M.D. PhD.

Yunzhe Wang
1st Affiliatd Hospital of Zhengzhou University
Cardiology Dept.
2023/12/22
 P wave is peaked in Ⅱ、Ⅲ、aVF leads,
voltage≥0.25mV, termed as “P pulmonale”
 P wave is also steep & high in V1、 V2, but may be
lower, flat, even inverted in some cases
 Voltage of erect P wave≥0.15mV; arithmetic sum
of voltage of biphasic P≥0.20mV
 duration is normal, 0.12~0.20s
 P become wider in Ⅰ、Ⅱ、aVR、aVL, ≥0.12 s
 Bifid, termed as P “mitrale”, distance
between 2 peaks ≥0.04 s
 Arithmetic sum of voltage for biphasic P ＞
0.2mV in V1; terminal negative component,
wider than 1mm (0.04 s), deeper than 1mm
(0.1mV)
 Ptfv1 ≥0.04mV*S（P-wave terminal force in V1）
 QRS complex (adult, over 30 yrs old)
 RV5 or RV6 ≥2.5mV
 RV5+SV1 ≥4.0mV（M）(note: RavF
≥3.5mV)
 RⅠ≥1.5mV
 RⅠ+SⅢ ≥2.5mV
 RaVL ≥1.2mV or RaVF ≥2.5mV
 QRS interval & peak of R wave: QRS interval
＞0.10 Sec; Width of RV5 or RV6 ＞0.05 Sec
 ST-T: secondary changes
 ST segment:Downward shift of in V5、V6、
aVL or aVF ≥0.05mV
 T wave: Lower, flat, biphasic changes
 TV5 or TV6 lower than 1/10 RV5 or RV6
 ST segment upward shift, erect or peaked
T wave in V1
 Axis deviation
 Left axis deviation, ≤-10º
 Anticlockwise rotation
 QRS complex
 RV1 ≥ 1.0mV, RV1+SV5 ≥1.2mV
 V1 qR
 RaVR ≥ 0.5mV, R/S ＞1 in aVR
 V1 R/S＞1, V5 R/S ＜1
 Significant clockwise deviation, rS complex
in V1~V4, even V1~V6
 QRS interval & peak of R wave
 QRS interval: normal in most cases
 Significant RV hypertrophy, QRS interval＞
0.10 Sec
 Timing of R peak in V1 over 0.03 Sec
 ST-T
 Downward shift of ST in V1~V3
≥0.05mV, inverted T wave
 Downward shift of ST in Ⅱ and Ⅲ, T
wave may become lower, flat, even
inverted in these leads
 Upward shift of ST and erect peaked T
wave in V5
 Axis deviation
 Right axis deviation, >+90°
 Clockwise rotation
 Necrotic changes and abnormal Q wave: in
leads that main waves is upward, QRS → QR or Qr;
in leads that main waves is downward, QRS → QS
or Qr

 Injured region → arc-type elevated ST segment

 Ischemic changes → inverted or peaked T
wave
 Necrotic Q wave

 Timing ≥0.04s

 Amplitude ≥ ¼R in the same lead

 Presented region: opposite to the

necrotic region
 Super acute Acute Later Remnant

Inverted, but Erect in most

T wave peaked inverted
shallower cases
Arc-type Arc-type Come back to
ST segment
elevation elevation Base line
Abnormal Q — + + +
LAD：
anterior wall of LV
anterior septum
LCX：
lateral wall of LV
RCA：
RV
posterior wall of LV（most)
inferior wall of LV（most）
 I II III avR avL avF V1 V2 V3 V4 V5 V6

Inferior — + + — — + — — — — — —
Extensive
anterior — — — — — — ± + + + + +
anterosept
al wall — — — — — — + + + — — —

Anterior — — — — — — — + + + ±

Lateral + — — — + — — — — — + +
ECG SUMMERY
Components & measurement of normal ECG
ECG Paper
 Normal S. rhythm

 Originated from SAN (sino-atrial node)

 P wave: upright in lead Ⅱ, inverted in lead
aVR
 PR interval: 0.12 - 0.20 Sec
 P-R relationship is normal, every P is followed
by a QRS
 Frequency: 60-100 tpm
 S. bradycardia
 Originated from SAN (sino-atrial node)
 P wave: upright in lead Ⅱ, inverted in lead aVR
 PR interval: 0.12 - 0.20 Sec
 R-R or P-P interval = or > 1.0 Sec
 In most cases, P-R relationship is normal, every
P is followed by a QRS
 Frequency: < 60 tpm, but seldom <40 tpm
 Accompanying with S. arrhythmia sometimes
 S. tachycardia

 Originated from SAN (sino-atrial node)

 P wave: upright in lead Ⅱ, inverted in lead
aVR
 PR & QT interval are shorter than usual
 R-R or P-P interval < 0.6 Sec
 P-R relationship is normal, every P is followed
by a QRS
 Frequency: > 100 tpm, but seldom > 150 tpm
 ST is slightly depressed, T may be flattened
Differential Diagnosis of Escape beats

PAC PVC
Erect,
P’ wave divergent from None or inverted
sinus P
N. or prolonged
P’－R interval if intervened
——

QRS complex supraventricular Wider & bizarre

Opposite to main
T wave Normal
wave of QRS

Compensatory
Incomplete Complete
pause
 Conduction block

Classification on block degrees

 Ⅰº: delayed conduction

 Ⅱº: some excitations blocked, unable to

conduction

 Ⅲ º: completely blocked
Ⅰº AVB

 PR interval ＞0.20 Sec

 Ⅱº type I （Mobitz I, Wenckebach type）

 P－R interval progressively, until one QRS complex is

dropped
 R－R interval →shorter
 Timing of Longest RR interval <algebraic sum of 2
shorter ones
 Timing and morphology of QRS complex is normal
except for accompanying abnormal intra ventricular
conduction
 NP: NQRS >2:1, for example, 3:2， 4:3
 Ⅱº type Ⅱ AVB

 PR intervals invariable, but has regular dropped

QRS
 RR interval is fixed
 Longer RR intervals is the euploid of shorter ones
 NP: NQRS = 2:1, 3:1, etc.
 Consistent dropped beats is more severe
 More severe than type I
 Ⅲ º AVB

 No relationship between P wave and

escape QRS
 Frequency of P > FQRS
 PP interval and RR interval is regular
 Sinus P, or atrial flutter, fibrillation
 QRS complex
 Determined by site of pacing point
 Before His branch, QRS is with normal
morphology, frequency 35-50 bpm
 After His branch, QRS wider and bizarre,
Frequency less than 35 bpm
 Right bundle branch block
1. QRS malformation：V1、V2 show rsR’ or M
shape，R’ wide and high；V5、V6 leads shows
qRS or RS pattern，S wave deep and wide；
2. QRS duration≥0.12s（complete），＜0.12s
（incomplete）； V1 VAT≥0.06s；
3. secondary ST-T changes：V1、V2 ST segment
slightly depress，T inverted；V5、V6 ST
segment elevate，T positive。
 Left bundle branch block
1. QRS ： V1、V2 wide and large QS 、 qrS/rS
pattern，r wave very small，S wave deep and
large； V5、V6 wide R wave，notched； I 、
V5、V6 no q；
2. QRS duration≥0.12s（complete），＜0.12s（
incomplete）；V5 VAT≥0.06s；
3. secondary ST-T changes：V1、V2 ST elevated,
T(+)；V5、V6 ST depressed、T inverted。
 Pre-excitation syndrome

1. shorter P-R<0.12s
2. (△ wave，delta wave) in initial part of QRS
3. QRS duration≥0.12s， P-J interval normal（<0.26s）
4. secondary ST-T changes:ST segment depression，T
inverted in leads with positive QRS and delta waves）
Paroxysmal supraventricular tachycardia

 （1）from atrium or junctional area，P’ wave

hard to find
 （2）clinical symptoms with sudden appear and
sudden arrest
 （2）fast,regular，160~250bpm
 （3）QRS shows supraventricular shape,may
accompanied with bundle branch block or
intraventricular block
 ventricular tachycardia

 （1）QRS 140~200BPM；may slightly irregular

 （2）QRS wide,malformation duration>0.12s in
common
 （3）AV dissociation（ P less than QRS）will confirm
the diagosis
 （4）A to V conduction to capture ventricles or form
ventricular fusion wave can support the diagnosis
 note：last for <30s，non-sustained VT ；>30s，
sustained VT
 Atrial Flutter

 ECG presentations
1. P disappear，replaced by regular F waves with
identical shape ,amplitude and intervals

2. 250-350bpm of atrium

3. QRS shows supraventricular shape, RR

interval decided by the ratio of AV conduction

4. T wave not clear

 Atrial Fibrillation

 P wave disappear，replaced by irregular f waves

with different shape ,amplitude and intervals
 350～600bpm of atrial
 QRS shows supraventricular shape, RR interval
absolutely irregular
 T wave not clear
 note：in II、III、aVF、V1、V2 f waves clear
 Ventricular Flutter

 ECG presentations
1. P-QRS-T disappear，replaced by
identical waves with same shape ，
amplitude and intervals
2. 200~250bpm
3. lose of cardic output
 Ventricular Fibrillation

 P-QRS-T disappear，replaced by irregular

fibrillation waves with different shape and
amplitude and intervals
 200~500bpm
 totally lost of cardiac output
 hyperkalemia

Ⅰ aVR V1 V3 V5

Ⅱ aVL

V2
V4

Ⅲ aVF

V6
 hypokalemia

Ⅰ Ⅱ Ⅲ aVR aVL aVF

V1 V3 V5 V6

remember the triad of ST segment depression,

low amplitude T waves, and prominent U waves
K+< 3 mmol/L
 P wave is peaked in Ⅱ、Ⅲ、aVF leads,
voltage≥0.25mV, termed as “P pulmonale”
 P wave is also steep & high in V1、 V2, but may be
lower, flat, even inverted in some cases
 Voltage of erect P wave≥0.15mV; arithmetic sum
of voltage of biphasic P≥0.20mV
 duration is normal, 0.12~0.20s
 P become wider in Ⅰ、Ⅱ、aVR、aVL, ≥0.12 s
 Bifid, termed as P “mitrale”, distance
between 2 peaks ≥0.04 s
 Arithmetic sum of voltage for biphasic P ＞
0.2mV in V1; terminal negative component,
wider than 1mm (0.04 s), deeper than 1mm
(0.1mV)
 Ptfv1 ≥0.04mV*S（P-wave terminal force in V1）
 QRS complex (adult, over 30 yrs old)
 RV5 or RV6 ≥2.5mV
 RV5+SV1 ≥4.0mV（M）(note: RavF
≥3.5mV)
 RⅠ≥1.5mV
 RⅠ+SⅢ ≥2.5mV
 RaVL ≥1.2mV or RaVF ≥2.5mV
 QRS interval & peak of R wave: QRS interval
＞0.10 Sec; Width of RV5 or RV6 ＞0.05 Sec
 ST-T: secondary changes
 ST segment:Downward shift of in V5、V6、
aVL or aVF ≥0.05mV
 T wave: Lower, flat, biphasic changes
 TV5 or TV6 lower than 1/10 RV5 or RV6
 ST segment upward shift, erect or peaked
T wave in V1
 Axis deviation
 Left axis deviation, ≤-10º
 Anticlockwise rotation
 QRS complex
 RV1 ≥ 1.0mV, RV1+SV5 ≥1.2mV
 V1 qR
 RaVR ≥ 0.5mV, R/S ＞1 in aVR
 V1 R/S＞1, V5 R/S ＜1
 Significant clockwise deviation, rS complex
in V1~V4, even V1~V6
 QRS interval & peak of R wave
 QRS interval: normal in most cases
 Significant RV hypertrophy, QRS interval＞
0.10 Sec
 Timing of R peak in V1 over 0.03 Sec
 ST-T
 Downward shift of ST in V1~V3
≥0.05mV, inverted T wave
 Downward shift of ST in Ⅱ and Ⅲ, T
wave may become lower, flat, even
inverted in these leads
 Upward shift of ST and erect peaked T
wave in V5
 Axis deviation
 Right axis deviation, >+90°
 Clockwise rotation
 Necrotic changes and abnormal Q wave: in
leads that main waves is upward, QRS → QR or Qr;
in leads that main waves is downward, QRS → QS
or Qr

 Injured region → arc-type elevated ST segment

 Ischemic changes → inverted or peaked T
wave
 Super acute Acute Later Remnant

Inverted, but Erect in most

T wave peaked inverted
shallower cases
Arc-type Arc-type Come back to
ST segment
elevation elevation Base line
Abnormal Q — + + +
 Location Diagnosis of infarction region
I II III avR avL avF V1 V2 V3 V4 V5 V6

Inferior — + + — — + — — — — — —
Extensive
anterior — — — — — — ± + + + + +
Anterose
ptal — — — — — — + + + — — —

Anterior — — — — — — — + + + ±

Lateral + — — — + — — — — — + +
TEST
ECG 01
ECG 01

Old inferior Wall Myocardial Infarction

ECG 02
ECG 02

Hypokalemia
ECG 03
ECG 03

sinus bradycardia
ECG 04
ECG 04

Second degree AV block (Mobitz I)

ECG 05
ECG 05

atrial fibrillation
ECG 06
ECG 06

atrial flutter
ECG 07
ECG 07

Hyperkalemia
ECG 09
ECG 09

acute anteroseptal myocardial infarction

ECG 10
ECG 10

third degree AV block

junctional escape rhythm
ECG 11
ECG 11

ventricular tachycardia
ECG 12
ECG 12

premature ventricular contractions

ECG 13
ECG 13

ventricular flutter
ECG 14
ECG 14

first degree AV block

ECG 15
ECG 15

sinus tachycardia
Right atrial hypertrophy
ECG 16
ECG 16

complete right bundle branch block

ECG 17
ECG 17

pre-excitation syndrome (type A)

ECG 18
ECG 18

ventricular fibrillation
ECG 19
ECG 19

complete left bundle branch block

ECG 20
ECG 20

Left ventricular hypertrophy

ECG 21

左心室肥大伴ST-T改变
ECG 21

supraventricular tachycardia
ECG 22
ECG 22 ventricular tachycardia
ECG 23
ECG 23 RBBB
ECG 24
ECG 24 Acute MI (Extensive anterior)
Normal ECG
107
pre-excitation syndrome:type B

108
109
Second degree AV block (Mobitz II)
110
Sinus bradycardia
PAC
 R-R interval  QT interval  Heart rate
 P wave duration  QRS duration  Rv5+Sv1
 P-R interval  Axis
Have a good day