ECG Interpretation
The First Rule of ECG Interpretation: A Case Study
Let's start with a patient scenario. A 30-32 year old man comes to
your OPD. He’s been having left shoulder pain for a day or two.
When you ask, he says he doesn't usually play cricket but joined
an office match and bowled a few overs with his left arm. Since
then, his shoulder has been hurting.
It sounds like a simple muscular issue, and in a busy OPD, you
might just prescribe a painkiller like Dynapar. However, because
it's the left shoulder, you decide to be cautious and run an ECG.
This is the ECG you get:
You look at it carefully. The question is: Does this man have
Coronary Artery Disease (CAD)?
Now, look at the ECG again. This is as normal as an ECG can be.
There might be a slight artifact, but there is nothing wrong with
this tracing.
But my question was not whether the ECG is normal. My question
was: does the patient have Coronary Artery Disease?
If your answer was "no," and you sent this patient home because
his ECG was normal and his story about bowling made sense, then
there could be a serious problem.
The outcome of this case: The patient continued to wander
around with his shoulder pain, was given painkillers, and because
of this ECG, was sent home. Now who is responsible for the
patient's death? The person who didn’t admit him ?
This brings us to the most important secret of ECG interpretation.
An ECG is a useless investigation, especially when it is normal.
Never send a patient home just because their ECG is normal. I
have heard hundreds of stories of patients sent home with a
normal ECG who never returned.
Key Principle: Always treat a symptomatic patient (chest pain,
sweating, breathlessness) as ACS (Acute Coronary Syndrome)
unless proven otherwise. If a patient comes in with chest pain and
their ECG is normal, keep them for observation. If they're in the
OPD, have them sit for a while. In a hospital setting, admit them
for a couple of hours for observation.
Perform a serial ECG after two hours.
Even if that is normal, then you can start thinking about other
causes.
Never send a patient home based on a single, normal ECG. When
you are sitting in your OPD looking at an ECG, you can be either a
god or the angel of death (Yamraj) for that person. Your one
decision can save their life or end it.
Understanding Ischemia vs. Infarction
Let's clarify a few terms that always cause confusion: Ischemia,
Infarction, Angina, STEMI, and Non-STEMI.
The heart supplies blood to the entire body, but it also has to
supply blood to itself. It does this through the coronary arteries.
When plaque builds up in these arteries (from eating samosas or
not exercising), they can become blocked.
Imagine the heart muscle is a field, and the coronary artery is the
pipe supplying water to it.
When the pipe gets blocked, the part of the field it supplies
begins to dry out.
This initial "drying" of the heart muscle is called Ischemia.
The symptoms the person feels because of this ischemia
(chest pain, breathlessness, sweating) are called Angina.
If you can restore blood flow within 40-60 minutes, the "dried
grass" can become green again. The heart muscle recovers.
However, if the blockage persists and that patch of muscle dies
permanently, becoming barren land, that is called an Infarction.
An infarction that shows ST-segment elevation on an ECG is a
STEMI.
An infarction that does not show ST-segment elevation is a Non-STEMI.
What to Look For: Key ECG Changes
Now that we know what ischemia and infarction are, what signs
do we look for on the ECG? You already know most of them, like
ST elevation. I will teach you how to see them.
1. Tall T Waves (Hyperacute T Waves)
Imagine Yamraj (the God of Death) is pulling the patient up from
above, using the ECG tracing as a string.
The very first thing to get pulled up is the T wave.
The earliest sign of ischemia in a patient having an MI is often
that their T wave starts to get taller. It becomes a Tall T wave.
However, Tall T waves can be caused by
two main things:
1.Ischemia/Infarction (MI)
2.Hyperkalemia (high potassium)
(A third, less critical cause is Benign
Early Repolarization
How to Differentiate:
This is a simple trick. Imagine trying to sit on the peak of the T wave.
Ischemia: The T wave is tall but rounded. You could comfortably sit
on it.
Hyperkalemia: The T wave is tall and pointed or peaked. If you tried
to sit on it, it would prick you (chubh jayegi).
This distinction is crucial. If a chest pain patient has tall, rounded T
waves, you suspect ischemia. If a dialysis patient who missed two
sessions has tall, pointed T waves, you suspect hyperkalemia. Context is
everything.
The T wave can become so tall that it seems to swallow the QRS
complex within it. These are called Hyperacute T waves and are often
the very first sign of an MI, sometimes appearing even before ST
elevation.
2. ST Segment Changes (Elevation & Depression)
If the pulling continues, after the T wave, the entire ST segment
gets pulled up or pushed down.
How to Identify ST Changes:
You need to compare two points on the ECG:
PQ Junction: The point where the P wave meets the QRS
complex.
J Point: The point where the QRS complex ends and the ST
segment begins.
The Rule:
If the J point is above the PQ junction, it's ST Elevation.
If the J point is below the PQ junction, it's ST Depression.
Morphology of ST Elevation (The "Happy Face" vs. "Sad Face"
Rule):
Not all ST elevations are equally dangerous. Look at the shape.
Happy Face ST Elevation (Concave/Scooped): This is less
worrisome.
Sad Face ST Elevation (Convex/Rounded Upwards): This is a
bad sign. It indicates a more severe issue. As the condition
worsens, the ST segment can become flat, then convex, and
finally merge with the T wave to form a "tombstone" pattern.
Morphology of ST Depression (The "Sandal" vs. "Slipper"
Rule):Similarly, the shape of ST depression matters.
Good (Less Bad) ST Depression: It has a slope, like a high-
heeled sandal. It can be up-sloping or down-sloping.
Bad ST Depression: It is flat and horizontal, like a flat slipper
(chappal). This horizontal depression is more concerning.
Reciprocal Changes:
Sometimes, you'll see ST elevation in one area of the heart
and ST depression in the opposite area on the same ECG. The
ST depressions are called reciprocal changes. This confirms a
significant event is occurring.
3. Pathological Q Waves
A Q wave indicates a past (old) MI. When a part of the heart
muscle dies (infarction) and is replaced by scar tissue, it creates a
deep Q wave on the ECG.
Criteria for a Pathological Q Wave:
A Q wave is considered significant or pathological if it meets
these three criteria:
1.Deep (Big): Its depth is more than 25% of the total height of
the QRS complex.
2.Broad (Wide): It is wide, not just a narrow spike.
3.Present in ≥ 2 Contiguous Leads: It must appear in at least
two neighboring leads that look at the same part of the heart.
Where to Look:
Anatomical Lead Groups
A finding on an ECG is only considered significant if it is confirmed
by at least two witnesses—that is, in at least two anatomically
contiguous leads. These are leads that look at the same wall of
the heart.
Think of each lead as having eyes that are looking at the heart
from a different angle.
The Lead Groups:
Inferior Wall: Leads II, III, aVF
Anterior Wall: Leads V1, V2, V3, V4
Lateral Wall: Leads I, aVL, V5, V6
How to Use This:
If you see ST elevation in Lead II, you must immediately check its
neighbors, Lead III and aVF. If the change is also present in one or
both of them, you can confidently diagnose an Inferior Wall MI. If
the change is only in Lead II, it might be an artifact.
Putting It All Together: Case Examples
Case 1:
Observation: Significant ST elevation in V2, V3, and V4. It is
also present in V1.
Diagnosis: V1-V4 are the anterior leads. This is an Anterior
Wall STEMI.
Case 2:
Observation: Tombstone-like ST elevation in Lead III.
Confirmation: Check its neighbors, II and aVF. Elevation is
present in both.
Reciprocal Changes: There is ST depression in the opposite
leads, I and aVL.
Diagnosis: Inferior Wall STEMI with Reciprocal Changes.
Case 3:
Observation: ST Elevation in V4, V5, V6. Also in I and aVL.
Diagnosis: These are anterior and lateral leads. This is an
extensive Antero-Lateral Wall STEMI.
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