BASICS OF ECG INTERPRETATION

Essien, Ene Samuel

MS5, King Caesor University

KCU ECG MAY 2022

What is an EKG?
The electrocardiogram (EKG) is a representation of the electrical events
of the cardiac cycle.

Each event has a distinctive waveform, the study of which can lead to
greater insight into a patient’s cardiac pathophysiology.

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Pacemakers of the Heart
• SA Node - Dominant pacemaker with an intrinsic rate of 60 - 100
beats/minute.

• AV Node - Back-up pacemaker with an intrinsic rate of 40 - 60

beats/minute.

• Ventricular cells - Back-up pacemaker with an intrinsic rate of 20 - 45

bpm.

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Types of pathologies that we can identify and study
from ECG
• Flutter (HR 250-350b/min)
• Arrhythmias (HR >350b/min)
• Myocardial ischemia and infarction
• Pericarditis
• Chamber hypertrophy
• Electrolyte disturbances (i.e. hyperkalemia, hypokalemia)
• Drug toxicity (i.e. digoxin and drugs which prolong the QT
interval)
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Impulse Conduction & the ECG
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
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Waveforms and Intervals on ECG

NB:
TP segment is the ECG baseline
because it doesn't change but other
segments can due to pathology

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J and U waves

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Normal Intervals • PR Interval
• 0.12 - 0.20 sec (less than one
large box)
• QRS Interval
• 0.04 – 0.12 sec (1-3 small
boxes)
• QT Interval
• 0.35 – 0.45sec in men, 0.46s in
women
• Based on sex / heart rate
• Half the R-R interval with
normal HR
• QTc – Corrected QT interval
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 EKG LEADS
• Leads are electrodes which measure the difference in electrical potential
between either:
Two different points on the body (bipolar leads)
One point on the body and a virtual reference point with zero electrical potential,
located in the center of the heart (unipolar leads)

• The standard EKG has 12 leads:

3 Standard Limb Leads,
3 Augmented Limb Leads,
6 Precordial Leads

• The axis of a particular lead represents the viewpoint from which it looks at
the heart. KCU ECG MAY 2022
Standard Limb Leads

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Augmented Limb Leads

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All Limb Leads
Note the directions in which
they are looking at the heart;

• Left side of the heart;

 Leads I, and aVL

• Inferior side of the heart ;

 Leads II, III and aVF

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Precordial Leads
V1: 4th intercostal space, R sternal border

V2: 4th intercostal space, L sternal border

V3: between V2 and V4

V4: 5th intercostal space, mid-clavicular line

V5: 5th intercostal space, anterior axillary

line

V6: 5th intercostal space, mid-axillary line

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Precordial Leads

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ALL LEADS

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Summary of Leads

Limb Leads Precordial

Leads
Bipolar I, II, III None
(Standard limb leads)

Unipolar aVR, aVL, aVF V1-V6

(Augmented limb leads)

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Arrangement of Leads on the ECG paper
(on each Rhythm strip)

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Anatomic Groups - SEPTUM

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Anatomic Groups- ANTERIOR WALL

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Anatomic Groups - LATERAL WALL

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Anatomic Groups - INFERIOR WALL

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Anatomic Groups - SUMMARY

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Normal ECG

12 Lead
ECG Paper

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10 ECG RULES OF NORMAL (Prof Chamberlains)
1) PR interval should be 3-5 small sq 0.12-0.2s
2) The QRS complex should not be less than
3smalls sq 0.12s
3) The QRS complex should be predominantly
upright in leads
4) QRS & T waves tend to have the same general
direction in the limb leads
5) All waves are negative in lead aVR
6) The R wave must grow from V1 to at least V4,
the S wave must grow from V1 to at least V3 and
disappear in V6
7) The ST segment must start isoelectric except in
V1 and V2 where it may be elevated
8) The P waves should be upright in leads I, II and
V2 to V6
9) There should be no Q wave or only a small q of
0.04s in width in leads I, II and V2 to V6
10) The T wave must be upright in I, II, V2 to V6
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THE QRS AXIS
The QRS axis represents the net overall direction of the
heart’s electrical activity.

Abnormalities of axis can hint at:

Ventricular enlargement
Conduction blocks (i.e. hemiblocks)

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The QRS Axis
By near-consensus, the
normal QRS axis is defined
as ranging from -30° to +90°.

-30° to -90° is referred to as a

left axis deviation (LAD)

+90° to +180° is referred to as

a right axis deviation (RAD)

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Determining the Axis
1) The Quadrant Approach
2) The Equiphasic Approach

Predominantly Predominantly Equiphasic

Positive Negative
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 The Quadrant Approach
1) Examine the QRS complex in leads I and aVF to determine if they are predominantly
positive or predominantly negative. The combination should place the axis into one of
the 4 quadrants below.
QRS up in I and up in aVF = Normal axis

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 The Quadrant Approach …
2) In the event that LAD is present, examine lead II to determine if this deviation is
pathologic. If the QRS in II is predominantly positive, the LAD is non-pathologic (in
other words, the axis is normal). If it is predominantly negative, it is pathologic.
3) A quick way to determine the QRS axis is to look at the QRS complexes in leads I and
II.

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Quadrant Approach: Example 1

The Alan E. Lindsay

ECG Learning Center
http://medstat.med.utah
.edu/kw/ecg/

Negative in I, positive in aVF  RAD

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Quadrant Approach: Example 2

The Alan E. Lindsay

ECG Learning Center
http://medstat.med.utah
.edu/kw/ecg/

Positive in I, negative in aVF  Predominantly positive in II 

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Normal Axis (non-pathologic LAD)
ECG INTERPRETATION

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Be Systematic
1. Rate
2. Rhythm
3. Axis
4. Intervals
5. Ischemia
6. Chamber hypertrophy
7. Bundle Branch Blockade

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The ECG Paper
• Horizontally
• One small box - 0.04 s
• One large box - 0.20 s
• Vertically
• One large box - 0.5 mV

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 DETERMINING THE HEART RATE

• Rule of 300

• 10 Second Rule

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 Determining the Heart Rate
Rule of 300
• Take the number of “big boxes” between neighboring QRS complexes (R-R interval),
and divide this into 300.
• The result will be approximately equal to the rate
• Although fast, this method only works for regular rhythms.
# of big Rate
boxes
It may be easiest to memorize the table: 1 300
2 150
3 100
4 75
5 60
6 50
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What is the heart rate?

(300 / 6) = 50 bpm

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 Determining the Heart Rate
10 Second Rule
• As most ECGs record 10 seconds of rhythm per page, one can simply
count the number of beats (QRS Complexes/ R waves) present on the EKG
and multiply by 6 to get the number of beats per 60 seconds.
• In a 6 sec rhythm strip, count the number of R waves, then multiply by 10.

• This method works well for irregular rhythms.

10sec ECG; HR = # R waves X 6

6sec ECG; HR = # R waves # X 10

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What is the heart rate?

12 x 6 = 72 bpm

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How determine 10sec & 6sec ECG
3 sec 3 sec

Every 3 seconds (15 large boxes) is marked by a vertical line.

In above its 2 vertical lines (3x2 =6sec ECG)
This helps when calculating the heart rate.
To know if it’s a 10s or 6s ECG, count the big boxes and
multiply by 0.2
NOTE: the following strips are not marked but all are 6
seconds long. KCU ECG MAY 2022
RHYTHM ANALYSIS

Step 1: Calculate rate. 9X10 = 90b/min

Step 2: Determine regularity.
Step 3: Assess the P waves.
Step 4: Determine PR interval.
Step 5: Determine QRS duration.

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 Step 2: Determine regularity

Look at the R-R distances (using a caliper or markings on a pen or paper).

Regular (are they equidistant apart)?
Occasionally irregular? Regularly irregular? Irregularly irregular?

Interpretation?
Regular
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Step 3: Assess the P waves

• Are there P waves?

• Do the P waves all look alike?
• Do the P waves occur at a regular rate?
• Is there one P wave before each QRS?

• Interpretation?

Normal P waves, with 1 P wave for every QRS

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Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds, (3 - 5 boxes)

Interpretation?

0.12 seconds
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Step 5: QRS duration

• Normal: 0.04 - 0.12 seconds, (1 - 3 boxes)

Interpretation?
0.08 seconds
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Rhythm Summary

• Rate 90-95 bpm

• Regularity regular
• P waves normal
• PR interval 0.12 s
• QRS duration 0.08 s
Interpretation?
Normal Sinus Rhythm
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Normal Sinus Rhythm (NSR) Parameters

Rate 60 - 100 bpm

Regularity regular
P waves normal
PR interval 0.12 - 0.20 s
QRS duration 0.04 - 0.12 s

Any deviation from above is sinus tachycardia, sinus bradycardia

or an arrhythmia
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ARRHYTHMIA FORMATION
Arrhythmias can arise from problems in the:
• Sinus node
• Atrial cells
• AV junction
• Ventricular cells

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SA NODE PROBLEMS
The SA Node can:
fire too slow - Sinus Bradycardia (HR < 60b/min)
• SA node is depolarizing slower than normal but impulse is conducted normally
(i.e. normal PR and QRS interval).

fire too fast - Sinus Tachycardia (HR >100 – 150 b/min)

• SA node is depolarizing faster than normal, but impulse is conducted

normally.

• Sinus Tachycardia may be an appropriate response to stress, not a

primary arrhythmia.
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Rhythm #1

• Rate? 30 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.12 s
• QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
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Rhythm #2

• Rate? 130 bpm

• Regularity? regular
• P waves? normal
• PR interval? 0.16 s
• QRS duration? 0.08 s
Interpretation? Sinus Tachycardia
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 ATRIAL CELL PROBLEMS
Atrial cells can:
• fire occasionally from a focus - Premature Atrial Contractions (PACs)

• fire continuously due to a looping re-entrant circuit - Atrial Flutter (P

waves are formed at a rate of 250 - 350 bpm)

• fire continuously from multiple foci - Atrial Fibrillation ((P waves are
formed at a rate of > 350 bpm)

• fire continuously due to multiple micro re-entrant “wavelets” - Atrial

Fibrillation
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Rhythm #3

• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2 & 7 different contour
• PR interval? 0.14 s (except 2&7)
• QRS duration? 0.08 s
Interpretation? NSR with Premature Atrial Contractions
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Rhythm #4

• Rate? 70 bpm
• Regularity? regular
• P waves? flutter waves
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Flutter
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Rhythm #5

• Rate? 100 bpm

• Regularity? irregularly irregular
• P waves? none
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Fibrillation
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THE JOURNEY SO FAR_
ECG electrophysiology and cardiac anatomy

• Impulse Conduction • Normal Intervals

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EKG LEADS_
Leads as Cameras in various angles/axis

• All Leads • Net Overall direction of electrical

activity

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Anatomic Groups - SUMMARY

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INTERPRETATION _ so far
• RATE • RHYTHM_ who run this show?
• 300 • Calculate rate.
• 1500 • Determine regularity.
• Multiply by 6 • Assess the P waves.
• Multiply by 10 • Determine PR interval.
• Determine QRS duration.

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Normal Sinus Rhythm (NSR) Parameters

Rate 60 - 100 bpm

Regularity regular
P waves normal
PR interval 0.12 - 0.20 s
QRS duration 0.04 - 0.12 s

Any deviation from above is sinus tachycardia, sinus bradycardia

or an arrhythmia
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 CHECKPOINT
Let’s take a look at two ECGs and comment on their
Rate, Rhythm and Axis

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 AV JUNCTIONAL PROBLEMS
The AV junction can:
• Fire continuously due to a looping re-entrant circuit - Paroxysmal
Supraventricular Tachycardia (PSVT)
• Deviation from NSR; The heart rate suddenly speeds up, often triggered by a PAC
(not seen here) and the P waves are lost.
• Etiology: There are several types of PSVT but all originate above the ventricles
(therefore the QRS is narrow).
• Most common: abnormal conduction in the AV node (re-entrant circuit looping in
the AV node).

• Block impulses coming from the SA Node - AV Junctional Blocks

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Rhythm #6

• Rate? 74 148 bpm

• Regularity? Regular  regular
• P waves? Normal  none
• PR interval? 0.16 s  none
• QRS duration? 0.08 s
Interpretation? Paroxysmal Supraventricular
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Tachycardia (PSVT)
 AV Junctional Blocks;
1st Degree AV Block:
2nd Degree AV Block, Type I / Mobitz I
2nd Degree AV Block, Type II / Mobitz II
3rd Degree AV Block

PR interval 0.12 - 0.2sec

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Rhythm #7

• Rate? 60 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.36 s (>0.20 s)
• QRS duration? 0.08 s
Interpretation? 1st Degree AV Block
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Rhythm #8

• Rate? 50 bpm
• Regularity? regularly irregular
• P waves? Normal, but 4th no QRS
• PR interval? lengthens
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type I or Mobitz I
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Rhythm #9

• Rate? 40 bpm
• Regularity? regular
• P waves? normal, 2 of 3 no QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type II or Morbiz II
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Rhythm #10

• Rate? 40 bpm
• Regularity? regular
• P waves? no relation to QRS
• PR interval? none
• QRS duration? wide (> 0.12 s)
Interpretation? 3rd Degree AV Block
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 VENTRICULAR CELL PROBLEMS
Ventricular cells can:
1) fire occasionally from 1 or more foci - Premature Ventricular Contractions
(PVCs)

2) fire continuously due to a looping re-entrant circuit - Ventricular Tachycardia

3) fire continuously from multiple foci - Ventricular Fibrillation

NB:
• When an impulse originates in a ventricle, conduction through the ventricles
will be inefficient and the QRS will be wide and bizarre.
• Ventricular Arrhythmias (Ventricular Tachycardia and Ventricular Fibrillation)
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Ventricular Conduction

Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
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Rhythm #11

• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s (7th wide 0.16 s)
Interpretation? KCU ECG MAY 2022
Sinus Rhythm with 1 PVC
 2 PVCs
When there are more than 1 premature beats and look alike, they are
called “uniform”. When they look different, they are called “multiform”.

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Rhythm #12

• Rate? 160 bpm

• Regularity? regular
• P waves? none
• PR interval? none
• QRS duration? wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
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Rhythm #13

• Rate? none
• Regularity? irregularly irreg.
• P waves? none
• PR interval? none
• QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
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1. MYOCARDIAL INFARCTION
2. ELECTROLYTE IMBALANCE
3. VENTRICULAR HYPERTROPHY

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 DIAGNOSING A MI
To diagnose a myocardial infarction you need to go beyond looking
at a rhythm strip and obtain a 12-Lead ECG.

12- Lead ECG

Rhythm Strip

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 ST Elevation Infarction
Here’s a diagram depicting an evolving
infarction:
A. Normal ECG prior to MI
B. Ischemia from coronary artery occlusion results
in ST depression (not shown) and peaked T-waves
C. Infarction from ongoing ischemia results in
marked ST elevation
D/E. Ongoing infarction with appearance of
pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Q- waves,
but normal ST segment and T- waves
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 ST Elevation Infarction
Here’s an ECG of an inferior MI:

Look at the inferior

leads (II, III, aVF).

Question: What
ECG changes do
you see?
ST elevation and
Q-waves

What is the rhythm? Atrial fibrillation (irregularly

KCU ECG MAY 2022 irregular with narrow QRS)!
 Non-ST Elevation Infarction
The ECG changes seen with a non-ST elevation infarction are:

Before injury Normal ECG

Ischemia ST depression & T-wave inversion

Infarction ST depression & T-wave inversion

Fibrosis ST returns to baseline, but T-wave

inversion persists

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 Non-ST Elevation Infarction
Here’s an ECG of an evolving non-ST elevation MI:

In leads V2-V6. Note;

• ST depression &
• T-wave inversion

Question: What
area of the heart
is infarcting?
Anterolateral

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 VENTRICULAR HYPERTROPHY
Ventricular hypertrophy is primarily evident in the chest leads(V1/2/5/6),
and limb leads (aVL and Limb lead I) which usually show similar changes
to those in V5 and V6

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Left Ventricular Hypertrophy
• Large R waves in V5/6
• Prominent S waves in V1/2 and tall T waves in V1/2
• T wave inversion in V5/6
• LAD
• ST segment elevation in V1/2 (slightly concave)
• Prolongation of QRS duration: beyond 0.12seconds and QT interval
prolongation
• Notching of the QRS complex(dueto prolongation of the R wave peak
time)

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Left ventricular hypertrophy

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 Criteria for Diagnosis of LVH
Sokolow lyon criteria:
• (R in V5 or R in V6) + (S in V1 or S in V2) >35mm
• Specificity >80% but Sensitivity usually less than 20%

Cornell voltage criteria

• Men: S in V3 +R in aVL > 28mm
• Women: S in V3 + R in aVL > 20mm
• Specificity >95% but sensitivity of about 42%

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 Right Ventricular Hypertrophy
• Large R waves in V1, V2
• Prominent S waves in V5, V6
• Slight Prolongation of the QRS complex > 0.08 sec but does not reach
0.12sec unless there is concomitant Bundle branch Block
• Prolongation of the QT interval beyond 0.35seconds
• rSR’ pattern in V1, V2 this usually resembles but not RBBB
• RAD
• T wave inversion in V1/2
• S1S11S111 pattern (S waves occasionally seen in leads 1,2 and 3)
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Right Ventricular Hypertrophy

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Right ventricular hypertrophy

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 ELECTROLYTE IMBALANCE
Significant electrolyte imbalances include:
• Hypo/Hyperkalemia, Hypo/Hypercalcemia
K+ NR 3.5-5.0mmol/L under control by aldosterone, to some extent by ADH,
Insulin, catecholamines
• Ca2+; NR 2.1-2.6mmol/L (8-10mg/dL) under control by
Parathormone, Vitamin D, calcitonin

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K+ imbalance - Hyperkalemia:
ECG manifestations:
• Flat/small P wave,
• Prolonged PR interval,
• QRS widening and
• Tall and picked T waves

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K+ imbalance - Hypokalemia
ECG manifestations:
• QRS prolongation,
• ST segment depression,
• T wave inversion and
• some times appearance of the U wave

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hypokalemia

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 Ca2+ imbalance Hypercalcemia
ECG manifestations:
• Widened T wave,
• Short QT interval <0.35seconds,
• Osborn wave

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hypercalcemia

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Ca2+ imbalance - Hypocalcemia
ECG manifestations: Prolonged QT interval > 0.45 sec

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hypocalcemia

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SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

To summarize:
1. Calculate RATE
2. Determine RHYTHM
3. Determine QRS AXIS
4. Calculate INTERVALS
5. Assess for HYPERTROPHY
6. Look for evidence of INFARCTION

Now to finish this module lets analyze a 12-lead ECG!

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy
Infarct
Case; A 16 yo young man ran into a guardrail while riding a
motorcycle. In the ED he is comatose and dyspneic. This is his
ECG.

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SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What is the rate? Approx. 132 bpm

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What is the rhythm? Sinus tachycardia

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What is the QRS axis? Right axis deviation

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What are the PR, QRS and PR = 0.12 s, QRS = 0.08 s,
QT intervals? QTc = 0.482 s

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Is there evidence of atrial No (no peaked, notched or
enlargement? negatively deflected P waves)

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Is there evidence of No (no tall R waves in V1/V2 or
ventricular hypertrophy? V5/V6)

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

Infarct: Are there abnormal Q Yes! In leads V1-V6 and I, avL

waves?

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy
Infarct
Infarct: Is the ST elevation or Yes! Elevation in V2-V6, I and avL.
depression? Depression in II, III and avF.

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Infarct: Are there T wave changes? No

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 SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
ECG analysis: Sinus tachycardia at 132 bpm, right axis deviation, long
QT, and evidence of ST elevation infarction in the anterolateral leads
(V1-V6, I, avL) with reciprocal changes (the ST depression) in the
inferior leads (II, III, avF).

• This young man suffered an acute myocardial

infarction after blunt trauma.
• An echocardiogram showed anteroseptal
akinesia in the left ventricle with severely
depressed LV function (EF=28%).
• An angiogram showed total occlusion in the
proximal LAD with collaterals from the RCA and
LCX.
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BUNDLE BRANCH BLOCKS (BBB)

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Bundle Branch Block Principles
• Ventricular depolarization slow & out of synchrony
• QRS widens and notches
• Look at QRS width (Rate, Rhythm, Axis, Intervals)
• Most notable changes in lateral and anterior leads

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Left Bundle Branch Block (LBBB)
• Main bundle branch, Or both fascicles
• Initial forces right
• LV force (QRS) delayed and prolonged
• Final forces left
• Axis normal or left

Causes:
• Ischemia (CAD, MI), HTN heart Dz, Aortic
stenosis, DCM, Degeneration (age),
Hyperkalemia, Digoxin toxicity, Dz of
conductions sytem eg fibrosis
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 Left Bundle Branch Block: ECG
• Wide QRS (>120ms) =>0.13s f or
=>0.14s m
• Lateral aspect (leads I, aVL, V5-6):
• Tall notched R wave
• No Q waves
• ST depressions
• T wave inversions
• Anterior aspect (leads V1-3):
• Broad S wave
• J point elevation

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Right Bundle Branch Block (RBBB)

Causes:
• Ischemia
• RVH (Cor Pulmonale)
• PE
• Myocarditis or CM
• RHD
• Degenerative (age)
• Congenital (ASD)

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 Right Bundle Branch Block (RBBB)

Criteria
• Wide QRS (>120ms or >3 small sq)
• Anterior (V1 also in V2,3):
• rSR’ pattern (rabbit ears)
• Lateral (I, aVL, V5-6):
• Broad terminal S wave
• R is faster than S

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Thank you!

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