Normal ECG Interpretation

Mohammed Mousa, MD.

Lecturer of cardiology , EP specialist
Cardiology Depatrtment, Ain Shams University
General rules:

1. ECG stands for Electro Cardio Graphy, so it

represents electric activity of the heart i.e. not
structure or mechanics.
2. Normal ECG does not mean normal individual.
3. ECG has 12 leads which represent 12 cameras
for electric activity of the heart.
4. Always be systematic to miss nothing
Is this ECG is a normal ECG ?
Lead positioning:
The paper and the graph
Systematic analysis of ECG:
Name and date
Standardization
1- Name and date:

• The same patient and of a known date.

2- Standardization
• Normal speed: 25 mm/sec
• Normal size 10 mm/1 mv.
2- Standardization
Specific causes of low voltage
include:
• Pericardial effusion
• Pleural effusion
• Obesity
• Emphysema
• Pneumothorax
• Constrictive pericarditidis
• Previous massive MI
• End-stage dilated cardiomyopathy
• Infiltrative myocardial diseases — i.e. restrictive cardiomyopathy
 due to amyloidosis, sarcoidosis, haemochromatosis
• Scleroderma
• Myxoedema
3- Rhythm
• Regular or not ?
Equal RR intervals.
• Sinus or not ?
Each QRS complex is preceded by a single P wave with the
same size and morphology +ve in lead II and –ve in lead
aVR.
3- Rhythm
4- Rate
• Normal adult heart rate ranges from 60 to 100 beat per
minute.
• If regular
heart rate =
300/ no. of large squares between 2 QRS complexes
Or 1500/ no. of small squares between 2 QRS complexes

• In case of irregular heart rate

heart rate =10 x no. of QRS complexes in 6 seconds (30 large
squares) .
4- Rate
4- Rate:
5- Axis
• The mean QRS axis is
determined by the anatomic
position of the heart and the
direction in which the stimulus
spreads through the ventricles
(i.e. the direction of
ventricular depolarization)
• An axis of -30 degree or more
is described as left axis
deviation, and one that is +90
degree or more is termed right
axis deviation.
5- Axis
5- Axis
Causes of LAD:
• Causes of LAD:
• Left anterior hemiblock.
• Inferior myocardial infarction.
• Pacemaker.
• Emphysema.
• Hyperkalaemia.
• Wolff-Parkinson-White (WPW) syndrome.
• Ostium primum atrial septal defect.
• Left ventricular hypertrophy
5- Axis
Causes of RAD
• Normal finding in children and tall thin adults.
• Right ventricular hypertrophy.
• Chronic lung disease even without 
pulmonary hypertension.
• Anterolateral MI.
• Left posterior hemiblock.
• Pulmonary embolism.
• WPW syndrome.
• Ostium secundum atrial septal defect.
• Ventricular septal defect.
6- P wave
• It represents atrial
depolarization.
• Normal size 2.5 X 2.5
mm.
• Normally seen
+ve in lead II
-ve in aVR
Biphasic in lead V1
7- PR interval
• The PR interval
represents the time from
onset of atrial activation
to onset of ventricular
activation.
• It is measured from the
BEGINNING of P wave
till the Beginning of QRS
complex
• Normally it ranges from 3
to 5 small squares.
QRS naming
8- QRS width
• Normally it is less
than(2.5 small squares).
• If the spread of a
stimulus through the
ventricles is slowed (i.e.
interventricular
conduction delay) for
example by bundle
branch block , the QRS
width is prolonged.
9- QRS voltage
• It is observed in chest leads.
• S in V1 + R in V6
< 35 mm ( 7 )
• R in V1 is < S in V1
Electrical alternans
10- Abnormal Q waves
• Normal Q waves:
1- in lead a VR.
2- Small ( less than 1mm)
3- in single lead.
Some causes of pathological Q
waves
• Myocardial infarction
• Cardiomyopathies — Hypertrophic (HOCM),
infiltrative myocardial disease
• Rotation of the heart — Extreme clockwise or
counter-clockwise rotation
• Lead placement errors — e.g. upper limb leads
placed on lower limbs
• LBBB
11- R wave progression:
• Normally R wave is small in V 1 and enlarges by
transition to V6.
• By lead V3 or V4 the R wave is larger than S.
Tall R in V1
Causes of poor R wave progression
1. Old anterior myocardial infarction
2. Lead misplacement (frequently in obese
women)
3. Left bundle branch block or left anterior
fascicular block
4. Left ventricular hypertrophy
5. WPW syndrome
6. Dextrocardia
7. Tension  pneumothorax with mediastinal shift
8. Congenital heart disease
12- ST segment
• Normally it is isoelectric in all leads
13- T waves
14. QT interval
14. QT interval

• QT = 16 X40 =640 msec

QT = 8 X40 = 320 msec

• cQT= 640 / √1 = 640 msec
Long QT
 First line treatment in ER….
• Hypomagnesimia: 1-2 g slow IV (diluted in
50-100 mL Dextrose 5%) over 20-60 minutes,
then 0.5-1 g/hr IV.

• Hypocalcemia: 10 ml of calcim gluconate

10% very slowly over 5-10 min

• Hypokalemia: 40 mmol K + 1 L saline 0.9% at

a rate of 10 mmol/h preferably in a large vein
Normal ECG in athlete (isolated LVH)
 Abnormal ECG in athlete ( LVH+ strain
+LAE+LAD)
THANK YOU
Name and date
Standardization
Name and date
Standardization