ECG

INTERPRETATION
SDK
 ROAD MAP
• Basic Concept
• ECG Lead and Leads Placement
• ECG Waves & their Components
• Points to be observe(RRAHIM)
 AIMS
• The aims of this lecture are.

• To make students certain in their interpretation of

normal electrocardiogram (ECG) tracings.

• To make students confident in their interpretation of ECG

tracings with common clinical conditions that leads to

ECG abnormalities.
 OBJECTIVES
• By the end of this Lecture, students should be able
to

• Identify and list the characteristics of a normal ECG.

• Interpret and communicate the appearance of

normal ECG.

• List and explain common clinical abnormalities that

leads to abnormal ECG recordings.
 INTRODUCTION

• An electrocardiogram (ECG / EKG) is an

electrical recording of the heart.

• It is used in the investigation of heart disease.

QUICK REVIEW
QUICK REVIEW

• SA node
• Intra-atrial pathways
• AV node
• Bundle of His
• Left and Right bundle
branches
– left anterior fascicle
– left posterior fascicle
• Purkinje fibers
 CORONARIES SUPPLIES
LCA
RCA
ØSeptal wall of LV
ØRight ventricle
ØAnterior wall of LV
ØInferior wall of LV

ØPosterior wall of LV (75%) ØLateral wall of LV

ØSA node (60%) ØPosterior wall of LV (10%)

ØAV node (>80%)
 ECG

• Abnormalities in the normal electrophysiological

conduction system may occur with heart disease,

and are reflected in the ECG pattern

Conditions where ECG can be recommended
• Palpitations or Irregular heart rate
• Chest pain
• Fast heart rates (> 100 bpm)
• Slow heart rates (< 60 bpm)
• Collapse or syncope.
• Chest trauma
• Pre-operative assessment of at-risk patients, for
example, the elderly.
 ECG MACHINE
• ECG machine serves as a voltmeter
– measures the flow of electricity

• It performs this action by the help of leads, that

are placed on the limbs and anterior chest wall.

• Leads are of two types unipolar & bipolar leads

and the total number of leads are 12.
 ECG MACHINE
• All ECG machines run at a standard rate (25 mm per
second) and use paper with standard-sized squares.
O.O Us
• Each small square (1 mm) represents 40 ms (0.04
seconds),

•
oils
While each large square (5 mm) represents 200 ms (0.2
seconds).

• On the y axis, each small square represents 0.1 mv.

x Time
Volt mu M 90.5mV
y

ECG MACHINE
 The ECG Paper
• Horizontally
– One small box is 0.04 s
– One large box is 0.20 s
• Vertically
– One large box is 0.5 mV
 The ECG Paper
• Horizontally
– One small box is 0.04 s
– One large box is 0.20 s
• Vertically
– One large box is 0.5 mV
0.04 Sec

0.2 Sec
1 Sec 1 Sec

6 Second Strip
 The ECG Paper (cont)
3 sec 3 sec

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

• Vertical line.
• This helps when calculating the heart rate.
 Paper speed and standardization
Ø Recordings are usually made at 25 mm per second
(mm/s).
Ø A standard deflection (a box that looks like half a
rectangle) should be inscribed at the beginning or
end of the ECG.
Ø The ECG is usually standardised so that the
amplitude of a 1 millivolt impulse causes a
deflection of 10 mm
Ø An increased amplitude (or voltage) usually
indicates increased muscle mass of the heart.

mm
is
 ECG Complex
An ECG complex is comprised of
 ECG Complex
An ECG complex is comprised of
 An ECG complex is comprised of
• A, P wave representing atrial depolarization.
• The presence of P waves indicates ‘sinus rhythm’, the
heart’s normal rhythm.
• A, PR interval, representing conduction through the AV
node and the bundle of His.
• This should be between 120–200 ms, or less than 5 mm on
the ECG paper i.e 3 to 5 small squares.
 An ECG complex is comprised of
• The QRS complex, representing depolarisation of the ventricles.
– A Q wave is any negative deflection at the beginning of a QRS complex.
– Small Q waves in some leads may be normal.
– Large Q waves (> 2 mm) may be abnormal.
– An R wave is the first positive deflection, and an S wave is the negative
deflection immediately following an R wave.
– The QRS complex should be less than [0.12 sec or 120 ms, (3 mm)]
i.e 3 smallest squares.

• The ST segment, between the end of the S wave and start of the T wave.
– The ST segment should be ‘isoelectric’, that is, at the same level as the part
between the T wave and the next P wave(TP Segment).

• A, T wave, representing repolarization of the ventricles.

An ECG complex is comprised of
What is PR & QRS duration in Seconds
PR= 4 Small squares 0.04x4=0.16
QRS=2 Small Squares 0.04X2=0.08
What is the Measurement of Height and Depth
from Baseline
What is the Measurement of Height and Depth
from Baseline
 ECG LEADS
Leads are electrodes which measure the difference
in electrical potential between either:
1. Two different points on the body (bipolar leads)

2. One point on the body and a virtual reference

point with zero electrical potential, located in the
center of the heart (unipolar leads).
 LEADS
• There are 12 leads
• Six are referred to as ‘Limb leads’.
– Standard Limb leads I, II, III and
– Augmented Limb Leads such as aVR, aVL and aVF.

• The other six are referred to as ‘chest’ or ‘precordial’

leads. These leads are V1, V2, V3, V4, V5 and V6.

• Out of 12 leads 3 are Bipolar (having two clear poles + and –

whereas other 9 are unipolar(having clear + pole and a
common – pole)
LEADS
Bipolar Leads/ standard limb Leads
• 1 positive and 1 negative
electrode
– RA always negative
– LL always positive
• Traditional limb leads are
examples of these
– Lead I
– Lead II
– Lead III
• View from a vertical plane
Unipolar Leads/Augmented Limb Leads
• 1 positive electrode & 1
negative “reference point”
– calculated by using
summation of 2 negative
leads
• Augmented Limb Leads
– aVR, aVF, aVL
– view from a vertical plane
Unipolar Leads/Augmented Limb Leads
Unipolar Leads/Precordial or Chest Leads
Precordial or Chest Leads .V1-V6. view from a horizontal
plane
Unipolar Leads/Precordial or Chest Leads
 Summary of Leads
Limb Leads Chest Leads
(Precordial Leads)

Bipolar I, II, III -------------

(standard limb leads)
3

Unipolar aVR, aVL, aVF V1-V6

(augmented limb leads)
9
Arrangement of Leads on the ECG
Normal ECG
Progression of R waves from V1 to V6
Progression of R waves from V1 to V6
 In normal ECG lead V1,
The QRS complex is mainly
A. Positive B. Negative
B. Negative
C. Equivocal

In leads from V1 to V6 the positive electrode is

placed on
A. On the chest wall A. On the chest wall
B. On the arms only
C. On the arms & legs
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
 Inferior Wall

• II, III, aVF

– View from Left Leg Å
– inferior wall of left ventricle
 Inferior Wall

• Posterior View
– portion resting on diaphragm
– ST elevation suspect inferior
injury

Inferior Wall
 Lateral Wall
• I and aVL
– View from Left Arm Å
– lateral wall of left
ventricle
 Lateral Wall
• V5 and V6
– Left lateral chest
– lateral wall of left ventricle
 Lateral Wall

• I, aVL, V5, V6
– ST elevation suspect
lateral wall injury

Lateral Wall
 Anterior Wall
Ø Anterior wall infarctions may be subdivided into
Ø Strictly anterior:
Ø Strictly anterior infarction causes diagnostic changes in V 3
and V4.
Ø Anteroseptal:
Ø Anteroseptal infarction results in loss of the normal small
septal R waves in leads V1 and V2 as well as diagnostic
changes in leads V3 and V4.
Ø Anterolateral infarctions:
Ø Anterolateral infarction results in changes in more laterally
situated chest leads (V5, V6) and the left lateral limb leads (I,
aVL), as well as the anterior leads V3 and V4.
 Anterior Wall
• V3, V4
– Left anterior chest
– Å electrode on anterior chest
 Anterior Wall
• V3, V4; ST segment elevation suspect anterior
wall injury

I aVR V1 V4

II aVL V2 V5
III aVF V3 V6
 Septal Wall
• V1, V2
– Along sternal borders
– Look through right ventricle & see
septal wall
 Septal Wall
• V1, V2. septum is left ventricular tissue
Thank you