BASIC ECG READING

Elnah A. Gulliab, M.D.

Internal Medicine
 Willem Einthoven receives Nobel Prize

The EKG is not only the oldest but, in fact, over 100 years
after its introduction, continues as the most commonly used
cardiovascular laboratory procedure.
 What is an ECG?
 Is a graphic recording of electric potentials
generated by the heart.
 Immediately available, non invasive, inexpensive
and highly versatile test
 It is use to detect arrythmias, conduction
disturbances, myocardial ischemia, other related
life threatening metabolic disturbances.
 Normal Impulse Conduction

Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
 Impulse conduction and ECG

Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
Limb Leads
Precordial Chest Leads
Precordial Leads
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
 The ECG Paper

Horizontallybox - 0.04
One small s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
 ECG paper

3 sec 3 sec

 Every 3 seconds (15 large boxes) is marked by a

vertical line.
 This helps when calculating the heart rate.
ECG waveforms and Intervals

P wave - Atrial

depolarization
QRS - Ventricular
depolarization

T wave - Ventricular
repolarization
ECG waveforms and Intervals
 ECG waveforms and Intervals
 PR interval
 beginning of P wave to the beginning of the next QRS
 Normally, < .2 seconds or one large box.
 If it is > .2 seconds, it is a first degree block
 ECG waveforms and Intervals
 QRS interval
 beginning of Q to the end of the S wave)
 should be < .12 seconds (< 3 small boxes)
 If QRS is > .12, check for bundle branch block.
 ECG waveforms and Intervals
 QT interval
 beginning of QRS to end of T wave
 should be less than half of the preceding RR interval -
this varies with the rate
 For normal rates, QT < .4 seconds (2 large boxes).
 ECG Interpretation
 Rate / Rhythm
 Axis
 Atrial Abnormality or Hypertrophy
 Heart Blocks
 Ischemia or Infarction
 Ventricular Hypertrophy
 Misc.
 (Non specific ST wave changes,Persistent
posterobasal forces)
 I. RATE AND RHYTHM

 Step 1: Calculate rate.

 Step 2: Determine regularity.
 Step 3: Assess the P waves.
 Step 4: Determine PR interval.
 Step 5: Determine QRS duration.
 Step 1. Calculate Rate

3 sec 3 sec

 Option 1
OPTION #1
 Count the # of R waves in a 6 second rhythm strip,
then multiply by 10.
INTERPRETATION?
9 x 10 = 90 bpm
 Step 1. Calculate Rate

R wave

 Option 2
 Find a R wave that lands on a bold line.
 Count the # of large boxes to the next R wave. If the
second R wave is 1 large box away the rate is 300, 2
boxes - 150, 3 boxes - 100, 4 boxes - 75, etc. (cont)
 Step 1: Calculate Rate
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0

 Option 2 (cont)
 Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50

Interpretation? Approx. 1 box less than 100 = 95

bpm
 Step 2: Determine Regularity

R R R R

Look at the R-R distances - using a caliper or

markings on a pen or paper
Regular (are they equidistant apart)?
 Step 3: Assess the P waves

 Look at the p waves:

cycle length do not vary by 10%
rate is 60-100/minsame contour in same lead?
Upright in I, II, aVF & left precordial leads
followed by QRST?
Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)

Interpretation? .12 seconds

 Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)

Interpretation? 0.08 seconds

 Rhythm / Rate Summary

Rate 90-95 bpm

Regularity regular
P waves normal
PR interval 0.12 s
QRS duration 0.08 s
Interpretation? Normal Sinus Rhythm
 II. AXIS

Normal axis -30 to +90

Left axis deviation -30 to -90

Right axis deviation +90 to +/- 180

indeterminate -90 to +/- 180

What is the axis?
What is the axis?
 III. ATRIAL
ABNORMALITY/HYPERTROPHY

Right atrial hypertrophy

Peaked P wave in lead II >
2.5mm amplitude. V1 has
increase in the initial positive
deflection.

Left atrial hypertrophy

Notched wide (> 3mm) P wave
in lead II. V1 has increase in the
terminal negative deflection.
IV. BUNDLE BRANCH BLOCKS
 Complete bundle branch block - QRS interval is
>120ms in duration
 Incomplete bundle branch blocks -QRS interval is
between 100-120 ms in duration
 May occur w/o structural abnormality (rbbb is
more common than lbbb)
 T wave is typically opposite in polarity to the last
deflection of QRS
 Right Bundle Branch Block
 Terminal QRS vector is oriented to the right and
anteriorly
 Lead V1 = rSR ; Lead V6 = qRS
 Left Bundle Branch Block
 Major QRS vector is directed to the left and
posteriorly
 Lead V1 = wide QRS ; Lead V6 = positive R
complex
What is your interpreatation?
V. ISCHEMIA / INFARCTION
ISCHEMIA
INFARCTION
 VI. VENTRICULAR
HYPERTROPHY
 Left Ventricular Hypertrophy
 V1/V2 – S wave plus V5/V6 R wave = >35mm
 (SV1 + RV5 or RV6)
 AVL = > 12mm R wave
 Right Ventricular Hypertrophy
 R wave is > S wave in V1
 R wave decrease from V1 to V6
Common ECG abnormalities
 Sinus Bradycardia

Regularly occurring PQRST

Rate < 60 / min
 Sinus Tachycardia

Regularly occurring PQRST

Rate > 100 / min
 Atrial Fibrillation

Irregular RR interval
No discernible P waves
 Premature Ventricular
Contractions

Prematurely occurring complex.

Wide, bizarre looking QRS complex.
Usually no preceding P wave.
T wave opposite in deflection to the QRS
complex.
Complete compensatory pause following
every premature beat.
 Ventricular Tachycardia
 At least 3 consecutive PVC’s
 Rapid, bizarre, wide QRS complexes
(> 0.10 sec)
 No P wave (ventricular impulse origin)
 Ventricular Fibrillation
 Associated with coarse or fine chaotic
undulations of the ECG baseline
 No P wave
 No true QRS complexes
 Indeterminate rate
ECG reading exercise
What is your interpretation?
What is your interpretation?
What is your interpretation?
What is your interpretation?
What is your interpretation?
What is your interpretation?
What is your interpretation?
What is your interpretation?
What is your interpretation?
What is your interpretation?