ECG IN 100 STEPS

By
Dr. S. Aswini Kumar MD
WHAT IS ECG ?

1. ECG - Electro-cardio- gram

2. ECG - Graphical recording of electrical

activity of human heart

3. ECG - Does not always have a direct correlation with

mechanical activity of heart

 ECG READING

4. ECG reading - not a Bali-kera-mala

5. ECG reading - simple arithmetic + x .

.

6. ECG reading - requires logical sequence 1 2 3 4

ECG MACHINE

7. ECG Machine - Modified Galvanometer

8. Recording : produced by vertical movt. of heated Stylus

across paper moving horizontally

9. The principle :
+

Current Electrode +ve Deflection

+

Electrode Current

- ve Deflection
ECG PAPER

10. ECG paper - Black Background

- Heat sensitive
- Grey substance coated
- Erased by heated stylus

11. ECG paper - moves at a constant speed

- 25 mm per second
- can be increased to
- 50 mm per second

12. ECG paper - has horizontal and vertical lines

- I mm apart
- just as in a graph paper
THICKNESS OF LINES

13. Every 5th Horizontal line - Thicker

14. Every 5th Vertical line - Thicker

15. Every 25th Vertical line - Extended up

 DURATION

16. Measured in horizontal direction

1 small division (S.D.) = 1mm = 0.04 sec

17. 1 Big division (B.D.) = 5mm = 0.20 sec

18. 1 Extended division (E.D.) = 25 mm = 1 sec

- 2 SD = 0.08 sec
- 2 BD = 0.40 sec
- 2 ED = 2.00 sec
 AMPLITUDE

19. Measured in vertical direction

Principle : 1 mv of current produces a deflection of 10 sd

20. 1 small division (s.d) of height of wave

is = 0.1 millivolt. (ie, isd = 0.1 mv)

21. However the amplitude or voltage of defections

is expressed in mm of height or depth of waves

r r = 6mm

s s = 12mm
CONVENTIONAL 12 LEAD ECG

has three types of leads :

22. Standard Limb Leads I II III

23. Augmented Unipolar Limb Leads aVR aVL aVF

24. Unipolar chest leads V 1 V2 V3 V4 V5 V6

 STANDARD LIMB LEADS

25. Recorded by placing (+) electrodes

in Right Arm (RA), Left Arm (LA), Left Leg (LL)

26. Recording ECG with

- I +
RA - + LA + -300
- -
aVR aVL
II III
I 0o
+ +
RL LL
II 600
1200 III aVF 900
Earth

27. Positive electrodes placed in LA and LL why ?

Because current moving towards
a + electrodes produces a + deflection.
And that is what we want.
 AUGMENTED UNIPOLAR LIMB LEADS

28. Electrode made by connecting RA, LA&LL through 5000 Ohm resistance

RA LA

Neutral Electrode
named
CTW Central Terminal of Wilson
LL

29. Another electrode placed on RA, LA & LL (Named Exploring Electrode)

VR I + VL

VR. VL. VF
III II

+ VF

30. Disconnecting corresponding leads from CTW Augments current by 50 %

50 % aVR aVL aVF

 UNIPOLAR CHEST LEADS
31. Similar nutral electrode CTW

RA LA

CTW
LL

32. Similar exploring electrode placed over the chest at

4 Rt IC space near RSB - V1

4 Lt IC space near LSB - V2 V V
V3R 1 2 V
Between V2 and V4 - V3 3 V
V4R V
4 V
5 Lt IC space in MCL - V4 5 6
Same plane as V4 in AAL - V5
Same plane as V5 in MAL - V6 Apex AAL MAL

33. Rt sided chest leads obtained in place of V3 & V4 on Rt - V3R V4 R

NORMAL WAVE PATTERN

34. Each heart beat represented by

a regular sequence of wave patterns

35. These waves were named by Einthoven S

P Q R

as P.Q.R.S.T and U waves.

T U

36. For convenience these waves can be regrouped

as P wave
QRS complex,
T wave and P QRS T U

u wave
ELECTRICAL CORRELATION

37. P wave - Atrial depolarisation

P

38. QRS complex - Ventricular depolarisation

QRS

39. T wave - Ventricular repolarisation

T

Atrial repolarisation : some where within - PR- QRS

Too small to be seen.
ABOUT EACH WAVE
(Definition)

40. P wave - initial wave of heart beat complex

- upward and convex
P

41. Q wave - initial negative deflection

following a P wave
P Q

R
42. R wave - initial positive deflection
following a Q wave P
Q

R
or the - first positive
deflection of QRS complex
P
ABOUT EACH WAVE (Definition) (Contd.)
R

43. S wave - negative deflection

following R wave S

OR
OR - second negative deflection
QRS QS

44. T wave - upward convex wave R

following QRS
T

45. U wave - Small upward convex

wave following T wave T U
Not always seen.
 INTERVALS (Definition)

P Q
46. PR interval
measured from beginning of P
to beginning of initial wave of
QRS complex Q,R or QS.
P R P QS

47. QRS duration

measured from beginning of
initial wave of QRS complex to the
end of last wave of QRS complex Q S
Q S

48. RR interval R
P RR
from tallest point of R
to tallest point of next R
PP
SS
LEAD SELECTION

49. All leads need through scrutiny before final interpretation

50. For rhythm assessment - lead II and V1 ( P waves best seen)

51. For Axis assessment I II III a VR aVL aVF

-1500 -300

aVR aVL

I 0o

II 600
1200 III aVF 900
NOW START READING ECG IN 12 MAJOR STEPS

I. STANDARDISATION

52. Standardisation :
standard lead -
} standard against
which other leads are read

53. Normal Standardisation

1mv current - produces deflection of 10 sd.

.
. . Std: 1 mv = 10 sd.

54. Half standard ECG

Reduce deflections to 1/2

.
. . Std: 1 mv = 5 sd.
.
. . To calculate voltage X2
Always look for the label 1/2 V1 1/2 V2 etc.
II RATE
( Heart Rate)

55. Calculate the rate : 300/ No BD in RR ; III ly 2 BD - 150

Simple method 3 BD - 100
Look for R falling on Bid Divisions 4 BD - 75
If RR = 1 BD, HR = 300/mt. 5 BD - 60
6 BD - 50
56. For more accurate value
1500/ No of Small divisions
between adjacent RR

57. If rhythm is irregular

Count QRS within 6 sec of ECG paper
Multiply by 10 to get HR in 60 sec.
III RHYTHM

58. Rhythm - is said to be Normal Sinus Rhythm (NSR) if

- HR 60-100/mt. - Each P - QRS - T.

- PR interval -Normal - QRS duration - Normal

59. Normally slight variation during respiration

HR with inspiration with expiration

Sinus Arrhythmia
Exp Insp Exp
Criteria - Difference between shortest & widest RR
should be > 0.12 sec.

60. Abnormal Rhythm

- Arrhythmia
- Study lead II & V1 - (Rhythm Strip)
- P waves best seen in II & V1
 IV AXIS:

61. Axis - means electrical axis of heart

Lt
Normal

Rt axis deviation

Lt axis deviation

Rt

62. Determination of axis - Crude but simple method

study lead I and III alone
Net
-ve
63.
I

(N) (RAD)
III (LAD)
Diverge
Converge
V P WAVE

64. P Wave - normally upward convex

- normally inverted in aVR may be in V1

- abnormally inverted in Junctional Rhythm

- replaced by fibrillary waves in AF.

65. P wave - normally not > 2.5 mm in width

- if 3 mm or more in width & notched

- called P mitrale - Left Atrial Enlargement - Mitral Stenosis

66. P wave - normally not > 2.5 mm in height

- if 3 mm or more in height and peaked

- called P. pulmonale - Right Atrial Enlargement - Cor pulmonale

VI PR INTERVAL (PQ)

67. PR Interval - Measure from

Beginning of P wave to
P Q
Beginning of QRS complex
Normal Range 0.12 - 0.20 sec ie 3-5 sd.

68. PR Interval - Prolonged

- More than 0.20 sec.
- I0 Heart Block as in
- Rheumatic Carditis. P Q

69. PR Interval - Shorter

- less than 0.12 seconds
P
- Wolff Parkinson White Syndrome
Q
- Junctional Rhythm
VII Q WAVE

70. Normally. No significant Q in any lead.

may be Small q in III, II, V5 V6

71. Q present & more than .04 sec ie, 1 sd. in width

It is is significant or pathological Q .04 sec.

It indicates an Electrical Window in myocardium

due to Myocardial Infarction ( AMI).

72. Before saying a Q as pathological make doubly sure

Because you are diagnosing

Transmural Myocardial Infarction

In that case Q will be present in more than one lead

representing the particular wall of heart.

VIII QRS DURATION

73. QRS Duration - measured from

- initial wave of QRS
- to the last wave of QRS
- Normal < 2 sd. 0.08 sec.

74. QRS Duration - Prolonged

R
r
- > 2 sd
- ventricular Conduction Defect:
- RBBB or LBBB or VCD

75. QRS Patterns - Numerous

- Vary from lead to lead
- Person to person
IX ST SEGMENT

76. ST Segment - From End of S wave ( J point)

- To beginning of T. wave
J

Normally - ST same plane as baseline or Isoelectric line

IEL

77. ST Segment Elevation ( J point elevation of 1mm or more from baseline )

in comparison
to Isoelectric line
Coving ST

Q S
Pericarditis (Concave) myocardial injury in AMI (Convex)

(Square wave)
78. ST Segment Depression
(Slanting)

Angina Pectoris Ventricular Strain pattern in LVH or RVH

X . T WAVE

79. T wave normally upright in all leads except R T

in AVR and some times in V1

N Peaked Flat Symmetrically Assymetrically Biphasic

Inverted Inverted

R T
80. T wave tall and peaked
Hyperacute phase of Infarction, Hyperkalemia

81. T wave Symmetrically inverted T

R
in Ischaemia of Myocardium

R
T wave Asymmetrically inverted
In strain pattern of LVH ( V5 V6) & RVH ( V1)
XI R/S IN V1

82. Amplitude of R in V1 ie R/S ratio in V1 r 6

Amplitude of S in V1
Normally R in V1 is smaller than S in V1 s 13
Therefore R/s Ratio in V1 is <1

83. If R/S ratio in V1 is > 1 ie R is > S in V1

Voltage Criteria for Right ventricular Hypertrophy ( RVH)
Other Criteria for RVH:
QR pattern in V1,ST dep. & T inv in V1, Persistent Deep S in V5 or V6

84. Other conditions where R> S in V1

True Posterior Wall Infarction R’

r
Right Bundle Branch Block. s
XII SV1 + RV6

R 15
85. Add Amplitude of S wave in V1 +
+
R wave in V6 or V5 whichever is taller
V1 10 V6
Normal < 35mm

25
86. If SV1 + RV6 is > 35 mm
V1
in a person above 35 yrs
It forms the voltage criteria for +
20
Left Vetricular Hypertrophy (LVH)
V6

87. Other criteria for LVH are : RV5 or RV6 > 26 mm

R1 + SIII > 26mm ST depression T inversion V5 V6
 STAGE OF EVOLUTION OF IHD

88.

S T Angina Pectoris
ST depression Disappears
during chest pain after chest pain

89.
T
Hyper Acute
Phase of Infarction
Ventricluar ST Tall peaked
Activation time Elevation T wave

90.

Acute
ST T
Q myocardial Infarction

Path Q ST Elevation T Inversion

 WALL OF INFARCTION

91.
Inferior
Wall
Infarction

92.
Anterior
Wall
Infarction

93.
Lateral
Wall
Infarction
AGE OF INTERACT

94. If all changes of Acute MI ( ST ,T , path Q) ST

are present simultaneously: Recent Infarction Q

T

95. If ST becomes Isoelectric

Q T
but T and Q changes persist: Healing Infarct.

96. If only Q or QS persist

Q QS
long after chest pain : Old Infarct .
MISCELLANEOUS CONDITIONS

97. Acute Pericarditis : ST elevation in all leads

Concordant ST elevation

98. Hyperkalemia : Tall peaked T Prolonged PR Flat P

Wide QRS Conduction abnormalities

99. Hypokalemia : Flat or inverted T, Depressed ST

Pathological u wave
100. FINAL IMPRESSION - Eg: NORMAL ECG

I. Standardisation 1 mv = 10 sd
II. Heart Rate : 75/mt
III. Rhythm : NSR
IV. Axis : Normal ECG dt 1-11-99
V. P : Normal Normal Sinus Rhythm
VI. PR : 0.16 sec No evidence of IHD
VII. Q wave : Nil pathological No evidence of chamber
VIII. QRS duration : 0. 06 sec enlargement.
IX. ST segment : Isoelectric Imp: Normal ECG
X. T wave : in all leads
XI. R/S V1 : 3 / 6 mm

XII. SV1 + RV6 : 30 mm

100. FINAL IMPRESSION - Eg : ABNORMAL ECG

I. Standardisation : 1 mv = 10 sd
II. Heart Rate : 54/mt
III. Rhythm : Sinus Bradycardia ECG dt 2-1-99
IV. Axis : Left Axis Deviation Sinus Bradycardia
I0 Heart Block
V. P : Wide and notched Acute Inferior Wall
Myocardial Infarction
VI. PR : 0.28 sec
VII. Q wave : path Q in II III aVF Lt Atrial Enlargement
VIII. QRS duration : 0.06 in V1 Lt Ventricular Hypertrophy
IX. ST segment : Elevation II III aVF with strain
Slanting ST in V5 V6
X. T wave : Inverted II III aVF V5 V6
XI. R/S V1 : 3/20 MM
XII. SV1 + RV6 : 20+26 = 46 mm
Thank You
And…
We thank the author for the valuable
contribution!