Dr. David D.

Ariwibowo, SpJP
ECG Interpretation
I. Calibration : Standard recording : speed 25 mm/sec & amplitude 1 mV.
II. Basic rhythm : (after no III-VI)
Sinus / Supraventricular (atrial/junctional)/
Ventricular rhytm.
III. QRS (R-R) Regularity : Regular  Brady/Normal/Tachy.
& Rate Irregular  Fibrilation.
IV. P wave : Presentation/ Regularity/ Rate/ Axis/ followed by QRS/
Width/ Height/ Morphology.
V. PR interval : Normal / Short / Long.
VI. QRS complex : Width/ Height/ Morphology.
QRS axis : Normal / LAD / RAD / Superior
VII. ST segment : Normal / Depression / Elevation
(Morphology & Location).
VIII. T wave : Normal / Tall / Inverted (Morphology & location)
IX. QT Interval : Normal / Short / Long.
X. U wave : Normal / Prominent/ Inverted
 Conclusion  Diagnosis
I. Calibration the standard recording

 The horizontal direction: paper speed of 25 mm/sec  1 small square = 0.04

sec (40 msec); 1 large square = 0,20 sec (200 msec): 5 large square = 1 sec.
 The vertical direction: amplitude of ECG signals of 1 mV.  Amplitude of 1 mV
 10 small squares or 2 large squares.
II. Basic rhythm
 Decide after no III-VI.
III. QRS Regularity: R-R interval
 To identify a basic rhythm correctly  view the heart
rhythm over a much longer period of time.
 Rhythm strip
 A long tracing of a single lead or multiple leads.
 Any lead can be chosen  choose the most informative.
R-R interval regularity
III. QRS rate
 Sinus rate.
(60-100 bpm).
 Supraventricular rate.
 Atrial rate.
(60-100 bpm).
 Junctional rate.
(40-60 bpm).
 Ventricular rate.
(30-40 bpm).
III.A. QRS rate for regular rhythms.
 1500 / Number of small square in one R – R’ intervals
 300 / Number of large square in one R – R’ intervals
# of Large Rate
square

1 300

2 150

3 100

4 75

5 60

6 50
Example 1: What is the heart rate?

(300 / 6) = 50 bpm
Example 2: What is the heart rate?

(300 / ~ 4) = ~ 75 bpm
Example 3: What is the heart rate?

(300 / 1.5) = 200 bpm

III.B. QRS rate for irregular rhythms.
6 Second Rule
Count the number of beats present on the 6 seconds (6 x 5
large square) and multiply by 10 to get the number of BPM.

 12 x 10 = 120 bpm
IV. P Wave
 Sequential activation of the RA & LA.
 It is common to see notched or
biphasic P waves.
 Normal (Lead II):
1. Wide < 2.5 mm (< 0.11 sec).
2. Notched Duration < 1 mm (0,045 sec).
3. Amplitudo < 2.5 mm ( 0.25 mV)
P Wave deflection
 Should be upright in I, II, and V2 to V6
P wave axis
V. PR Interval
 Time interval from onset of atrial depolarization to onset
of ventricular depolarization.
 Normal 0.12-0.20 sec.
PR Interval abnormalities
I. Short PR interval (< 0.12 sec)  Pre-excitation syndrome.
A. Lown-Ganong-Levine Syndrome.
B. Wolff-Parkinson-White Syndrome.
II. Long PR interval (> 0.20 sec)
A. AVB grade I.
B. AVB grade II type 2.
C. Trifascicular block
III. Irregular PR interval:
A. AVB grade II type 1.
B. TAVB
C. AV dissociation
VI. QRS complex
 Simultaneous activation of the right and left ventricles.
 Normal < 0.12 sec

Durasi QRS 0,04’’ s/d 0,12’’

QRS Morphology
R r qR qRs Qrs QS

Qr Rs rS qs rSr’ rSR’
QRS Morphology: Limb leads.
 The QRS complex dominantly upright in I & II.
 QRS & T waves tend to have the same general
direction in the limb leads.
QRS Morphology: Precordial leads
 q-waves reflect normal septal activation (<0.04 sec & <25% R
amplitude) in I, II, V2 to V6
 r-waves begin in V1 / V2 & progress in size to V5 at least V4 (R-V6 is
usually < R-V5).
 S-waves begin in V6 or V5 and progress in size to V2. (S-V1 is usually
smaller than S-V2).

V1 V2 V3
V4
Sternum
V5
V6

Spine
QRS Axis
 The normal QRS axis range -30 o to 110 o
 Implies that the QRS be mostly positive (upright) in leads I
& II.
VII. ST Segment
 Normal ST segment elevation occurs in leads with large S
waves (e.g., V1-3) with concave upward configuration .
 The ST segment should start isoelectric except in V1 and
V2 where it may be elevated
 Also be seen in other leads  called early repolarization.
ST Segment Changes
ST Elevation
1. Acute myocardial Infarction
2. Myocarditis
3. Pericarditis
4. Aneurysm
5. Early repolarisation

ST Depression
1. Myocardial ischaemia.
2. Ventricular hypertrophy ("strain“).
3. Hypokalaemia
4. Digoxin effect
5. Non-specific
VIII. T Wave
  Ventricular repolarisation.
 The normal T wave :
1. Asymmetrical.
 The first half more gradual slope than the second
half.
2. No widely accepted criteria exist regarding T
wave amplitude.
 Generally ≥ 1/8 but < 2/3 of the the corresponding R
wave, rarely > 10 mm.
 The tallest in leads V3 and V4.
T Wave
3. The orientation ~ the QRS complex.
 Inverted in lead aVR.
 May be inverted in lead III & V1 occasionally accompanied by V2
(isolated inversion in V2 is abnormal).
 The T wave must be upright in I, II, V2 to V6.
Tall T wave
1. Acute myocardial ischaemia (hyper acute T).
2. Hyperkalaemia.
3. Early repolarization (normal variant).
Inverted T waves
1. Myocardial ischaemia
 Symmetrical inverted  highly suggestive.
 Asymmetrical inverted  non-specific finding.
2. Acute – recent myocardial Infarction.
3. Pericarditis.
4. Digoxin effect.
5. Hypokalaemia.
6. LV strain.
7. Persistent juvenile pattern (normal variant).
 Inversion in V1-V2, common in blac k people.
IX. QT Interval
 Duration of ventricular depolarization and repolarization
 Normal QTc: < 0.44 sec (Roughly < ½ RR interval)
 QTC = QT /  RR.
 Best measured in aVL
QT Interval Changes
Short QT
1. Hypercalcaemia
2. Digoxin

Long QT
1. Congenital LQTS
2. AMI
3. Cardiomyopathy
4. Myocarditis
5. MVP
6. Electrolyte disorders
7. Drugs
8. Hypothermia
9. CVA
10. Neck surgery
X. U Waves
Normal
1. Usually present in V2-3.
2. Height ± 80% T waves
U Waves changes
Prominent U wave (≥ 1 mm, or > T wave height)
1. Hypokalemia
2. Hypomagnesemia
3. Hyperthyroidism
4. Class I antiarrhythmics
5. Tricyclics, phenothiazines
6. CNS disease
7. Bradycardia
8. LVH
9. Digoxin

Inverted U wave
1. Ischaemic heart disease
2. Anterior ischaemia
3. Hypertensive heart disease
Thank You