A Simple Guide to

Interpretation of ECG

Agus Setyo Wahyudi, Amd.Kep

ICCU/ICU Ward of dr. Soebandi General
Hospital Jember
2008
 DEFINITION
• ECG :
– is a record of the heart’s electrical activity on
graph paper.
 The ECG can provide information on:
• Arrhythmias
• Myocardial ischemia and infarction
• Pericarditis
• Chamber hypertrophy
• Electrolyte disturbances (i.e.
hyperkalemia, hypokalemia)
• Drug toxicity (i.e. digoxin)
 Properties of Cardiac Cells
Property Ability
Automaticity Generates electrical impulse
spontaneously
Rhythmicity The release of the impulse in a
rhythmic fashion
Conductivity Transmit the impulse from one
cardiac cell to another
Exitability Response to stimulus by the cell
with the ions shifting across the
cell membrane.
The Conduction System of the Heart
Relation between conduction system
and ECG

Key :
P wave : depolarization of atrium
QRS Complex : depolarization of ventricle
T wave : Repolarization of ventricle
Regulators of the Heart
 ECG PAPER

TIME

A
M
P
L
I
T
U
D
E

1/2 1 2

STANDART
CALIBRATION
The normal ECG Waveform:
 P - Wave

• Represent depolarization of atrium

• Normal value :
– Duration 0,04 to 0,11 second
– Height < 2,5 mm
– Always positive on lead II
– Always negative on lead VR
 QRS Complex

• Represent depolarization of ventricle

• Normal value:
– Duration: 0,07 – 0,10 second
– Height depend on lead
• QRS complex consist of Q, R and S wave
 Q-wave

• First negative deflection on QRS complex

• Normal Value:
– Duration < 0,04 second
– Height < ¼ of the R-wave amplitude
• Abnormal Q-wave called pathologic Q-wave

Normal Q-wave pathologic Q-wave

 R & S-wave
• R-wave
– First positive deflection on QRS Complex
– Commonly, QRS complex positive on lead I, II, V5 & V6.
– On lead aVR, V1 & V2 usually small or none.
• S-wave
– Negative deflection after R-wave
– S-wave appear deeper on lead aVR, V1 & V2 than on lead V5 &
V6
 QRS Complex Waveform

How to write:
Deflection ≥ 5 mm = Large letter QRS
Deflection < 5 mm = small letter qrs
 T-wave
• Represent repolarization of ventricle
• Positive on almost lead except on aVR & V1
• Height of the T-wave :
– ≤ 5 mm on limb lead
– ≤ 10 mm on precordial lead
 Gelombang U
• Represent the recovery period of the purkinje fibres.
• Positive deflection after T-wave and before the next
• Usually positive in lead V2 & V3
• Biasanya tegak dan paling besar terdapat di V2 dan
V3.
• U-wave often unclear because hidden in T-wave.
• Height = 1/10 of T-wave amplitude

INVERSI - U
 ST Segment
• ST segment begins at the end of the S wave and terminates
at the upsroke of the T-wave.
• The J point (junction point) marks where the S wave ends
and the St segment begins.
• Normal value : ISOELECRIC
• ST Segment that is above a isoelectric line called ST
segment elevation.
• ST segment that is under a isoelectric line called ST segemnt
depression.
J-Point

J-Point
J-Point
ST-Normal ST- Elevation ST-depression
 PR Interval
• PR Interval is measured from the beginning
of P-wave to the beginning of QRS
complex.
• Normal duration is 0.12 – 0,20 second.
 QT Interval
• Represents the depolarization and
repolarization of the ventricles.
• Is measured from the beginning of
QRS complex to the end of T-wave.
• Depends on heart rate.

• Can be determinated by bazett’s

pattern or table.
• Table :
– HR 60 bpm : 0,33 – 0,43”
– HR 80 bpm : 0,29 – 0,38”
– HR 100 bpm : 0,27 – 0,35”
 Bazett’s pattern
• QT.c = QT
R–R
• QT.c = corrected QT
• QT = measured QT
• R-R = measured R-R Interval
• All of measurement in second
• Normal value:QT.c = 0.33 – 0,43 second
The 12-Leads of ECG
 Attachment of the Leads
Limb leads Precordial leads
LEAD I, II, III, aVR, aVL, aVF LEAD V1 – V6

RA LA

RL LL
 The 12-Leads

The 12-leads include:

–3 Limb leads
(I, II, III)
–3 Augmented leads
(aVR, aVL, aVF)

–6 Precordial leads
(V1- V6)
Limb Leads
Precordial Leads
Relationship Anatomy & Lead
 How to calculate heart rate ?

• 1500 : ∑ small box in R-R interval

• 300 : ∑ large box in R-R interval
• ∑ R-R interval in 6 second and multiplied by 10
What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm
What is the heart rate?

www.uptodate.com

(300 / ~ 4) = ~ 75 bpm
What is the heart rate?

(300 / 1.5) = 200 bpm

 AXIS

The QRS axis represents the net overall direction

of the heart’s electrical activity
 Determining the Axis

Predominantly Predominantly Equiphasic

Positive Negative
The QRS Axis : Frontal Plane
The QRS Axis : Frontal Plane
Is this axis normal?
What is the axis?
Normal or abnormal axis?
Normal axis?
Normal axis?
Axis ?
The QRS Axis : Horizontal Plane

Counter Clock wise Clock wise

Rotation Rotation
ECG INTERPRETATION
1. Rhythm
2. Rate
3. P-wave
4. PR Interval
5. QRS Complex
 Duration
 Axis (Frontal & Horizontal Plane)
 Morphology
6. Segment ST
7. Gel T
8. Gel U
9. Conclusion
 5 Steps to determine arrhythmias :

1. RHYTHM : REGULER OR IRREGULER

2. RATE : < 60 ? , 60-100, > 100 bpm
3. P wave : Normal, every P-wave is followed by
QRS complexes
4. Interval PR : normal ( 0,12” – 0,20”), lengthen ? or
shorten ?
5. QRS complex : normal ( 0,04” - 0,10”), wide ? or
narrow ?
Normal Sinus Rhythm

 Rhythm : reguler
 HR : 60-100 bpm
 P-wave : normal, every P is always followed by QRS
 PR Interval : normal (0,12 - 0,20 second)
 QRS Complex: normal (0,04 – 0,10 second)
ECG INTERPRETATION
• If the normal ECG is
known then
interpretation of
abnormal becomes
easier
Latihan 1
Latihan 2
Latihan 3
Latihan 4
Latihan 5
 Referensi
• Sunoto Pratanu. 2000. Kursus Elektrokardiografi.
Surabaya. PT karya Pembina Swajaya
• Susan L wood. 2005. Cardiac Nursing fifth
edition. USA. Lippincott Williams & Wilkins.
• Chia BL. 2000. Clinical Electrocardiography
third edition. Singapore. World Scientific.
• Josephine Teo. 1999. A Simple Guide to ECG
Interpretation. Singapore Nurse Association
• Dr. Alan E landsay. ECG Learning Center.
http://library.med.utah.edu/kw/ecg