Rate

(300)/(# of large squares between QRS complexes)

Sinus: 60-100 bpm
Ectopic Foci
Atrial: 60-80bpm
Junctional: 40-60bpm 60-100bpm
Ventricular: 20-40bpm
Atrial Rate
Regular Paroxysmal Tachycardia: 150-250bpm
Atrial Flutter: 250-350bpm (ventricular rate will be a fraction of this) 60-80bpm
Atrial Fibrillation: >350bpm
Ventricular Rate
40-60bpm
Paroxysmal Tachycardia:150-250bpm
Ventricular Flutter: 250-350 bpm
Torsades de Pointes: 250-350bpm
Ventricular Fibrillation: >350bpm 20-40bpm
Irregular (6) x (# R-R complexes in 10 second rhythm strip)

Rhythm
Irregular
Normal Sinus Rhythm (NSR) Regular R-R interval varies across tracing
Regularly Irregular Irregularly Irregular
• P wave precedes each QRS R-R interval is the same Repeating pattern of varying R-R R-R intervals vary erratically (ex//. AFib,
• QRS follows each P wave across tracing intervals (ex//. AFlutter) VFib)
• P wave axis is normal (positive in
2/3 of the following: I, II, aVF and
positive in V1 and aVL)
• Rate between 60-100bpm

Origin of Electrical Activity

SA Node Atrial AV Node Ventricular
P Waves Present, upright Present, inverted Inverted Rare, Inverted
PR Interval Normal Normal or short Short or absent Absent
QRS Normal Normal Normal Wide
Rate (normal) 60-100 60-80 40-60 20-40
Rate (tachy) <200 <200 Can be >200 Can be >200
Escape Rhythm/Beats
When the SA node is arrested (transiently or permanently) for any reason, the overdrive suppression produced by the SA node is lost, this allows
the fastest automaticity foci will “escape from the overdrive suppression to become the dominant foci, producing an Escape Rhythm (run of beat)
or Beat (single beat). Even if only transient, another focus will take up the rhythm making.
Type Description Tracing + ECG features
Atrial • Regular rhythm
Escape • Slower rate (60-80bpm)
Rhythm • P’ waves that look different than SA
node P waves
SINUS ATRIAL ESCAPE
Regular slower rate, with P’ waves that differ from sinus P waves
Junctional • Regular rhythm
Escape • Slower rate (40-60bpm)
Rhythm • Absent or inverted P waves
• Due to sinus arrest + failed atrial escape
rhythm OR complete conduction block
SINUS JUNCTIONAL ESCAPE
Regular slower rate, no P waves or inverted P waves (before, after or within QRS)
Ventricular • Regular rhythm
Escape • Slower rate (20-40bpm)
Rhythm • Absent P waves
• Due to complete conduction block OR
total failure of SA node and all
automaticity foci (rare)
Regular slower rate, no P waves

Axis
Lead I Lead II aVF Angles DDx
Normal + + + or - -30 to 90
RAD - + + 90 to 180 RVH, Left posterior hemiblock, Acute right heart strain (ex//.
PE), COPD, Lateral MI, WPW, Dextrocardia, Septal Defects
X-RAD - - - -90 to -180
LAD + - - -30 to -90 Left anterior hemiblock, Inferior MI, LVH (sometimes),WPW,
RV pacing, Normal variant, Elevated diaphragm, Lead
misplacement, Endocardial cushion defect
Conduction Abnormalities
AV Blocks
1) Is the PR interval 3-5 little boxes?
a. Yes- No AV Block
b. Longer- AV Block
c. Shorter- may be atrial or junctional rhythm
2) What is the P:QRS ratio?
a. 1:1- 1st Degree AV Block
b. 2:1 or more- 2nd or 3rd AV Block
3) Are the P waves responsible for the QRS complexes?
a. Yes- 2nd Degree or 1st Degree Block
b. No- 3rd Degree AV Block
4) Is the PR constant or changing?
a. Changing: 2nd Degree, Type I (Wenckebach)
b. Constant: 2nd Degree, Type II (Mobitz II)

Bundle Branch Blocks

1) Is the QRS narrower than 3 little boxes in lead at WIDEST QRS!!
a. Yes- No Bundle Branch Block
b. No- Bundle Branch Block
2) Look at V1, is it predominantly positive or negative? RBBB Criteria LBBB Criteria
a. Positive: RBBB (RSR’ pattern where R’>R) • QRS>120ms (wide) • QRS >120ms (wide)
b. Negative: LBBB (slurred S waves, can have small r • RSR’ (bunny ears) • Broad R (upgoing) or RSR’
wave)
configuration in V1 wave in V6
3) Look at V6, is it predominantly positive or negative?
• Slurred (wide) S wave in V6 • Small R wave and big S wave
a. Positive: LBBB (RSR’ pattern or broad R wave)
b. Negative: RBBB (slurred S waves) • Intrinsicoid <0.04 in V6 (<1 (rS) in V1
little square) • Intrinsicoid >0.06 in V6
Wolff-Parkinson-White Syndrome • QRS and T are discordant
Re-entry circuit involving the atrium and the ventricles due to the Can assess for ischemia Cannot assess for ischemia
presence of bundles of Kent. àBecause ST segment changes
• Delta waves (early ventricular depolarization) happen with LBBB
• SVT
• Illusion of shortened PR interval and wide QRS
Hypertrophy/Chamber Enlargement
ECG Finding Differential Diagnosis
RAE Lead II: P wave > 2.5 little boxes tall (notched) Tricuspid stenosis, tricuspid regurgitation, COPD, PE, ILD, MV disease, CHD
LAE Lead II: P wave > 2.5 little boxes wide (notched) Mitral stenosis, mitral regurgitation, due to decreased left ventricular compliance (longstanding hypertension,
Lead V1: second part of biphasic wave is >1x1mm obstructive cardiomyopathy, aortic stenosis, aortic regurgitation, infiltrative heart disease)

RVH Lead V1: R>S Pulmonary stenosis, mitral stenosis, ventricular septal defect, atrial septal defect, pulmonary hypertension
RAD + tall R (COPD, PE, sleep apnea, ILD)
LVH Need to meet 1 of 3: Hypertension, aortic stenosis, hypertrophic cardiomyopathy, amyloid, athletes
S in V1/V2 + R in V5/V6 > 35mm STEMI DIAGNOSIS IS CHANGED:
R in aVL >11mm • LBBB: ST segment will shift in the opposite direction of the main QRS vector ("discordant ST shift").
S in V2 = 42mm or R in V6 = 63mm • STEMI in LBBB: ST segment shifts in the same direction as the main QRS vector ("concordant shift")

Ischemia/Infarction
Areas of Infarction/Ischemia for right dominant anatomy
Vessel Involved Infarct Area Leads Cx

Left Anterior Anteroseptal V1, V2

Descending (LAD) Anterior V3, V4 LAD RCA
LAD
Anterolateral I, aVL, V3-6
Extensive Anterior I, aVL, V1-6
Left Circumflex Lateral I, aVL, V5-6
(LCx) Isolated Posterior MI V1, V2 (prominent R waves)
Left Main Coronary
Large region of infarct, combine above
Artery (LCA)
Right Coronary Inferior II, III, aVF
Artery (RCA) *Note: If left dominant, LCA would be occluded
Right Ventricle Posterior MI??
Posterior MI (associated with inferior MI) V1, V2 (prominent R waves)
Pathologic Q Waves
• Insignificant Q Waves (aka normal Q waves): found in leads lateral leads I, aVL, V5, V6 Site of STEMI ST Elevation ST Depression
and inferior leads II, III, aVF. Septal V1, V2 None
• Pathological Q waves: tall (>1/3 of QRS), wide (>1 little box) or any Q waves in anterior Anterior V3, V4 None
leads V1-V4.
Anteroseptal V1, V2, V3, V4 None
o Past or current infarction. Deep Q waves = late or old infarct.
Other Signs Lateral I, aVL, V5, V6 II, III, aVF (inferior)
• Peaked or inverted T waves (reversion of T waves represents recovery) Anterolateral I, aVL, V3, V4, V5, V6 II, III, aVF (inferior)
• ST elevation by at least 2 little squares (current MI, will return to normal with recovery) Inferior II, III, aVF I, aVL (lateral)
• Reciprocal changes (see chart) Posterior None V1, V2, V3, V4
• Poor R wave progression (less than 3mm in V3) à R waves should grow larger from V1-6 (anterior)
• Note: ST depression = ischemia, ST elevation = infarct
J Point Analysis
• Point where QRS complex meets ST segment
• Position: elevated or depressed
• Morphology: slurred or notched

Miscellaneous ECG Changes

Pericarditis
• Early: diffuse ST segment elevation with upwards and concave slope (J), +/- PR segment depression, upright T waves
• Later: isoelectric ST segment, flat or inverted T waves, +/- tachycardia

Hyperkalemia
• Mild-Moderate: tall peaked T waves
• Severe: progressive changes where P waves flatten and disappear, QRS widens and be abnormal, axis shifts (L or
R), ST shift with tall T waves, sine wave pattern

Long QT
• Long QT is when the QT segments is > half of the R-R interval
• Sign of hypokalemia

Segments
Interval/Segment Normal Change Pathophysiology
Atrial depolarization Wide (>2.5 squares) Left atrial enlargement (P mitral)
Negative phase >1x1mm in V1
P Wave II: rounded, < 2.5mm tall and Tall (>2.5 squares) in II or V1 Right atrial enlargement (P pulmonale)
<2.5mm wide Saw tooth P waves and continuous atrial activity at Atrial flutter
V1: biphasic 300bpm
Heart block
1st: fixed prolong PR (1:1 P:QRS ratio)
2nd, type I (Wenckebach): lengthening PR intervals
until skipped beat
Sinus node to start of ventricular 2nd, type II (Mobitz): constant PR interval and then a
Long PR (5mm+)
depolarization dropped beat
P-R Interval 3rd: complete block, dissociation between P and QRS
3-5mm in length (each with their own pacemaker, P-P interval and R-R
interval are at their own constant pace)
Sinus bradycardia
Hypokalemia
Short PR Pre-excitation syndrome (WPW)

Ventricular contraction, be sure to
check R-R vs P-P
Width 3mm (narrow means the His-
Purkinje system is being used; wide
QRS Complex
means that the electrical impulse is
being conducted through the
myocytes or diseased conduction
system)
Septal depolarization
Q Wave
First downward deflection
R and S Wave Depolarization of ventricles
Completion of ventricular
depolarization
S-T Segment At electrical baseline
*Note: LVH, LBBB, and pericarditis
also have ST segment changes
Repolarization of ventricles
T Wave Positive (every but aVR and V1),
isolated negative T waves in V1, V2
are also normal
Wide QRS
Significant Q Waves
R>S (V1)
S (V1/V2) + R (V5/V6) >35mm
RSR’
ST Elevation
ST Depression
ST Depression Lateral (I, aVL, V5, V6)
ST Depression Anterior (V1, V2, V3, V4)
Inversion (continuous leads)
Elevation (continuous leads)
Flattened (continuous leads)
Variations (continuous leads)
Discordant (continuous leads)
Junctional rhythm (would have inverted P waves that
can be before, after or during QRS)
Bundle Branch Block
VT
Ventricular Hypertrophy
Cardiomyopathy
WPW
Ectopic ventricular beat/foci
Hyperkalemia
Drugs (antidepressant and anti-arrhythmics)
Tall (>1/3 of QRS), wide (>1 little box) or any Q
waves in anterior leads V1-V4
Indicates new or historical MI
RVH
LVH
V1 RBBB; V6 LBBB (see section)
Infarction (in affected leads, possible reciprocal
changes)
Pericarditis (widespread, slope up and concave)
LVH (if QRS is down going and ST elevation is
“scooped” concave up)
IschemiaàNSTEMI
LVH (if QRS is up going and ST elevation is
“scooped” concave down)
STEMI in right heart
STEMI in posterior heart
Bundle branch block
Ischemia
Hypertrophy
Drug (digoxin)
PE
Infarction (STEMI, NSTEMI, Prinzmetal)
Hyperkalemia (wider and peaked)
Hypokalemia
Pericarditis
Drug (digoxin)
Pericardial effusion
Non-specific w/o clinical significance
T wave alternans: beat to beat variations due to PVC
overlap (R on T phenonmenà VT or Vfib)
Normal
 Bundle branch block
Concordance Ischemia/infarct
Risk of Torsades de Pointes (Rapid ventricular rhythm
caused by low potassium, meds that block potassium
channels or congenital long QT abnormalities. Looks
like ventricular tachycardia where the amplitude
increases and decreases over time)
Increased
Duration of ventricular Genetics (long QT syndrome which channelopathy)
depolarization + repolarization Drugs (Abx, SSRIs, anti-psychotics, anti-arrhythmics)
Q-T Interval
Electrolytes (low Ca2+, low Mg2+, low K+)
360-400ms, or < half of R-R interval Other (hypothyroidism, hypothyroidism,
cardiomyopathy)
Risk of Vfib (rare)
Electrolytes (high Ca2+)
Decreased
Drugs (digoxin)
Others (hyperthyroidism)
May be repolarization of Purkinje Electrolyte (low K+)
Prominent (>25% of T wave)
Fibres or delayed/prolonged of Drugs (digoxin, anti-arrhythmics)
myocardium Ischemia
U Wave
Inverted (compared to T wave) Volume overload
More visible in slow heart rates,
<25% of T wave amplitude

Rules
1. A ventricular pacemaker has a wide QRS. Therefore, a narrow QRS rules out the ventricle
A junctional pacemaker will not have a normal PR interval. A normal PR interval rules out the AV node.
2. A normal PR interval also rules out the ventricle.
3. Atrial fibrillation is irregular with no pattern. A regular rhythm rules out fibrillation.
4. Ventricular fibrillation has no QRS’s. The presence of QRS’s rules out VF.
5. Regular rhythm with normal PR interval is 99% of the time, sinus rhythm.
6. Inverted P waves are usually not sinus. P wave from SA node is toward Lead II. P waves from atria, AV node or ventricle are
typically away from Lead II. Inverted P waves usually rule out the sinus node.