Interpreting ECGs

System for interpreting ECGs:

1 Rate, rhythm, axis
2 P wave and PR interval
3 QRS
4 ST segment and T wave
5 QT interval

Rate
= number of QRS complexes in rhythm strip x 6

Rhythm
Sinus = P waves upright in II, inverted in aVR, all look the same within a lead
Atrial rhythm = Regular but does not meet criteria for sinus rhythm

Axis
Normal = I and aVF positive
Left axis deviation = 1 positive and aVF negative
Right axis deviation = 1 negative and aVF positive

P wave
Tall = >2.5mm = right atrial enlargement
Bifid = left atrial enlargement

PR interval = start of P to start of QRS

Normal = 3-5 small squares = 120-200msec
Prolonged PR interval = heart block
Short PR interval = pre-excitation (accessory pathway not slowed by AV node)

QRS – consider width, height, shape, and progression

Normal width = <3 small squares = <120msec
-Wide QRS indicates abnormal ventricular conduction and will be followed by ST segment and T
wave abnormalities
Tall QRS can indicate ventricular hypertrophy whereas low voltages can indicate pericardial effusion
Q waves are normal in left leads = V5-6, I, aVL; abnormal Q waves are >1small square long + >2mm
deep
R wave progression = QRS predominantly negative in V1 -> predominantly positive in V6; por
progression can indicate anterior MI

ST segment – consider elevation, depression, and shape

T wave – consider orientation and height

T wave inversion is normal in V1 and aVR and nonspecific in V2 and inferior leads
T waves can be tall in early MIs and hyperkalemia

QT interval = start of QRS to end of T

QTc >500msec is associated with increased risk of Torsades VT

Myocardial ischemia
Changes associated with ischemia:
1 Hyperacute T waves
2 ST elevation/depression
3 Q waves
4 T wave inversion

ECG criteria for STEMI: >1mm STE in 2 contiguous limb leads or >2mm STE in 2 contiguous chest
leads or new LBBB
In a posterior ECG 0.5mm STE is required to diagnose a STEMI

STEMI equivalents are

-Wellen’s syndrome: Deeply inverted or biphasic T waves in anterior leads
-Old LBBB or paced and meet Sgarbosa criteria

Part of heart Leads Reciprocal changes (PAILS)

Septal V1-2
Anterior V2-4 Inferior
Lateral V5-6, I, aVL Septal
Inferior II, III, aVF Lateral
Posterior V7-9 Anterior

Key feature of posterior STEMI is ST depression in V1-3

Diagnosed with >0.5mm STE in V7-9
V7-9 are produced by moving V4-6 posteriorly

It is important to identify right ventricular infarcts because GTN can cause hypotension
Features of right ventricular infarct are STE III>II, STE V1>V2, and inferior MI
Right ventricular infarct is identified by ST changes in V4R
V4R is produced by shifting V4 from left to right

Conduction disease
Conduction pathway:
SA node -> AV node -> Bundle of His -> RBB + L anterior + L posterior fascicles

Types of conduction disease:

-Disease at SA node = escape rhythm
-Disease at AV node = heart block
-Disease at bundle branches = Bundle branch block
-Disease at fascicles = fascicular block

Escape rhythms
In SA node disease, the SA node doesn’t fire
If the SA node doesn’t fire, a more distal area will take over:
-SA node fires at 60-100 BPM and P waves are seen on ECG
-AV node fires at 40-60 BPM and P waves are buried in/just before/just after QRS (spread up + down
from AV node) on ECG = junctional beats
-Purkinje fibres fire at 14-40 BPM and QRS is wide and there are no P waves on ECG = ventricular
beats

Heart blocks
In 1st degree block, all P waves are conducted but slower than usual
On ECG there is a PR interval >200msec/5 small squares
In 2nd degree block, some P waves are conducted and it is divided into Mobitz I and II
Mobitz I = PR becomes longer until QRS is dropped
Mobitz II = PR is constant but QRS is dropped at a fixed or variable ratio

In 3rd degree block, no P waves are conducted

On ECG there are regular P waves and regular wide QRS complexes that aren’t associated

Bundle branch blocks

On ECG LBBB = Wide QRS, W in V1-3, M in V5-6, and left axis deviation
-W is due to deep S waves
-M is due to notched R wave

On ECG RBBB = Wide QRS, M in V1-3, W in V6, and normal axis

-M is due to RSR pattern
-W is due to slurred S wave
-If there is left axis deviation = Bifascicular block (RBBB + LAFB)
-If there is right axis deviation = Bifascicular block (RBBB + LPFB)
-Trifascicular block = Bifascicular block + PR prolongation

Tachyarrhythmias
Tachyarrhythmias can be regular or irregular and broad or narrow

Regular and broad = VT or SVT with aberrant conduction or bundle branch block
Regular and narrow = Sinus tachy, flutter, or SVT

Irregular and broad = VF or AF with aberrant conduction or bundle branch block

Irregular and narrow = AF

AF
ECG features of AF are irregularly irregular rhythm, no P waves, unstable baseline, and narrow QRS

Atrial flutter
ECG features of atrial flutter are sawtooth pattern in inferior leads, narrow QRS, atrial rate of 300,
and ventricular rate of 150

WPW
WPW is a atrioventricular reentry tachycardia because it is not contained within the AV node; most
other SVTs are AV nodal reentry tachycardia
ECG features of WPW are PR <120msec, delta wave, slight QRS prolongation, and ST/T changes
-PR is short because accessory pathway bypasses AV node
-Delta wave and slight QRS prolongation is because accessory pathway leads to abnormal ventricle
activation
-ST/T changes are due to abnormal QRS complex

VT
Definition of VT is 3+ consecutive ventricular beats
Sustained VT is when it lasts 30+ seconds
Features associated with VT rather than SVT with aberrancy are AV dissociation, fusion beats,
capture beats, and extreme axis deviation
Pericarditis
ECG features of pericarditis are widespread saddle STE, widespread PR depression, reversed changes
in V1 and aVR

Left ventricular hypertrophy

ECG features of LVH are deep S waves in V1-3, tall R waves in V4-6, ST/T wave changes in lateral
leads, L axis deviation

Hyperkalemia
ECG features of hyperkalemia are tall T waves -> wide P waves -> loss of P waves -> wide QRS -> sine
wave

Hypokalemia
ECG features of hypokalemia are tall + wide P waves, T wave flattening/inversion, STD, U waves