistent or meaningful relationship

between atrial and ventricular activity
 ATRIO-VENTRICULAR DISSOCIATION
 QRS complexes often abnormal in shape, duration and axis
(occasionally normal)
 QRS morphology constant
 QRS rate constant ( 15-60 beats/min )
 Any form of atrial activity seen (most commonly sinus
initiated)
THIRD DEGREE AV BLOCK

atrial and ventricular rhythms are independent of each other

atrial rate is usually faster than ventricular rate
ventricular rhythm is maintained by a junctional or
idioventricular escape rhythm or a ventricular pacemaker
Can result from block within the AV node (usually
congenital) or distal to the His bundle (usually acquired)
Acquired AV block most commonly can be secondary to
drug toxicity, ischemic heart disease, or various
degenerative processes; other less common causes
include infectious etiologies, rheumatic diseases,
infiltrative processes, neuromyopathic disorders,
hypoxia, electrolyte disturbances, and surgical
trauma
Atrial Pace Beats
Ventricular Pace Beats
Both Atrial & Ventricular Pace Beats