Ecg

10
Index
Subject Page
Introduction 1
Principles of ECG 5
ECG graph 12
Comment on ECG 13
 Rhythm 13
 Rate 14
 Axis 15
 P wave 18
 P-R interval 20
 QRS complex 22
 S-T segment 25
 T wave 29
 Q-T interval 29
 U wave 29
Abnormal ECG 30
 Chamber enlargement 30
 Bundle branch block 33
 Coronary Ischemia 35
 Heart block 37
 Others 40
How to interpret an ECG 41
How to diagnose an ECG 42
Innovation Simple ECG
Introduction
The electrocardiogram (ECG or EKG) is a special graph that represents the electrical
activity of the heart from one instant to the next. Thus, the ECG provides a time-voltage chart
of the heartbeat. For many patients, this test is a key component of clinical diagnosis and
management in both inpatient and outpatient settings. The device used to obtain and display
the conventional ECG is called the electrocardiograph, or ECG machine. It records cardiac
electrical currents (voltages or potentials) by means of conductive electrodes selectively
positioned on the surface of the body.
This book is devoted to explaining the basis of the normal ECG and then examining the
major conditions that cause abnormal depolarization (P and QRS) and repolarization (ST-T and
U) patterns.
Why is the ECG so clinically useful ?

The ECG is one of the most versatile and inexpensive of clinical tests. Its utility derives
from careful clinical and experimental studies over more than a century showing the following:
 It is the essential initial clinical test for diagnosing dangerous cardiac electrical
disturbances related to conduction abnormalities in the AV junction and bundle branch
system and to brady- and tachyarrhythmias.
 It often provides immediately available information about clinically important
mechanical and metabolic problems, not just about primary abnormalities of electrical
function. Examples include myocardial ischemia/infarction, electrolyte disorders, and
drug toxicity, as well as hypertrophy and other types of chamber overload.
 It may provide clues that allow you to forecast preventable catastrophies. A good
example is a very long QT(U) pattern preceding sudden cardiac arrest due to torsades de
pointes.
Physiological anatomy of the heart :

The heart is a hollow muscular pump situated in the left side of the thoracic cavity partly
behind the sternum, consisting of 4 chambers : 2 atria and 2 ventricles.
The heart is covered externally by epicardium ( which is the visceral layer of the
pericardial sac). The inside cavity of the heart lined by endothelial layer called the
endocardium. An intermediate muscular layer lying in between the epicardium & endocardium
known as the myocardium.
Page | 1
Physiology of Cardiac Muscle :

The heart is composed of three major types of cardiac muscle:
atrial muscle, ventricular muscle, and specialized excitatory and conductive muscle fibers.
The atrial and ventricular types of muscle contract in much the same way as skeletal
muscle, except that the duration of contraction is much longer. Conversely, the specialized
excitatory and conductive fibers contract only feebly because they contain few contractile
fibrils; instead, they exhibit either automatic rhythmical electrical discharge in the form of
action potentials or conduction of the action potentials through the heart, providing an
excitatory system that controls the rhythmical beating of the heart.
The cardiac muscle has certain special properties which are :
1. Rhythmicity: ability of the heart to beat regularly at constant rate.

2. Contractility: ability of the heart to contract and push blood into circulation.
3. Excitability: ability of the cardiac muscle to respond to an adequate stimulus
contraction.
4. Conductivity: ability of the cardiac muscle to conduct excitation wave from one part of
the heart to another.
In EKG study we are concerned with study of Rhythmicity and conductivity of the cardiac
muscle.
we will review a few simple principles of the heart’s electrical properties. The central
function of the heart is to contract rhythmically and pump blood to the lungs for oxygenation
and then to pump this oxygen-enriched blood into the general (systemic) circulation. The signal
for cardiac contraction is the spread of electrical currents through the heart muscle. These
currents are produced both by pacemaker cells and specialized conduction tissue within the
heart and by the working heart muscle itself.
Pacemaker cells are like tiny clocks (technically called oscillators) that repetitively
generate electrical stimuli. The other heart cells, both specialized conduction tissue and
working heart muscle, are like cables that transmit these electrical signals.
Electrical Activation of the Heart :

In simplest terms, therefore, the heart can
be thought of as an electrically timed pump. The
electrical “wiring” is outlined in Figure.
Normally, the signal for heartbeat initiation
starts in the sinus or sinoatrial (SA) node. This
node
is located in the right atrium near the opening of
the superior vena cava.
Page | 2
The SA node is a small collection of specialized cells capable of automatically generating

an electrical stimulus (spark-like signal) and functions as the normal pacemaker of the heart.
From the sinus node, this stimulus spreads first through the right atrium and then into the left
atrium. Electrical stimulation of the right and left atria signals the atria to contract and pump
blood simultaneously through the tricuspid and mitral valves into the right and left ventricles.
The electrical stimulus then reaches specialized conduction tissues in the
atrioventricular (AV) junction. The AV junction, which acts as an electrical “relay” connecting
the atria and ventricles, is located at the base of the interatrial septum and
extends into the interventricular septum. The upper (proximal) part of the AV junction is
the AV node. (In some texts, the terms AV node and AV junction are used synonymously.) The
lower (distal) part of the AV junction is called the bundle of His. The bundle of His then divides
into two main branches: the right bundle branch, which distributes the stimulus to the right
ventricle, and the left bundle branch, which distributes the stimulus to the left ventricle.
The electrical signal then spreads simultaneously down the left and right bundle
branches into the ventricular myocardium (ventricular muscle) by way of specialized
conducting cells called Purkinje fibers located in the subendocardial layer (inside rim) of the
ventricles. From the final branches of the Purkinje fibers, the electrical signal spreads through
myocardial muscle toward the epicardium (outer rim).
The His bundle, its branches, and their subdivisions are referred to collectively as His-
Purkinje system. Normally, the AV node and His-Purkinje system form the only electrical
connection between the atria and the ventricles (unless a bypass tract is present). Disruption of
conduction over these structures will produce AV heart block.
Just as the spread of electrical stimuli through the atria leads to atrial contraction, so the
spread of stimuli through the ventricles leads to ventricular contraction, with pumping of blood
to the lungs and into the general circulation. The initiation of cardiac contraction by electrical
stimulation is referred to as electromechanical coupling. A key part of this contractile
mechanism is the release of calcium ions inside the atrial and ventricular heart muscle cells,
which is triggered by the spread of electrical activation. This process links electrical and
mechanical function.
The ECG is capable of recording only relatively large currents produced by the mass of
working (pumping) heart muscle. The much smaller amplitude signals generated by the sinus
node and AV node are invisible with clinical recordings.
Depolarization of the His bundle area can only be recorded from inside the heart during
specialized cardiac electrophysiologic (EP) studies.
Heart has two types of action

 Mechanical: Contraction &relaxation
 Electrical: Depolarization & repolarization
Page | 3
Blood supply of the heart through the coronary arteries
Anatomy of the coronary arteries

The left Coronary artery:
It arises from the left sinus of Valsalva and
passes forwards & to the left in the
atrioventricular groove for a short distance and
then divides into two branches:
1. The left anterior descending artery: it
passes downwards in the anterior
interventricular groove to the apex of the
heart & then turns backwards to
anastomse with the posterior descending
artery.
2. The circumflex artery: it continues its
course in the left atrioventricular groove
to anastomse with the right coronary. It
gives several obtuse marginal branches.
The right Coronary artery:

It arises from the (right sinus) of Valsalva and runs in the right atrioventricular groove to
the posterior surface of the heart to anastomse with circumflex artery.
In the back of the heart it gives the (posterior descending artery which runs downwards,
in the posterior interventricular groove, to anastomose with the anterior descending artery.
Pattern of coronary supply

 Balanced circulation:
The left coronary artery supplies left atrium, left ventricle & anterior part of the
interventricular septum.
While the right coronary artery supplies right atrium, right ventricle & posterior part of
the interventricular septum.
 Right dominance:
The right coronary supplies also the posterior part of the left ventricle.
 Left dominance:
The left coronary supplies also the posterior part of the septum & the posterior wall of the
right ventricle.
Page | 4
Principles of ECG
ECG
Electrocardiogram
Electro 
Cardio 
graph Gram 


ECG
relaxed ECG
waves << << <<
ECG Lead 
ECG positive wave <<
Lead 
negative wave << ECG
ECG
Lead 
biphasic wave << ECG
negative Positive
thickness of the muscle ECG Wave

right ventricle wave left ventricle wave
right ventricle left ventricle thickness of muscle
Page | 5
lead wave left ventricular hypertrophy
ECG heart
Atria 
Ventricles 
ventricle
septum left ventricle right ventricle ventricle
ventricle
left ventricle right ventricle septum
septum
right left left bundle branch
septum right bundle septum
septum waves
ECG positive wave << ECG Lead 

ECG negative wave << ECG Lead 
right left
septum
V1 chest lead
positive wave
septum thickness of muscle

wave
r wave
V6 chest lead
negative wave
Page | 6
septum thickness of muscle

wave
q wave
right ventricle septum

right ventricles waves
septum
V1 chest lead
bundle branch cavity
endocardium
positive wave
right ventricle thickness of muscle

wave
r wave
V6 chest lead
negative wave
right ventricle thickness of muscle

wave
q wave
waves right ventricle

septum wave ECG
right septum small r wave in V1
right wave septum q wave ventricle
V6 ventricle

left ventricle
left ventricle waves

V1 chest lead
Page | 7
endocardium bundle branch cavity

negative wave
left ventricle thickness of muscle

wave
S wave
V6 chest lead
positive wave
left ventricle thickness of muscle

wave
R wave
chest leads
right ventricle V1
r wave S V1
right ventricular pattern
left ventricle V6
V6
s wave
left ventricular pattern
Five waves
complex QRS P
T wave
Atrial depolarization P wave 

ventricular QRS complex 
depolarization
ventricular T wave 
repolarization
Page | 8
Atrial depolarization P wave

atrium P wave
P wave atrium
P wave Atrium 
Multiple P waves before QRS ventricle contraction atrium 
absent P wave contraction atrium 
Atrium P wave
ventricular depolarization QRS complex

ventricle
QRS ventricle 
ventricular tachycardia ventricle 
deformed QRS << ventricle arrhythmia
QRS ventricle
T wave
Ventricular repolarization
atrial depolarization Atrial contraction

ventricular contraction ventricular depolarization
ventricular relaxation ventricular repolarization
Atrial repolarization
which is small and masked by QRS complex
QRS
QRS
A.V. node
PR interval ECG
A.V. nodal conduction PR interval
A.V. node
PR interval
A.V. nodal conduction PR interval
A.V. nodal block heart block
Page | 9
ECG
12 leads ECG
Limb leads 
Chest leads 
Limb leads
Bipolar 
Unipolar 
: Bipolar limb leads

both upper limbs L1 
right upper limb and left lower limb L2 
left upper limb and left lower limb L3 
unipolar limb leads

right arm augmented voltage aVR 
left arm augmented voltage aVL 
left foot augmented voltage aVF 
Chest leads
precordial leads chest wall
6 chest leads
V1, V2, V3, V4, V5, and V6
ECG
ECG
ECG
6 leads
chest leads
th
Right 4 space adjacent to the sternum : V1 
Left 4th space adjacent to the sternum : V2 
Page | 10
Between V2 and V4 V3 
th
Left 5 space mid clavicular line : V4 
at same horizontal level of V4 but at anterior axillary line V5 
at the same horizontal level of V4 but at mid axillary line : V6 
Dextrocardia chest leads

as V3 but on right side V3R 
as V4 but on right side : V4R 
heart section
V1 and V2 Right ventricle 
V5 and V6 left ventricle 
V3 and V4 Septum 
V1 and V2 ischemia << ischemia right ventricle
V5 and V6 ischemia left ventricle
topographism
leads of ECG Wall of the heart
Leads Wall
II - III - aVF Inferior
I - aVL High lateral wall
V1 - V2 Septal ( antro-septal)
V3 - V4 Strict anterior
V5 - V6 Low lateral
V1 - V3R V6R RV free wall
Louis Leads Atrial Activity
N.B. posterior wall potentials are recorded in the anterior leads as a mirror image for
waves provided to be drawn in the posterior leads because posterior leads are
technically difficult to be made.
topographism
wall artery Leads
Page | 11
ECG Graph paper

ECG
5X5
voltage 
duration 
duration
ECG
25 mm
0.04
0.20 0.04 X 5
1/5
300 60 X 5
1500 60 X 25
Voltage
1 mV signal ECG
10mm
Standard 2 big squares 1mV Caliberation
half caliberation
waves one big square
double caliberation
4 big squares
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Comment on ECG
ECG
1. Rhythm
2. Rate
3. Axis
4. P wave
5. P-R interval
6. QRS complex
7. S-T segment
8. T wave
9. Q-T interval
10. U wave
1. Rhythm
ECG Rhythm
Sinus or not 
Regular or irregular 
sinus
P wave is followed by QRS complex
complex S R Q QRS complex
Q R S
ventricular complex
P wave
regular
Numbers of big squares between each R-R interval are equal
<< R-R interval
R-R interval
rhythm is irregular
irregular rhythm
Atrial fibrillation marked irregularity 
extra systole occasional irregularity 
long strip rhythm

Page | 13
3 lead long strip

R-R interval
2. Rate
rate normal
beat per minute << 90 60
tachyarrhythmia << 100 

bradycardia << 60 
rate
rhythm
R-R interval 300 = heart rate << regular rhythm
R-R interval 1500
Irregular << rhythm

rate
R-R interval 300
average mean 300
15
30 15 5 10
10 30/3
10
RR interval
9
3
3 9/3
100 beats per min. 300/3 << 300 rate
Page | 14
3 Lead 2
6 30
30
10
rate
heart rate
50 10 X 5
30 15

rhythm rate ECG
3. Axis
aVF lead lead
aVF
QRS
Page | 15
QRS
Positive << QRS Lead
lead
positive QRS
normal
lead
positive << QRS
aVF lead
Positive << QRS
Axis is normal
Axis is normal
Lead
negative << QRS
aVF lead
positive << QRS
QRS
QRS
right axis deviation
QRS
positive lead
Page | 16
negative lead
left axis deviation
lead lead
aVF
Normal Positive
positive Lead
Negative aVF lead
left axis
deviation
negative Lead
positive aVF lead
right axis deviation

axis deviation
Left axis deviation right axis deviation
Normal axis deviation
normal axis deviation
Normal axis is not deviated
right and left axis deviation
Causes of right axis deviation Causes of left axis deviation

 Children  Q waves of inferior MI
 Tall thin adults  Artificial cardiac pacing
 Right ventricular hypertrophy  Left ventricular hypertrophy
 Chronic lung disease  Hyperkalemia
 Anterolateral myocardial infarction  Ostium primum ASD
 Pulmonary embolus  Injection of contrast into left coronary
 Atrial septal defect artery
 Ventricular septal defect Note : pt. of left ventricular hypertrophy not
usually has LAD
Page | 17
4. P wave
Atrial depolarization
1st positive wave before complex
Lead II and V1
Less than (2.5 X 2.5 ) small squares

Width (duration ) : = ˂ 2.5 small square ( ˂ 0.12 sec. ).
Height (amplitude) : = ˂ 2.5 small square ( ˂ 2.5 mm).
P wave
Present 
Absent 
P wave
Lead II and V1 less than 2.5 X 2.5 small squares Normal 
Abnormal 
<< abnormal << P wave

P mitral M shaped 1
2.5 P wave
left atrial enlargement left atrial strain
P pulmonale Peaked and high voltage P 2

2.5 P wave
right atrial strain
Pulmonale Mitral 3
2.5 P wave
Biphasic 4
P wave negative positive

Mitral Normal
Page | 18
V1
V1
biphasic P wave
right atrium
left atrium
activateSA node
right atrium
Left atrium activate
right SA node
wave
right atrium
wave
Left atrium
P wave
negative Positive biphasic
right atrial strain (enlargement) Positive 
left atrial strain ( enlargement) negative 
Lead
absent << P wave

irregular << rhythm
AF
regular << rhythm

P wave
QRS
QRS
wide << QRS
Page | 19
wide
3 QRS
3
3
Wide QRS
Ventricular tachycardia 
Ventricular fibrillation 
narrow << QRS
supra ventricular tachycardia 

Nodal rhythm 
rate
<< supra ventricular tachycardia
Nodal rhythm
Sawtooth appearance
atrial flutter
5. P-R interval
AV conduction (physiological delay)
Lead II
3-5 small squares (0.12 - 0.20 sec. )
PR
QRS complex P
P-R interval
3 - 5 small squares Normal 
5 small squares Prolonged 
Page | 20
3 small squares Shortened 

prolonged << P-R interval
<< P-R interval 1
just prolongation of P-R interval
First degree heart block
<< P-R interval 2

beat
progressive prolongation of P-R interval until dropped beat
Wenckebach phenomena
peace maker << <<
peace maker
not fixed << P-R interval 3

ventricles atria
atrio-ventricular dissociation
ventricle S.A. node atrium
variable P-R P-R interval

QRS complex P wave
complete heart block
Page | 21
shortened << P-R interval

Wolff-Parkinson-White
A.V. node impulse delay

ventricle atria impulses accessory pathway
P-R interval normal pathway
3 small squares

QRS complex waves
wide QRS complex << complex
Wolff-Parkinson-White Criteria
Short P-R interval 1
Wide QRS complex 2
Delta wave 3
Wolff-Parkinson-White
V1
type B right ventricular pattern 
type A left ventricular pattern 
6. QRS complex
Ventricular depolarization
T P complex
Right ventricle (V1,2) 

Left ventricle (V5,6) 
first negative wave in the complex << Q wave

first positive wave in the complex << R wave
following R the negative wave following R << S wave
Q wave
first negative wave in the complex
Page | 22
one small square
R wave
pathological Q
Deep and wide
ECG
myocardial infarction
Q wave infraction
Non Q wave infarction
Q wave ( deep and wide )
anterior infarction << V1,2 

septal infarction << V3,4 
Lateral infarction << V5,6 
antro-septal infarction << V1,2,3,4 
Extensive anterior infarction << V1,2,3,4,5 
Normal ECG pathological Q


the cavity of the heart << lead of aVR
Q wave << Normally aVR
aVL pathological Q dextrocardia << pathological Q
pathological Q S wave r wave V1

V1 pathological Q ( deep and wide )
Lead aVR and V1

pathological Q
Page | 23
anterior V2 V1 << infarction

V1
r wave is too small to be detected
pathological Q
R wave
only positive in the complex first positive wave in complex
voltage criteria
big squares
3 small squares small squares

Vent. Tachycardia RBBB or LBBB wide complex
S wave
first negative wave following R
Chest leads S and R wave
V5 V1 S 
V6 V1 R wave 
principles
V1 right ventricle r
V6 left ventricle R
S in V2 is ˃ S in V1 
S progress from V2 to V5 
S usually absent in V6 
Waves
capital and small
5 mm wave amplitude 
small <<
5 mm wave amplitude 
capital <<
s r << Small R, S << capital
Not every “QRS” contain “Q”,”R” & “S”, but it may be :

Monophasic (R or QS) 
Page | 24
Biphasic (RS or QR) 

Triphasic (QRS or RSR’) 

high voltage low voltage R wave
˂ 1 big square (low voltage) ˃ 5 big squares (high voltage )
 Terminal heart failure  Ventricular hypertrophy
 Cardiomyopathy
 IHD
 Obesity
 Emphysema
 Pericardial effusion
7. S-T segment
leads
T S
S-T segment
Iso-electric line 
Elevated 
Depressed 
iso-electric line depression elevation

J point
J point
 Point where QRS complex returns to iso-
electric line.
 Beginning of S-T segment.
 Critical in measuring S-T elevation.
iso-electric line
T-P line P-R
Page | 25
S-T elevation
PR ST segment elevation
Pericarditis 
Myocardial infarction 
Prinzmetal’s angina 
Pericarditis
ST segement elevation
Leads
Myocardial infarction Angina

some leads
myocardial infarction angina

Cardiac enzymes
infarction
timing
elevated S-T ECG
angina
S-T depression
ST segment depression
Digitalis 
Hypokalemia 
clinical diagnosis << angina ischemia angina 
Myocardial infarction 
Pericarditis 
cardiac hypertrophy 
bundle branch block 
Digitalis 
hypokalemia 
pericarditis 
Page | 26
diffuse ST segment depression

Leads
digitalis
iso-electric line J point ST segment depression
sagging
hypokalemia
serum potassium
Pericarditis
stitchy << pain clinically
some leads
clinical diagnosis << angina ischemia angina 
myocardial infarction 
hypertrophy 
bundle branch block 
V3 V2 V1
right ventricle Leads
V3 V2 V1
right ventricular hypertrophy
strain pattern
right ventricular hypertrophy With strain pattern

secondary changes
left ventricular enlargement

V6 V5 V4 ST segment depression
right bundle branch block

left bundle branch block
Page | 27
rSR’ V1
Right bundle branch block

ST segment
depressed
right bundle

V6
V6 V5 V4
left ventricular hypertrophy secondary
ventricular hypertrophy
bundle branch block
clinical diagnosis << angina ischemia  angina
ischemia
hypertrophy leads
iso-electric line J point
iso-electric line J point << digitalis toxicity
ECG changes Pericarditis

cardiac muscle ECG
pericarditis
very superficial myocarditis
Page | 28
8. T wave (Never absent )
Less than 6 small squares
R wave 1/3
positive Upright 
negative wave Inverted 
T wave ( positive )
Normal 
T Hyperacute 
hyperkalemia
ECG
T wave inverted
normal
T wave inversion
dynamic T Upright
9. Q-T interval
T wave QRS complex
11 small square 0.44 sec
Long Q-T interval

Drugs ( many antiarrhythmics, tricyclics & phenothiazines) 
Electrolyte abnormalities (K+, Ca++, Mg++) 
CNS disease (especially subarachnoid hemorrhage, stroke, trauma) 
Hereditary LQT 
10. U wave
Page | 29
These waves, usually most apparent in chest leads V2-V4,

may be a sign of hypokalemia or drug effect or toxicity (e.g.,
amiodarone, dofetilide, quinidine, or sotalol).
Abnormal ECG
Chamber enlargement 1
Bundle branch block (BBB) 2
Coronary ischemia (MI & ischemia) 3
Heart block 4
Others 5
1. Chamber enlargement
Atrial enlargement 
Ventricular enlargement 
atrial enlargement
Right atrial enlargement 
Left atrial enlargement 
ventricular enlargement
Right ventricular enlargement 
Left ventricular enlargement 
atrial enlargement
atrium P wave
P wave atrium
Lead II and V1 P wave
peaked << P wave
<<
P pulmonal
right atrial enlargement
broad << P wave

P mitral <<
Left atrial enlargement
Page | 30

Mitral Normal
V1
biphasic P wave
right atrium
left atrium
activate SA node
right atrium
Left atrium activate
right SA node
wave
right atrium
wave
Left atrium
P wave
negative Positive biphasic
right atrial strain (enlargement) Positive 
left atrial strain ( enlargement) negative 
Lead
Ventricular enlargement
ventricular depolarization QRS
QRS complex abnormalities ventricle
V1,2,5,6 QRS
V1,2
r wave S wave
V5,6
s wave R wave
r wave S wave V1,2
Normal deep << S wave
Page | 31
s wave R wave V5,6
normal << R wave
exaggeration of normal
exaggeration of normal voltage criteria

V2 V1 5 big squares S
V6 V5 5 big squares R
7 big squares S+R
left ventricle
left ventricle
hypertrophy
Strain ischemia
ventricle
strain ischemia
strain ischemia
depressed ST segment 
inverted T wave 

Left ventricle
V5 and V6
V5 and V6 Strain ischemia
Left ventricle
right ventricle
V1,2 s wave R wave
Normal
V5,6 r wave S wave
Page | 32
Normal

I can diagnose right ventricle from V1
V6 V5 V2
Right ventricle
right ventricle
Strain ischemia
depressed ST segment strain ischemia
Inverted T wave
V2 V1
V1 and V2 right ventricle Strain ischemia
V5 and V6 left ventricle
Bi ventricular hypertrophy
V5 and V6 V1 and V2 strain ischemia
ECG bi ventricular hypertrophy
R S
exaggeration of normal 
reversal of normal 
exaggeration of normal V1
reversal of normal V2
2. Bundle Branch Block (BBB)
Right bundle branch block 

Left bundle branch block 
bundle branch block

M QRS
RSR'
right bundle branch block V2 V1

left bundle branch block V6 V5
Page | 33
right and left bundle branch block

Right V2 V1 RSR' pattern
left V6 V5 RSR'
QRS
QRS
shape 
direction 
voltage 
QRS
voltage direction shape
shape
M shaped
bundle branch block
direction
direction
V1 and V2
R S
V6 V5
S R
reversal of normal
direction
Normal << shape

Normal << direction
voltage
voltage
exaggeration of normal
Left ventricular hypertrophy
QRS
Page | 34
shape 
direction 
voltage 
shape abnormality
bundle branch block
voltage direction
ventricle
direction
Normal shape
Normal shape
direction
direction
reversal of normal
voltage
3. Coronary Ischemia ( MI & ischemia )

central area of necrosis
surrounded by an area of tissue damage surrounded by an ischemic pattern
pathological Q << area of necrosis 
elevated ST segment << tissue damage 
inverted T << ischemia 
wave or peaked T
infarction
necrosis
pathological Q
Once
Page | 35
pathological Q
Old myocardial infarction
pathological Q
Myocardial infarction
finger print of MI is the pathological Q
Infarction
elevated ST segment
recent MI << Elevated ST segment
recent MI old MI
topographism
anterior wall recent MI
Lateral wall Inferior wall
old MI
topographism
topographism MI
Elevated ST segment pathological Q

Recent Old
Infarction
artery
Infarction
necrosis
elevated ST segment
recent
Page | 36
ECG
pathological Q
ST
pathological Q elevated ST segment
Once elevated ST segment
Q Q recent MI
recent anterior MI Old inferior MI <<
Old inferior leads 
recent anterior leads 
Lead
artery
Ischemia
Depressed ST segment
topographism
Depressed
lateral ischemia anterior Inferior
topographism
4. Heart Block
ECG
Mainly hear block
A.V. nodal block
A.V. node
first degree heart block
second degree heart block
ventricle Atrium
third degree heart block
heart block
Page | 37
A.V. node
Just prolonged PR interval

sinus brady cardia

S.A. node sinus bradycardia
P QRS T
first degree heart block sinus brady cardia
:
definition of first degree heart block
just prolonged PR interval

A.V. node
A.V. node
Mobitz one 
Mobitz two 
Mobitz one
progressive prolongation of PR interval until dropped QRS
A.V. node
Long strip
RR interval
Mobitz one
irregular
Page | 38
dropped beat
Long strip
Mobitz Two
A.V. node
atrium
system
Mobitz Two
regular drop of QRS

P P QRS T P P QRS T
QRS P P
A.V. node
Mobitz one Irregular 

Mobitz Two Regular 

A.V. node
S.A. node Atrium
ventricle
idioventricular rhythm
ectopic focus
atrium
Page | 39
P wave
QRS
ventricle
ventricle QRS
bizarre shaped
deformed
A.V. node
narrow normal
P wave P QRS
A.V. dissociation
atrio ventricular dissociation
ventricle atrium
QRS P
QRS
deformed
Bizarre shaped
.Mobitz one << All type of heart block are regular except 
. third degree heart block << All types of heart block with normal QRS complex except 
Mobitz one regular
complete heart block Third degree normal QRS
5. Others
ECG as a Clue to Acute Life-Threatening Conditions without primary Heart or Lung
Disease
 Cerebrovascular accident (especially intracranial bleed)
 Drug toxicity
 Tricyclic antidepressant overdose, digitalis excess, etc.
 Electrolyte disorders
 Hypokalemia
 Hyperkalemia
 Hypocalcemia
 Hypercalcemia
 Endocrine disorders
Page | 40
 Hypothyroidism
 Hyperthyroidism
 Hypothermia
How to interpret an ECG

ECG
Relax and take a deep breath
Rhythm 1
Sinus or not 
Regular or not 
Rate 2
R-R interval 300 << regular << rhythm
10 30 R waves << Irregular << rhythm
Axis 3
Normal axis << positive aVF lead Positive Lead 
left axis deviation << negative aVF lead positive lead 
right axis deviation << positive aVF lead negative lead 
P wave 4
2.5 2.5
right atrial strain << peaked 2.5 
left atrial strain << m shaped 2.5 
P-R interval 5
complex P wave 5 3
QRS complex 6
first negative wave in the complex << Q wave 

first positive wave in the complex << R wave 
Page | 41
following R the negative wave following R << S wave 
R wave Q wave
R wave
R wave S wave
ST segment 7
T wave S
MI
T wave 8
absent
R wave 6
diagnosis
diagnosis
How to diagnose an ECG

rhythm
regular 
irregular 
irregular
irregular
Atrial fibrillation 
Extra systole 
Mobitz one 
atrial fibrillation
absent P tachy irregular
Normal QRS
Absent P
P wave atrial fibrillation
absent P wave
Page | 42
fibrillation some time

Absent P
AF
slow AF rapid
Slow AF
digitalis 
Beta blocker 
Heart block associated 
lone AF 
slow AF AF
irregular ECG
With absent P wave
AF
Extra systole
refractory period
stimlus
compensatory pause
irregular
irregular
ventricular extra systole
Mobitz one
Progressive prolongation of PR
interval until dropped QRS
Page | 43
rhythm
rate << regular
regular
Tachycardia 
bradycarida 
tachy cardia normo cardia
Regular tachycardia
Sinus tachycardia 
Ventricular tachycardia 
Supra ventricular tachycardia 
Atrial flutter 
Sinus Tachycardia
Sinus tachy cardia
S.A. node
Peace maker of the heart
ECG
P followed by QRS T
P QRS T
Ventricular tachycardia
Ventricular tachycardia
ventricle Arrhythmia
ventricle
QRS
Page | 44
deformed
T P QRS
wide QRS
Supra ventricular tachycardia

supra ventricular
tachycardia
supra ventricualr
atrium 
A.V. node 
P atrium
deformed
P A.V. node
( P ) Inverted
P
Inverted P wave
A.V. node
absent P
Masked by QRS
supra ventricular tachy cardia
absent Inverted P deformed P

P
P
Atrial flutter
Atrial flutter
atrium
Page | 45
A.V. node
reduction
Atrial beat in mathematical fashion
atrium
Atrial flutter specific
atrial fibrillation Atrial flutter

regular atrial flutter 
regular atrial fibrillation 
regular long strip

tachycardia rate
QRS
deformed 
Narrow normal 
deformed
ventricular tachycardia
Narrow normal
P
P wave
single
multiple
sinus tachycardia single

QRS T P wave
multiple P
Atrial flutter
Page | 46
Regular bradycardia
Sinus bradycardia 
first degree heart block 
Mobitz two 
third degree heart block 
Nodal rhythm 
Sinus bradycardia
regular bradycardia
sinus bradycardia
First degree heart block

Page | 47
Mobitz two
Mobitz two
regular drop of QRS complex
Third degree heart block

deformed QRS
AV dissociation
Nodal rhythm
nodal rhythm
peace maker A.V. node
peace maker A.V. node

P
inverted
Page | 48
absent QRS
regular bradycardia
QRS
deformed 
Narrow normal 
third degree heart block deformed
Narrow normal
P wave P wave
single
Multiple
first degree heart block sinus bradycardia single

just prolonged PR interval
multiple P wave
Mobitz two
Atrial flutter Mobitz two

bradycardia Mobitz two 
tachycardia atrial flutter 
Noda rhythm
long strip diagnostic approach

QRS rate rhythm
P
segmented
P
QRS
Page | 49
ST segment
Long strip
Page | 50

Ecg

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10

Why is the ECG so clinically useful ?

Physiological anatomy of the heart :

Physiology of Cardiac Muscle :

The cardiac muscle has certain special properties which are :

1. Rhythmicity: ability of the heart to beat regularly at constant rate.

Electrical Activation of the Heart :

The SA node is a small collection of specialized cells capable of automatically generating

Heart has two types of action

Blood supply of the heart through the coronary arteries

Anatomy of the coronary arteries

The right Coronary artery:

Pattern of coronary supply

thickness of the muscle ECG Wave

lead wave left ventricular hypertrophy

left ventricle right ventricle septum

ECG positive wave << ECG Lead 

septum thickness of muscle

septum thickness of muscle

right ventricle septum

right ventricle thickness of muscle

right ventricle thickness of muscle

waves right ventricle

right ventricle septum

right ventricle septum

endocardium bundle branch cavity

left ventricle thickness of muscle

left ventricle thickness of muscle

Atrial depolarization P wave 

Atrial depolarization P wave

ventricular depolarization QRS complex

atrial depolarization Atrial contraction

: Bipolar limb leads

unipolar limb leads

Dextrocardia chest leads

II - III - aVF Inferior

I - aVL High lateral wall

V1 - V3R V6R RV free wall

Louis Leads Atrial Activity

ECG Graph paper

long strip rhythm

3 lead long strip

tachyarrhythmia << 100 

Irregular << rhythm

aVF lead lead

right axis deviation

left axis deviation

Causes of right axis deviation Causes of left axis deviation

1st positive wave before complex

Less than (2.5 X 2.5 ) small squares

<< abnormal << P wave

P pulmonale Peaked and high voltage P 2

absent << P wave

regular << rhythm

narrow << QRS

supra ventricular tachycardia 

AV conduction (physiological delay)

3-5 small squares (0.12 - 0.20 sec. )

3 small squares Shortened 

<< P-R interval 2

not fixed << P-R interval 3

variable P-R P-R interval

shortened << P-R interval