ECG in Clinical Practice

Basic Concepts of ECG

ECG Waves
✓ P wave— Atrial depolarization
✓ QRS complex— Ventricular depolarization (Depolarization of the left ventricle contributes to main
QRS due to having 3 times more mass)
Q wave— Septal depolarization
R wave— Ventricular depolarization
S wave
✓ T wave— Ventricular repolarization
✓ U wave— Repolarization of interventricular septum (slow repolarization of interventricular
Purkinje fibers and also papillary muscles)
✓ J point— Termination of QRS complex & beginning of ST segment
Intervals & Segments in ECG
✓ PR interval/PQ interval (The time required for the impulse to travel from SA node to ventricular
muscle via AV node): Beginning of P & beginning of QRS
✓ PP interval: Two successive P waves distance
✓ RR interval: Two successive R waves distance
✓ QT interval: Beginning of Q & end of T
✓ PR segment: End of P & beginning of QRS
✓ ST segment (Beginning of ventricular repolarization): End of QRS & beginning of T
ECG Leads
1) LI — Left arm & right arm potential difference (LA & RA)
2) LII — Right arm & left leg potential difference (RA & LL)
3) LIII — Left arm & left leg potential difference (LA & LL)
4) aVR — Heart facing toward the right shoulder (Augmented unipolar RA lead) -Right wrist
5) aVL — Heart facing toward the left shoulder (Augmented unipolar LA lead) -Left wrist
6) aVF — Heart facing toward the left hip (Augmented unipolar LL lead) -Left foot
7) V1 — 4th intercostal space at right sternal border
8) V2 — 4th intercostal space at left sternal border
9) V3 — Midway between V2 & V4
10) V4 — 5th intercostal space in left midclavicular line
11) V5 — 5th intercostal space in left anterior axillary line
12) V6 — 5th intercostal space in left mid axillary line
View of the Heart in All Leads
✓ Anterior— V1 to V6
✓ Inferior— LII, LIII & aVF
✓ High lateral— LI & aVL
✓ Lateral— LI, aVL, V5 & V6
✓ Anterolateral— LI, aVL, V1 to V6
✓ Inferolateral— LII, LIII, aVF, LI, aVL, V5 & V6
✓ Right ventricle— V1 & V2
✓ Left ventricle— V5 & V6
✓ Interventricular septum— V3 & V4
ECG Paper
a) Small square: Height 1mm & horizontal 0.04 sec.
b) Big square (5 small squares): Height 5mm & horizontal 0.2 sec.
c) Recording speed (25 mm/s): 0.2 second = 5 mm Or, 1 second = 25 mm
d) Standardization: 1 mV current— 10 mm height (10 small squares)

Brief Discussion of ECG Interpretation

Look at the following points—
✓ Standardization
✓ Paperspeed
 ✓ Rhythm
✓ Heart rate
✓ Waves & segments
✓ Axis
✓ Abnormalities
Heart Rate & Rhythm
❖ Rhythm: RR interval— equal (Regular rhythm) or, irregular (Irregular rhythm)
❖ Heart rate:
1) Regular rhythm:
HR = 1500/Small squares between R-R or P-P
HR = 300/large squares between R-R or P-P
2) Irregular rhythm:
HR = Number of R in 30 small squares (6 sec.) × 10
P Wave
✓ Height × Duration = 2.5 × 2.5 small squares
✓ Positive in all leads except aVR
✓ Best seen in LII (Also in V1)
✓ Absent; Small; Tall; Wide, notched & biphasic; Inverted; Variable & multiple — Abnormal
PR Interval
✓ Varies with age and heart rate
✓ Normal— 0.10–0.20 second; Children– upto 0.16 second, Adolescent– upto 0.18 second & Adult–
upto 0.20 second
✓ Prolonged; Short; Variable
QRS Complex
✓ Duration 0.08–0.11 sec. (3 small squares); Height <25mm
✓ Q wave
➢ Absent usually
➢ If present, below (depth × width) = (2 × 1 small square) is normal
➢ 25% or less in amplitude of following R wave in the same lead— Normal
➢ Present— Abnormal usually
R wave
➢ Small (<1 mm) in V1 & V2 and tall (<25mm) in V5 & V6; Increases progressively in height in V3
to V6 (aVL <13 mm; aVF <20 mm)
➢ Duration <0.01 second
➢ Tall, small or, poor progression— Abnormal
✓ S wave
➢ Normally deep in V1 & V2 & progressively diminished from V1 to V6
➢ V3 — R & S almost equal
ST Segment
✓ Normally in isoelectric line
✓ Elevated, or depressed— Abnormal usually
✓ ST elevation up to 1 mm in limb leads & 2 mm n chest leads (mainly V1 to V3)— Normal
✓ ST depression <1 mm— Normal
T Wave
✓ Upright except aVR (May be normally inverted in V1 & V2)
✓ Height 2–5 mm in standard leads and 2–10 mm in chest leads— Normal
✓ Minimum one-fourth of R wave of the same lead
✓ Tip is smooth (Rounded)
✓ Inverted, tall peaked & tented, small and biphasic— Abnormal
U Wave
✓ Better seen— chest leads (V2 to V4)
✓ Normal amplitude 1 mm (2 mm in athlete)
✓ Easily visible— when short QT & slow heart rate
✓ Inverted, or prominent— Abnormal
QT interval
✓ Better seen in aVL
✓ Normal 0.35–0.43 seconds
✓ Short or long— Abnormal
Cardiac Axis
✓ QRS complex (LI, LII & aVF)
✓ Greatest amplitude of R wave in LI, LII & aVF indicates the proximi of cardiac axis to that lead
✓ The axis lies at 90° to the isoelectric complex, i.e., positive and negative deflection are equal in
any of the lead LI, LII, LIII, aVL, aVR & aVF
✓ Normal axis -30° to +90° (Positive QRS in both L1 & aVF)
✓ Left axis deviation: LI— Tall R (Positive QRS) & aVF— Deep S (Negative QRS) means LAD. If LII is
negative, it is more likely to be LAD but if LII is positive, axis is normal.
✓ Right axis deviation: aVF— Tall R (Positive QRS) & LII— Deep S (Negative QRS) means RAD.
✓ Intermediate axis: Both LII & aVF— Deep S (Negative QRS) means LAD.