ECG or EKG: Interpretation of normal ECG

Dr. Kyaw Min

To get different perspectives of the heart


• electrodes,
• • • • • electrode cables filters, control modules, paper recording module special graph paper

• amplifiers

III.Electrocardiograp hic view of the heart V1-V2 V3-V4 V5-V6 anteroseptal wall anterior wall anterolateral wall II. aVL V1-V2 inferior wall lateral wall posterior wall (reciprocal) . aVF I.


A normal adult 12-lead ECG. Sinus rhythm is present with a heart rate of 75 beats per minute. .

Waves e e Positiv Negativ Segment s Intervals .

Voltage calibration: 2 large squares (10 mm) = 1 mV

5 mm = 0.5 mV

5 mm = 0.2 s


Paper speed: 25 mm/sec
= 0.2 s

1 large square 300 large squares (1 min).

= 300 x 0.2 s = 60s

vertical horizontal

Each large(5mm)square : 0.5mV 0.2s Each small(1mm)square : 0.1mV 0.04s

Waves, intervals and segments in normal ECG

atrial repolarization is submerged in QRS complex) . upright in all leads. 0.08 to 0. but inverted in aVR.P wave 0.25 mV or less) represents the wave of depolarization that spreads from SA node throughout the atria.1 s.

QRS complex is tallest in lead II.e. R wave is greater than S). -Prolonged QRS complex (> 0.QRS complex (0. .3 small squares) -represents ventricular depolarization.06 to 0.1s) in Bundle branch block . it is also predominantly upright (i. but in leads I and III.1 s) (1.In most people.

-A small Q wave is also common in lead III in normal people in which . aVL. or V5 – V6.Q wave Small ‘septal’ Q wave in any of leads II. usually less than 3 mm deep and less than 1 mm across. -represents the normal depolarization of interventricular septum from left to right.

T wave is always inverted in aVR. and often in V1.In a normal ECG. but usually upright in all the other leads. .T wave -represents ventricular repolarization .

U wave Sometimes a small U wave may be seen following T wave (last remnants of ventricular repolarization and slow repolarization of papillary muscles) .

and conduction through AV node and His-Purkinje system. bradyarrhythmia) .2 s (3 – 5 small squares) .P-R interval Normal range is 0. long PR interval reflects slow conduction heart block.the period of time from the onset of the P wave to the beginning of the QRS complex. -represents the time taken for depolarization of atria.12 to 0.

Q-T interval (0. myocardial ischemia electrolyte abnormalities) . Q-T interval decreases.2 to 0.4 s) represents the time for both ventricular depolarization and repolarization. At high heart rates. Long QT syndrome (K+ channel mutation.

should be horizontal and ‘isoelectric’. roughly corresponds to the plateau phase of ventricular depolarization -Important for diagnosis of ventricular ischemia (depressed or elevated) .ST segment the part between S wave and T wave. is the time at which the entire ventricle is depolarized.

Horizontal ST segment depression f more than 2mm indicates chaemia. .T segment An elevation of the ST segment the hallmark of an acute myocardial infarction.

II and III.Cardiac axis Depolarization wave of the heart normally spreads through the ventricles from 11 o’clock to 5 o’clock. . So the deflections in lead VR are normally mainly downward (negative) and lead II mainly upward (positive). towards leads I.e. Direction of the axis can be derived most easily from the QRS complex in leads I. i. II and III.

The cardiac axis By near-consensus. the normal QRS axis is defined as ranging from -30° to +90°.e. -30° to -90° is referred to as a left axis deviation (LAD) +90° to +180° is referred to as a right axis deviation (RAD) Abnormalities of axis can hint at: Ventricular enlargement and/or conduction defects (i. hemiblocks) .

the axis will swing towards the right : the deflection in lead I becomes negative and .“Right axis deviation” If right ventricle becomes hypertrophied.

so that the QRS complex becomes predominantly .“Left axis deviation” When left ventricle becomes hypertrophied. the axis may swing to the left.

g.Uses of ECG • Recording of rate and rhythm • diagnosis of cardiac arrhythmias • detection of conduction abnormalities (e. accelerated conduction) • screening tool for ischaemic heart disease (during a cardiac stress test) . heart block.

Uses of ECG • It guides therapy and risk stratification for patients with suspected acute myocardial infarction • It helps detect electrolyte disturbances (e.g. hyperkalaemia and hypokalaemia) .

RR interval = one ventricular cycle  Ventricula rate  heart rate PP interval = one atrial cycle  atrial rate .

• "300. 150.Heart Rate Determination • Method 1 Most rates can be calculated this way. Find an R wave on a heavy line (large box) count off for each large box you land on until you reach the next R wave. 60. 100. Estimate the rate if the second R wave doesn't fall on a heavy black line. 50" . 75.

5. Thus 300/7. The number of large boxes between first and second R waves = 7.Heart Rate Determination • Method 2 Use this method if there is a regular bradycardia. • If the distance between the two R waves is too long to use the common method • 300/[# large boxes between two R waves]. . i.rate < 50.5 large boxes = rate 40.e. .

Heart Rate = ? Heart Rate = 300/5 = 60/min .

• rate <60 = sinus bradycardia • rate >100 = sinus tachycardia .

• Diagnosis of cardiac arrhythmias .

Heart Rate = 300/4 = 75 bpm Rhythm : regular. Sinus rhythm .A normal 12-lead ECG and rhythm strip (Long lead II).

Cardinal features of Sinus rhythm • The P wave is upright in lead II. inverted in aVR • Each P wave is usually followed by a QRS complex • The heart rate is 60 – 99 beats/min • rate <60 = sinus bradycardia • rate >100 = sinus tachycardia .

Abnormalities of cardiac rhythm Look at the P waves and the width of the QRS complex • Supraventricular rhythms have narrow QRS complexes • Ventricular rhythms have wide QRS complexes (due to slower pathway through the Purkinje fibers) .

Atrial Arrhythmi as shaped P wave Abnormally Rate: 150 250 /m (Abnormal P waves. . one P wave/QRS) Rate: 250 350 /m (saw-tooth waves) Rate: 350+ /m Atrial fibrillation with a totally irregular ventricular rate. Atrial rate 300-500/min.

but sometimes P wave rate 200-240/min with 2:1 block Rate: 150 250 /m (Abnormal P waves. one P wave/QRS) . • Abnormal P waves. usually one P wave per QRS complex.Supraventricular rhythms • Atrial tachycardia: • QRS complex rate greater than 150/min. usually with short PR intervals.

saw-toothed pattern.Supraventricular rhythms • Atrial flutter: P wave rate 300/min. 2:1. 3:1 or 4:1 block Rate: 250 350 /m .

• QRS complex rate characteristically over 160/min without treatment. but there is a varying completely irregular wavy baseline . but can be slower • no P waves identifiable.Supraventricular rhythms • Atrial fibrillation: • the most irregular rhythm of all.

r Arrhythmi Ventricular as premature beat (extrasystole) Ventricular tachycardia (fast rate. wavy Defibrillator . no P wave. wide bizarre QRS) Ventricular fibrillation (erratic.

• Ventricular extrasystoles: • Early QRS complex. • QRS complex wide (greater than 120ms). • Next P wave is on time . followed by a compensatory pause • Abnormally shaped T wave. • No P wave. abnormally shaped.

accelerated idioventricular rhythm • Wide bizarrely shaped QRS complex . • QRS complex rate greater than 160/min.• Ventricular tachycardia: • No P waves.

fatal • Look at the patient. wavy baseline) Defibrillator . not the ECG Ventricular fibrillation (erratic. lasts a few minutes.• Ventricular fibrillation: • The most frequent cause of sudden death in patients with myocardial infarction • In the absence of emergency treatment.

Cardiac Physiology Electrocardiograp Diagnosi s hy Ventricular Fibrillation • Ischemia • Electric Shock .

heart block.g. accelerated conduction) .• Detection of conduction abnormalities (e.


First degree block: One P wave per QRS complex PR interval greater than .2 s .

PR intervals are constant QRS is dropped intermittantly .Mobitz Type 2: (2:1 or 3:1 block) Occasional non-conducted beats Two or three P waves per QRS complex Normal P wave rate.

And then repetition of the cycle .Progressive PR lengthening then non-conducted P wave.

Bundle Branch Block • If there is abnormal conduction through either the left or right bundle branches (bundle branch block). there will be a delay in the depolarization of part of the ventricular muscle • The extra time taken for depolarization of the whole of the ventricular muscle causes widening of the QRS complex .

hird degree block (complete block): o relationship between P waves and QRS complexes wave and QRS march out separately sually. rate 50-60/min . wide QRS complexes sual QRS complex rate less than 50/min ometimes narrow QRS complexes.

• Screening tool for ischaemic heart disease (during a cardiac stress test) .

Exercise or stress ECG .

indicating a positive test for ischemia.3 mV) of horizontal STsegment depression. .Lead V4: At rest After 4½ min of exercise 3 mm (0.

• It guides therapy and risk stratification for patients with suspected acute myocardial infarction .

and aVF. Later T inversion reciprocal ST depressions in leads III. .Anterior Q wave infarction • • Deep Q waves. ST segment elevation.

.Inferior Q wave infarction • may be associated with reciprocal ST depressions in leads V1 to V3.

Myocardial Infarction Sequence of ECG changes Normal ECG Raised ST segments Appearance of Q waves Normalization of ST segments Inversion of T waves .

• Ischemia – T inversion • Injury – ST segment elevation • Infarct – pathologic Q wave .

hyperkalaemia and hypokalaemia) .• It helps detect electrolyte disturbances (e.g.

prominent U wave) .(Very tall. slender peaked T wave) (T inversion.

wide. The QRS complex may be widened. • High K+: tall. peaked T waves with the disappearance of the ST segment.Electrolyte abnormalities • Low K+: T wave flattening and the appearance of a hump on the end of the T wave called a “U” wave.) • Low Ca2+ : prolongation of the QT interval . (Effects of abnormal magnesium levels are similar.

How to report an ECG • • • • • • Rate Rhythm Conduction intervals Cardiac axis A description of QRS complexes A description of the ST segments and T wave .

Description Heart rate 110/min. Sinus rhythm Normal PR interval (140 ms) Normal QRS duration (120 ms) Normal cardiac axis Normal QRS complexes Nor T waves Interpretation Normal ECG .