ECG THE BASICS

Dr Tilahun Jiru
EM & CC physician

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 outline
Introduction
Normal ECG
Reading ECG
Rate, Rhythm, Axis, Hypertrophy
Identifying Common pathologies

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 What is an EKG?
An EKG is a method of measuring, displaying and
recording the electrical activity of a heart

Electrical stimuli is amplified to create a “rhythm strip” by

a machine that consistently produces representations of the
heart’s electrical activity
Electrical System of Heart
Cardiac Action Potentials Ion Flow

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2

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 ECG Graph Paper
Y- Axis Amplitude in mill volts

X- Axis time in seconds

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 ECG Graph Paper

 X-Axis represents time - Scale X-Axis – 1 mm = 0.04 sec

 Y-Axis represents voltage - Scale Y-Axis – 1 mm = 0.1 mV
 One big square on X-Axis = 0.2 sec (big box)
 Two big squares on Y-Axis = 1 milli volt (mV)
 Each small square is 0.04 sec (1 mm in size)
 Each big square on the ECG represents 5 small squares
= 0.04 x 5 = 0.2 seconds
 5 such big squares = 0.2 x 5 = 1sec = 25 mm
 One second is 25 mm or 5 big squares
 One minute is 5 x 60 = 300 big squares
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 ECG Complex
P wave
PR Interval
QRS complex
ST segment
T Wave
QT Interval
RR Interval

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 ECG Complex

 P Wave is Atrial contraction – Normal 0.12 sec

 PR interval is from the beginning of P wave to
the beginning of QRS – Normal up to 0.2 sec
 QRS is Ventricular contraction –Normal 0.12 sec
 ST segment – Normal Isoelectic (electric
silence)
 QT Interval – From the beginning of QRS to the
end of T wave – Normal – 0.40 sec
 RR Interval – One Cardiac cycle 0.80 sec
 Identify the ECG Complex

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5
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2

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 Let us Identify the waves

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6 8

2
3
5

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 Identify the ECG Complex

The Wave or Interval Duration # of Boxes

 P wave : Atrial contraction 0.12 sec (3)
 PR interval – P to begin. of QRS 0.20 sec (5)
 QRS complex - Ventricular 0.12 sec (2)
 ST segment - Electrical silence Isoelectric
 T wave - repolarization 0.12 sec (3)
 QT interval - From Q to T end 0.40 sec (10)
 Let us Identify the waves
 Q wave – Septal = < 3 mm, < 0.04 sec (1 small box)
 R wave – Ventricular contraction < 15 mm
 S wave – complimentary to R < 15 mm
 ST segment – Isoelectric – decides our fate
 Normal ECG

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 ECG Leads

 Standard ECG is recorded in 12 leads

 Six Limb leads – L1, L2, L3, aVR, aVL, aVF
 Six Chest Leads – V1 V2 V3 V4 V5 and V6
 L1, L2 and L3 are called bipolar leads
 L1 between LA and RA
 L2 between LF and RA
 L3 between LF and LA
 ECG Bipolar Limb Leads

- + - -
R L R L

F
+ +
F
 ECG Unipolar Limb Leads

+ +
R L

+ F

Lead aVR Lead aVL Lead aVF

 ECG Unipolar Limb Leads

 Standard ECG is recorded in 12 leads

 Six Limb leads – L1, L2, L3, aVR, aVL, aVF
 Six Chest Leads – V1 V2 V3 V4 V5 and V6
 aVR, aVL, aVF are called unipolar leads
 aVR – from Right Arm Positive
 aVL – from Left Arm Positive
 aVF – from Left Foot Positive
 ECG Chest Leads

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 ECG Chest Leads
Precordial (chest) Lead Position
 V1 Fourth ICS, right sternal border
 V2 Fourth ICS, left sternal border
 V3 Equidistant between V2 and V4
 V4 Fifth ICS, left Mid clavicular Line
 V5 Fifth ICS Left anterior axillary line
 V6 Fifth ICS Left mid axillary line
 The Six Limb Leads
FRONTAL PLANE

RIGHT

LEFT

21 INFERIOR
 The Six Chest Leads

TRANSVERSE PLANE
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 The 12 Camera Photography

 There SIX cameras photographing frontal plane

 Lead 1 and aVL are left sided cameras
 Lead 2, aVF, Lead 3 are inferior cameras
 aVR is horizontal Rt. sided camera (cavitary lead)
 Lateral Leads – L1, aVL, V5 and V6
 Inferior Leads – L2, aVF, and L3 leads
 Septal Leads – V1 and V2
 Anterior Leads – V3 and V4
 Anterio-lateral leads – V3, V4, V5, V6, L1 and aVL
 The 12 Camera Photography

There SIX cameras photographing in transverse or

anterio-posterior plane
V1 and V2 record events of septum
V3 and V4 record events of the anterior wall
V5 and V6 record events of left lateral wall
To record right side events V2R to V6R are needed
– In dextrocardia, in RV infarction
 Beginning to
Recognize Rhythms

 Step 1: Are there P waves?

 Step 2: Are there QRS complexes?
 Step 3: Are the P waves and QRS
complexes related?
 Rate Determination

QRS

Next
QRS

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 What is the Heart Rate ?

Answer on next slide

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 What is the Heart Rate ?
 To find out the heart rate we need to know
◦ The R-R interval in terms of # of big squares
◦ If the R-R intervals are constant
 Use Rule of 300/ No of large square or 1500/No of
small square
 In this ECG the R-R intervals are constant
 R-R are approximately 3 big squares apart
 So the heart rate is 300 ÷ 3 = 100
 What is the Heart Rate ?

Answer on next slide

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 What is the Heart Rate ?
 To find out the heart rate we need to know
 The R-R interval in terms of # of big squares
 If the R-R intervals are constant
 In this ECG the R-R intervals are constant
 R-R are approximately 4.5 big squares apart
 So the heart rate is 300 ÷ 4.5 = 67
 What is the Heart Rate ?

Answer on next slide

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 What is the Heart Rate ?
 To find out the heart rate we need to know
 The R-R interval in terms of # of Big Squares
 If the R-R intervals are constant
 In this ECG the R-R intervals are not constant
 R-R are varying from 2 boxes to 3 boxes
 It is an irregular rhythm – Sinus arrhythmia
 Heart rate is 300 ÷ 2 to 3 = 150 to 100 approx

 Use rule of 10 sec i.e count No of QRS within 10sec

and then multiply by 6
 Atrial Fibrillation

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 Cardiac Impulse

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 QRS Axis
NW NE

SW SE
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 QRS Axis

 The QRS electrical (vector) axis can have 4

directions
 Normal Axis - when it is downward and to the left –
southeast quadrant – from -30 to +90 degrees
 Right Axis – when it is downward and to the right –
southwest quadrant – from +90 to 180 degrees
 Left Axis – when it is upward and to the left –
Northeast quadrant –from -30 to -90 degrees
 Indeterminate Axis – when it is upward & to the
right – Northwest quadrant – from -90 to +180
 Axis Determination

ALL UPRIGHT MEET LEAVE

NORMAL RIGHT LEFT

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 Axis Determination

Axis LI LII TIP

Normal Positive Positive Both Up

Right Negative Positive Meet

Left Positive Negative Leave

ERAD Negative Positive Meet

 What is the Axis ?

LEAD 1
aVR

LEAD 2 aVL

LEAD 3 aVF
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 ECG With Normal Axis

 Note the QRS voltages are positive and

upright in the leads - L1, L2, L3 and aVF
 L2, L3 and aVF tell that it is downward
 L1, aVL tell that it is to the left
 Downward and leftward is Normal Axis
 Normal QRS axis
 What is the Axis ?

LEAD 1

LEAD 2

LEAD 3
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 ECG With Right Axis

 Note the QRS voltages are positive and

upright in leads L2, L3
 Negative in Lead 1
 L2, L3 tell that it is downward
 L1 tells that it is not to the left but to right
 Downward and rightward is Right Axis
 See the Right –Meet criterion QRS in
L1 and L3 meet
 Right Axis Deviation - RAD
 What is the Axis ?

LEAD 1 aVR

LEAD 2 aVL

LEAD 3 aVF
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 ECG With Left Axis

 Note the QRS voltages are positive

and upright in leads L1and aVL
 Negative in L2, L3 and aVF
 L1, aVL tell that it is leftward
 L2, L3, and aVF tell that it is not
down ward - instead it is upward
 Upward and Leftward is Left Axis
 See the Left - Leave criterion QRS in
L1 and L3 leave each other
 Left Axis Deviation - LAD
 Atrial Waves

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 Right Atrial Enlargement

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 Right Atrial Enlargement

P wave voltage is 4 boxes or 4 mm

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 Right Atrial Enlargement
 Always examine Lead 2 for RAE
 Tall Peaked P Waves, Arrow head P waves
 Amplitude is 4 mm ( 0.4 mV) - abnormal
 DDX
 Pulmonary Hypertension, Mitral Stenosis
 Tricuspid Stenosis, Regurgitation
 Pulmonary Valvular Stenosis
 Pulmonary Embolism
 Atrial Septal Defect with L to R shunt
 Atrial Enlargements

RIGHT ATRIAL ENLARGEMENT LEFT ATRIAL ENLARGEMENT

 Left Atrial Enlargement

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 Left Atrial Enlargement

P wave duration is 4 boxes-0.04 x 4 = 0.16

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 Left Atrial Enlargement
 Always examine V 1 and Lead 1 for LAE
 Biphasic P Waves, Prolonged P waves
 P wave 0.16 sec, ↑ Downward component
 DDX
 Systemic Hypertension, MS and or MR
 Aortic Stenosis and Regurgitation
 Left ventricular hypertrophy with dysfunction
 Atrial Septal Defect with R to L shunt
 Ventricular Hypertrophy
 Ventricular Muscle Hypertrophy
 QRS voltages in V1 and V6, L 1
and aVL
 We may have to record to ½
standardization
 T wave changes opposite to QRS
direction
 Associated Axis shifts
 Associated Atrial hypertrophy

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 Normal ECG

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 Right Ventricular Hypertrophy

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 Right Ventricular Hypertrophy
 Tall R in V1 with R >> S, or R/S ratio > 1
 Deep S waves in V4, V5 and V6
 The DD is RVH, Posterior MI, Anti-clock
wise rotation of Heart
 Associated Right Axis Deviation, RAE
 Deep T inversions in V1, V2 and V3
 Is there any hypertrophy ?

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 Left Ventricular Hypertrophy

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 Causes and Criteria of LVH
Causes of LVH
 Pressure overload - Systemic Hypertension, Aortic Stenosis
 Volume overload - AR or MR - dilated cardiomyopathy
 VSD - cause both right & left ventricular volume overload
 Hypertrophic cardiomyopathy – No pressure or volume overload
Criteria of LVH
 High QRS voltages in limb leads
 S in V1 + R in V5 > 35 mm
 R in Lead I + S in Lead III > 25 mm or
 R in aVL > 11 mm or S V3 + R aVL > 24 ♂, > 20 ♀
 Deep symmetric T inversion in V4, V5 & V6
 QRS duration > 0.09 sec, Associated Left Axis Deviation, LAE
 What is in this ECG ?

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 Blood Supply of Heart
RCA

LCX

LAD

RCA

LCA
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 Blood Supply of Heart
Rt. and Lt. coronary arteries arise from aorta
They are 2.5 mm at origin, 0.5 mm at the end
Coronary arteries fill during diastole
 Heart has four surfaces
 Anterior surface – LAD, Left Circumflex
(LCx)
 Left lateral surface – LCx, partly LAD
 Inferior surface – RCA, LAD terminal portion
 Posterior surface – RCA, LCx branches
 Ischemia, Injury & Infarction
1. Ischemia produces ST segment
depression with or without T
Myocardial Ischemia inversion
2. Injury causes ST segment
elevation with or without loss of R
wave voltage
Myocardial Injury 3. Infarction causes deep Q waves
with loss of R wave voltage.

Myocardial Infarction

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 Ischemia and Infarction

TRANSMURAL Injury ST
Elevation

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 Serial ECG changes of MI

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 Blood Supply - MI - Leads

ANTERIOR LATERAL INFERIOR POSTERIOR

LAD LAD or LCx RCA RCA + LCx
V1, V2, V3, V4
66 V5, V6, L1, aVL L2, L3, aVF V1, V2 Mirror
 THIS IS NOT THE END

THANK YOU

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