ECG Interpretation

Prepared by:
Group (1)

Under supervision:
A.L: Walid Sayed

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Outlines

• Introduction to ECG
*Definition and purpose of ECG.
*History of ECG development

• Basic Principles of ECG

*The anatomy, physiology and electrical conduction system of the heart.

• ECG Lead Placement

*The standard ECG setup and correct lead placement.

• Understanding ECG Waveforms

*The significance of P waves, QRS complexes, and T waves.

• Basic Rhythm Interpretation

*Identifying normal sinus rhythm and common arrhythmias.

• Common Cardiac Conditions Identified by ECG

*How ECG can indicate conditions like myocardial infarction

• References

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Introduction
WHAT IS ECG?
• Electrocardiography is a graphic representation the electrical activity of the
heart, recorded over period of time.
• An electrocardiogram (ECG) or (EKG) is one of the simplest and fastest tests
used to evaluate the heart. Electrodes (small, plastic patches that stick to the
skin) are placed at certain spots on the chest, arms, and legs. The electrodes are
connected to an ECG machine by lead wires. The electrical activity of the heart
is then measured, interpreted, and printed out. No electricity is sent into the
body.
History of ECG:-

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Indication of ECG:-

✔ Suspected acute coronary syndrome, including myocardial infarction.

✔ Evaluation of implanted defibrillators and pacemakers.

✔ Irregular heart rhythms (arrhythmias).

✔ Evaluation of syncope.

✔ Effects and side effects of pharmacotherapy.

✔ To get a baseline tracing of the heart's function during a physical exam;

this may be used as a comparison with future ECGs, to determine if there
have been any changes.

✔ Determine baseline cardiac function as in preoperative, pre

diagnostic testing.

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Basic Principles of ECG:-
Anatomy of the heart:

The heart is a muscular organ that pumps blood throughout the body. It has four chambers:
two atria (upper chambers) and two ventricles (lower chambers). The right side receives
deoxygenated blood from the body and sends it to the lungs, while the left side receives
oxygenated blood from the lungs and pumps it to the rest of the body. Valves, like the mitral
and tricuspid valves, ensure one-way blood flow. Coronary arteries supply the heart muscle
with oxygen and nutrients.

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Valves of the heart:-

Atrioventricular Valves:

• Tricuspid valve: between right atrium and Rt. Ventricle.

• Mitral Valve: between Lt. atrium and Lt. ventricle.

Semilunar valves:

• Pulmonary valve: between Rt. ventricle and pulmonary artery.

• Aortic valve: between Lt. Ventricle and the aorta.

*Functions of valves: Flow of blood in one direction only.

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Conductive system:
The SA node, located in the right atrium, acts as the heart's natural pacemaker, generating
electrical signals. The AV node, positioned between the atria and ventricles, delays the
impulse slightly, allowing the atria to contract before the ventricles. The bundle of His
conducts the impulse to the ventricles through its branches, known as Purkinje fibers,
ensuring a coordinated contraction. This intricate system ensures efficient blood circulation
and is crucial for maintaining a regular heart rhythm. Dysfunction in this conductive system
can lead to arrhythmias and other cardiac issues.

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ECG lead placement:-
Standard 12 lead in ECG
10 electrodes required to produce 12-lead ECG
4 Electrodes on all 4 limbs (RA, RL, LL, LA)
6 Electrodes on precordium (V1–V6)
Interpretation of specific areas of the heart.
Inferior (II, III, aVF)
Lateral (I, aVL, V5, V6)
Anterior (V1–4)

12-lead Precordial lead placement.

V1: 4th intercostal space (ICS), Right sternal border.
V2: 4th ICS along the Left sternal border.
V3: Midway between V2 and V4
V4: 5th ICS, mid-clavicular line
V5: 5th ICS, anterior axillary line (same level as V4)
V6: 5th ICS, mid-axillary line (same level as V4)

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Additional Lead placements:
- Right sided ECG electrode placement.
- There are several approaches to recording a right-sided ECG.

A complete set of right-sided leads is obtained by placing leads V1-6 in a mirror-image position
on the right side of the chest.
It can be simpler to leave V1 and V2 in their usual positions and just transfer leads V3-6 to the
right side of the chest (i.e. V3R to V6R).

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Understanding the ECG waveforms:-
ECG waves are the graphical representation of the electrical activity of the heart on an
electrocardiogram (ECG). The ECG waves consist of the P wave, QRS complex, T wave,
and sometimes the U wave. Each wave corresponds to a specific phase of the cardiac cycle
and reflects the depolarization and repolarization of the atria and ventricles. By analyzing
the ECG waves, one can assess the heart rate, rhythm, conduction, and function.

-The P waves: the first waves to appear on an electrocardiogram (ECG), The P waves
represent the depolarization of the atria, which means the contraction of the upper chambers
of the heart.

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-PR waves: the distance between the beginning of p wave and the start of the QRS
complex. This represents the travel of the electrical impulse between the atrium and
ventricles.

-The QRS complex is the part of the electrocardiogram (ECG) that shows the
depolarization of the ventricles, which are the lower chambers of the heart. The QRS
complex consists of three waves: the Q wave, the R wave, and the S wave. The Q wave is
the first downward deflection, the R wave is the first upward deflection, and the S wave is
the downward deflection after the R wave.

-ST segment: The portion of the isoelectric line immediately after The S wave and prior to
the next positive deflection (T wave). Measures the time between depolarization and
depolarization of the ventricles.

-The T waves are the part of the electrocardiogram (ECG) that shows the repolarization of
the ventricles, which are the lower chambers of the heart. The T waves are normally
positive in most leads, except for aVR and V1.

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Common Cardiac Conditions Identified by ECG:-
- Highlight how ECG can indicate conditions like myocardial infarction.

ST Segment Changes:
One of the most significant findings of myocardial infarction is the presence of ST segment
elevation. The ST segment is the part of the ECG tracing that starts at the end of the S wave
and ends at the beginning of the T wave. The point where the end of the Q wave and the ST
segment meet is called the J point. If the J point is greater than 2 mm above the baseline, it
is consistent with an ST segment elevation myocardial infarction.
In the acute phase of non-ST segment elevation myocardial infarction, the ST segment may
actually be depressed in leads that face the compromised portion of the heart. It is not
possible to diagnose a non-ST segment elevation myocardial infarction by ECG alone.
Patients are treated presumptively and diagnosis is made if the level of serum cardiac
markers rise over several hours.

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An ECG also can help detect:
1-Arrhythmias – where the heart beats too
slowly, too quickly, or irregularly.

a) Ventricular tachycardia (VT or V-tach)

is a type of abnormal heart rhythm, or
arrhythmia. It occurs when the lower
chamber of the heart beats too fast to
pump well and the body doesn't receive
enough oxygenated blood.

b) Premature ventricular contractions

(PVCs) are extra heartbeats that begin in
one of the heart's two lower pumping
chambers (ventricles). These extra beats
disrupt the regular heart rhythm,
sometimes causing a sensation of a
fluttering or a skipped beat in the chest.

• Premature ventricular contractions are a

common type of irregular
heartbeat (arrhythmia).

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c) Ventricular fibrillation is a type of irregular heart rhythm (arrhythmia). During
ventricular fibrillation, the lower heart chambers contract in a very rapid and
uncoordinated manner. As a result, the heart doesn't pump blood to the rest of the body.

d) Atrial fibrillation is uncoordinated electrical activity in the atria that causes quivering or
irregular heart beat or arrhythmia. Atrial fibrillation, also known as AFib or AF.

e) Atrial flutter is similar to atrial fibrillation but the heart electrical signals spread through
the atria which are beating quickly through at regular rhythm at 75-150 BPM, p wave
appear as sawtooth.

f) Heart block, also called AV block, is when the electrical signal that controls your
heartbeat is partially or completely blocked. This makes your heart beat slowly or skip
beats and your heart can’t pump blood effectively. Symptoms include dizziness, fainting,
tiredness and shortness of breath. Pacemaker implantation is a common treatment.

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• Heart block is categorized as first-, second-, or third-degree:
1- First-degree heart block is the least severe. The electrical signals slow down as they
move from your atria to your ventricles. First-degree heart block might not require
treatment of any kind.

2- Second-degree heart block means that the electrical signals between your atria and
ventricles can intermittently fail to conduct.

• There are 2 types of second-degree heart block

a) Mobitz type I: The electrical signals get slower and slower between beats. Eventually
your heart skips a beat.

b) Mobitz type II: The electrical signals sometimes get to the ventricles, and sometimes
they do not. There is no progressive slowing of the electrical signal. This type of heart
block can often progress to third degree heart block.

3- Third-degree heart block is the most severe. Electrical signals do not go from your atria
to your ventricles at all with this type.

• There is a complete failure of electrical conduction. This can result in no pulse or a very
slow pulse if a backup heart rate is present.

2- Coronary heart disease – where the heart’s blood supply is blocked or interrupted by
a build-up of fatty substances.

3- Heart attacks – where the supply of blood to the heart is suddenly blocked.

4- Cardiomyopathy – where the heart walls become thickened or enlarged.

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References: -
1- https://www.physio-pedia.com/Electrocardiogram
2- https://www.hopkinsmedicine.org/health/treatment-tests-and-
therapies/electrocardiogram
3- https://images.app.goo.gl/SFTowgYJYEZZf8Wp7
4- https://www.nhs.uk/conditions/electrocardiogram/
5- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085598/
6- https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/ecg-test
7- https://litfl.com/ecg-lead-positioning/
8- “The ECG made easy 19th edition”
9- “A prime of ECG”
10- “Atlas of electrocardiography”
11- “An introduction of ECG”

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