PHYSIOLOGY

1.6 ECG INTERPRETATION

REI KRISTOFFER CUARESMA UBINA, MD | OCTOBER 11, 2020

→ Every 3 seconds (15 large boxes) is marked by a vertical line

OUTLINE
→ Recording 25mm/sec
I. Introduction A. Rate
A. Electrocardiogram B. Rhythm Analysis
B. Pacemakers of the Heart C. Axis
C. Normal Impuls Conduction D. Hypertrophy
II. The ECG Paper E. Infarction/Ischemia
III. ECG Interpretation F. Rhythm Disorders
• Normal Values
LEGENDS → P wave → ST segment
Remember Lecturer Book Presentation <0.11 sec <0.2 sec
0.5 – 2.5 mm → T wave
→ PR interval <2/3 of QRS
I. INTRODUCTION 0.12-0.2 sec amplitude
A. Electrocardiogram → QRS complex → U wave
• Recording and analysis of the electrical activity of the heart 0.04 – 0.12 sec < 2 mm
• The recording device is made to record a positive (upright) deflection > 5 mm in limb leads
whenever depolarization moves towards the positive electrodes (away from > 8-10 in chest leads
the negative electrode) or repolarization moves away from the positive
electrode (towards the negative electrode)

B. Pacemakers of the Heart

• PACEMAKERS OF THE HEART
• SA Node - Dominant pacemaker with an intrinsic rate of 60 – 100 bpm
• AV Node - Back-up pacemaker with an intrinsic rate of 40 - 60 bpm
•Ventricular cells - Back-up pacemaker with an intrinsic rate of 20 – 45
bpm

III. ECG INTERPRETAION

• Rate
• Rhythm
• Axis
• Hypertrophy
• Infarct / Ischemia
• Miscellaneous findings
→ Conduction abnormalities / Blocks
→ Electrolyte changes

A. Rate
• Normal Heart Rate
→ Newborns : 110-150
→ 2 years : 85-125
→ 4 years : 75-115
C. Normal Impulse Conduction → 6 years : 65-100
Sinoatrial node → Adults : 60-100

AV node

Bundle of His

Bundle Branches
• To Count Heart Rate in ECG

• Option 1
Purkinje fibers
→ Count the # of R waves in a 6 second rhythm strip, then multiply by
10.
→ Used for irregular rhythms
• Option 2
→ Count the number of small boxes R-R
II. THE ECG PAPER Use the formula
• THE ECG PAPER 1500/small boxes
→ Horizontally → Count the number of large boxes R-R
One small box - 0.04 s Use the formula
One large box - 0.20 s 300/big boxes
→ Vertically
One large box – 0.5 mV • Atrial Rate
→ P-P
• Ventricular Rate
→ R-R
→ Usually the P-P and R-R interval is the same for normal ECG

TRANS TALOSIG, DIEGO, VILLON, VICENTE, RENIEDO, MATIAS, DE LA CRUZ, GERVACIO 1 of 7

1.6 ECG Interpretation

B. Rhythm Analysis Step 6: Compare the P-P and R-R intervals

• Step 1: Determine regularity.

• Step 2: Assess the P waves.
• Step 3: Determine PR interval.
• Step 4: Determine QRS duration.
• Step 5: Determine QT interval C. Axis
• Step 6: Compare the P-P and R-R intervals

Step 1: Determine regularity

→ Look at the R-R distances Use a caliper or markings on a pen or paper

Step 2: Assess the P waves

→ Are there P waves?
First wave in the cardiac cycle
Upright in all leads except aVR (inverted)
Smooth and Rounded • Determining the Axis
1 P for every QRS
Absent in AF, junctional rhythm, ventricular rhythm

Step 3: Determine PR interval

→ Normal: 0.12 - 0.20 seconds (3 - 5 boxes)
If >0.20 seconds: 1st or 2nd deg AV block
If <0.12 seconds: WPW Syndromes

Step 4: Determine QRS duration

→ Normal: 0.04 - 0.12 seconds (1 - 3 boxes)
→ Wide QRS: IVCD, complete LBBB and RBBB, VT, aberrantly conducted
PAC, PVC

Step 5: Determine QT interval

→ The duration of the QT interval is
proportionate to the heart rate.
→ The faster the heart beats, the faster
the ventricles repolarize so the
shorter the QT interval.
→ Therefore, what is a “normal” QT
varies with the heart rate.
→ Corrected QT (QTc):
QTc = QTa / square root of RR
interval (sec) • If negative in I and
Qta = 0..52 seconds positive in aVF
(Right axis
deviation) → Add
Normal QT Interval Value 90 to the result
Males <0.47

Females <0.48

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1.6 ECG Interpretation

• DIFFERENTIALS FOR RIGHT AXIS DEVIATION (RAD) • Biatrial Enlargement

→ Normal variant in tall • LEAD V1 → large biphasic P with initial component > 2 mm and
thin individuals terminal negative component > 1 mm deep and wide
→ Right ventricular • ANY LEAD → amplitude > 2.5 mm with duration > 0.12 s
hypertrophy
→ Lateral wall infarction
→ Pulmonary embolism
→ Left posterior fascicular
block
→ WPW syndrome
→ ASD secundum

• DIFFERENTIALS FOR LEFT AXIS DEVIATION (LAD)

→ Normal variant in short fat individuals
→ Left ventricular hypertrophy
→ Inferior wall infarction
→ Left bundle branch block
• LEFT VENTRICULAR HYPERTROPHY
→ Left anterior fascicular block
→ WPW syndrome
→ ASD primum

D. Hypertrophy
• Left Atrial Enlargement
→ Increased P terminal forces in V1 > 0.04 sec wide and 1 mm tall
→ Notched P wave in lead II, P wave duration >0.12 sec

→ Sokolow Lyon Criteria

S in V1 + R in V5-V6 >35mm
RinavL>12
R in avF > 20
R in I + S in III > 25 S in V1 > 24
→ Cornell Voltage Criteria
Male: S in V3 + R in avL >28
Female:SinV3+RinavL >20

• DIFFERENTIALS FOR LVH

→ Hypertension
→ Aortic stenosis
→ Aortic insufficiency
→ Cardiomyopathy
→ Initial compensating mechanism in obesity, smoking, dyslipidemia,
obstructive sleep apnea, DM
→
• RIGHT VENTRICULAR HYPERTROPHY
• Right Atrial Enlargement
→ Peaked P waves in leads II, III, avF > 2.5 mm
→ Increased in the initial P wave in V1 > 0.08 sec

• R/S ratio in V6 <1

• RS ratio in V1 >1
• Right axis Deviation
• ST depression and T wave inversion in V1 to V3

→ RAD > 110 with any of the following

1) R > S wave in V1
2) Deep S in V5 – V6 (R:S ratio < 1)
3) ST depression and T inversion V1-V3

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1.6 ECG Interpretation

• DIFFERENTIALS FOR RVH • ST SEGMENT ELEVATION

→ Tall R in V1 → Significant if: > 2 mm in chest
Normal in young adults and children leads
COPD → 1 mm in limb leads
RBBB
True posterior infarction
WPW syndrome

• BIVENTRICULAR HYPERTROPHY
→ Meets 1 or more of the criteria for LVH and RVH
→ Chest leads show signs of LVH but axis is > 90

• DIFFERENTIALS FOR ST SEGMENT ELEVATION

E. Infarction/Ischemia
AMI
• ST Depression
Acute
→ May also indicate pericarditis
ischemia or Ventricular aneurysm
subendocardial Severe LV wall hypokinesia
infarction Early repolarization changes
→ Horizontal ST Prinzmetal angina
depression is more
specific than down- • Q WAVES
sloping ST depression → Marker of myocardial necrosis
→ Significant if > 1mm in → NOT significant if
any leads from J- point
in AVR
Differentials
in lead III or V1 alone
− digitalis effect in V1-V3 if associated with LBBB
− hypokalemia → Pathologic if
− in V5-V6 in LVH with strain > 0.04 seconds duration
− in V1-V2 in RVH with strain a > 25% of the R wave amplitude
− LBBB or RBBB
− NSTEMI

• Inverted T Waves
→ Indicates myocardial
ischemia (stenosis in
coronary arteries) or
previous MI – Wellen’s T
waves
→ Significant T wave
inversion is > 5mm
→ May be transient in nature

• ECG CRITERIA FOR MYOCARDIAL INFARCTION

→ ST Elevation
≥2mm in ≥ 2 contiguous chest leads
≥1mm in ≥ 2 contiguous limb leads
→ Pathologic Q waves ≥ 1⁄4 of R deflection

• SERIAL ECG CHANGES IN MI

• LOCALIZATION OF THE INFARCT

Leads Involved Corresponding Areas

II, III, AVF Inferior wall
I & AVL High lateral wall
V1, V2 Septal wall
V3, V4 Anterior wall
V5, V6 Lateral wall

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1.6 ECG Interpretation

• U WAVE • ATRIAL FLUTTER

→ Best seen at leads V2 – → Atrial rate of 220 to 350/minute
V3 o CRITERIA
Absent p waves
Biphasic saw-toothed flutter waves, fairly regular
F waves vary in amplitude, morphology and intervals
R-R intervals are irregularly irregular
Ventricular rate usually ranges from 90-170
QRS complexes are narrow unless AV conduction is abnormal
Hypothesized to be due to multiple wavelets in the atrium
competing for the conduction to the AV node

F. Rhythm Disorders
• BASIC RHYTHMS
Benign Ectopic Rhythms
− PACs
− PVCs
Slow Rhythms
− Sinus Bradycardia
− Heart Blocks • ESCAPE RHYTHM/BEAT
− Junctional Rhythm Atrial
− Idoventricular Rhythm − Sinus arrest causing
− Pulseless Electrical Acivtity escape rhythm
Fast Rhythms − With p’ waves
− Sinus Tachycardia Junctional
− Supraventricular Tachycardia − No P waves
− Atrial fibrillation − 40-60/min inherent
− Atrial flutter rate
− Ventricular Tachycardia − Produces a series of
− Ventricular Fibrillation lone QRS complexes
Ventricular
• ATRIAL ARRHYTHMIAS - may occur in complete
1. Atrial fibrillation AV block
2. Atrial flutter
3. Wandering Pacemaker • SINOATRIAL BLOCK
4. Multifocal Atrial tachycardia → Complete failure of a P wave to appear
→ A cycle appears which is twice the anticipated P-P interval
• ATRIAL FIBRILLATION → Transient doubling of P-P interval
→ Most common sustained arrhythmia associated with increased → SA exit block
CV mortality and morbidity No visible P-QRST complex for more than 1 cycle
→ Prevalence increasing with age, doubling with each successive Normal P wave morphology, before and after the pause
decade, 70% in ages 65-85 Pause is preceded and followed by a normal P-P cycle
→ Multiplier effect on risk P-P interval is a multiple of the normal P-P interval
− 3-5x stroke
− 3xCHF
− 1.5-3x death
→ Associated with heart disease but ~30% are without underlying
heart disease
→ Rapid and irregular atrial fibrillatory waves at a rate of 350 to
600/minute

o CRITERIA
Absent P waves REFERENCES
F waves vary in amplitude, morphology and intervals • Dr. Ubina’s PowerPoint
R-R intervals are irregularly irregular
• Guyton and Hall
Ventricular rate usually ranges from 90-170
QRS complexes are narrow unless AV conduction is
abnormal
Hypothesized to be due to multiple wavelets in the atrium
competing for the conduction to the AV node

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APPENDIX

CHEST OR PRECORDIAL LEADS

→ Designated as V1 to V6
→ Very sensitive to electrical potential changes underneath the
electrode

V1 4TH ICS R PARASTERNAL BORDER

V2 4TH ICS L PARASTERNAL BORDER

V3 BETWEEN V2 AND V4

V4 5TH ICS L MCL

V5 5TH ICS L AAL

V6 5TH ICS LEFT MAL

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