CORE PRINCIPLES OF

INTERPRETING ECG TRACING

BY

DR. EMMANUEL AFOLABI AMAO

(FMCGP).
THE MEDICAL DIRECTOR.
SHALOM MEDICAL CENTRE
OGBOMOSO.
Introduction
Electrocardiogram (ECG) is an essential investigation
procedure in medical practice.
It is essential and necessity for comprehensive care by all
physicians.
ECG recording and interpretation have been made
simpler in the recent time. There are some portable ECG
machines that are easy to use and have automated
interpretation.
Introduction (cont.) A
family physician should be abreast of new development
and be ready to refresh his/her knowledge of this
important diagnostic procedure.
ECG is an electronic recording of cardiac activities and it
describes conduction pattern, rhythm and abnormalities
in the heart.
A 12 LEAD ECG TRACING
Precaution for ECG recording
A relaxed, comfortable atmosphere
Avoid interference
Ensure good contact of electrodes with the body
Proper setting of the ECG machine
Clean and maintain your machine well.
Standardized Sequence
In order to minimize subtle abnormalities in the ECG
tracing it is important to follow a standardized
sequence of steps
1. Measurements
2. Rhythm Analysis
3. Conduction Analysis
4. Waveform Description
5. ECG interpretation
6. Compare with previous ECG (if any)
Electrode placement
Ideal limb and chest position for electrode placement
1. RL- Right leg
2. LL- Left leg
3. RA – Right arm just above the wrist
4. LA- Left arm
5. VI – Fourth intercostal space right sternal edge
6. V2- Fourth intercostal space left sternal edge
 Electrode placement (cont.)
7. V3 – Midway between V2 and V4
8. V4- 5th intercostal space mid-clavicular line
9. V5- Same level as V4 ant. Axillary line
10. V6- Same as V4 mid axillary line
11. V6R- 4th intercostal space right
mid-clavicular line
ELECTRODES PLACEMENT (cont.)
ANATOMY OF THE HEART
GROSS ANATOMY SHOWING SURFACE OF THE
HEART, THE CORONARY ARTERIES AND VALVES
GROSS ANATOMY SHOWING THE MUSCLE
LAYERS AND THE CHAMBERS
THE CONDUCTION PATHWAYS
ANATOMY OF THE HEART 2
ECG MACHINE IN USE, THE STRIP AND THE
PATIENT
Sequence of ECG interpretation
 Rhythm
 Rate
 Electrical axis
 P wave
 PR interval
 QRS complex
 ST Segment
 T waves
 QT interval
 U wave
RHYTHM
This is the frequency and time
relationships of atria and
ventricular depolarization.
The P wave and QRS complexes
are used to determine normal
rhythm as well as its disturbances
RHYTHM
P waves must be present and regular
 The P wave form should be consistent
The Frequency should be between 60
and 100 per minute.
Each P wave should be followed by a
QRS complexes. PR interval should be
within normal range and constant.
INTERPRETING ECG TRACING
RATE
RATE CALCULATION DEPENDS ON THE
REGULARITY OF THE RHYTHM.
REGULAR- 300 of the 5mm blocks (0.2s) is one
minute. Count the number of large blocks between the
RR interval and divide this into 300-
300/5=60beats/minute.
IRREGULAR- Count the RR or PP intervals over a
6seconds period e.g. 30x5mm blocks then x10 i.e.
Rate= 11x10=110beats/min. 30large squares contain
11QRS complexes.
ECG STRIP
1 Small horizontal block = 0.04 seconds
5 Small horizontal block = 1 Large block = 0.2s
5 Large horizontal blocks = 1 second
Normal strip = 30 large horizontal blocks = 6s
1 Small vertical block = 0.1mV
1 Large vertical block = 0.5mV
Amplitude (mV) =no. of small blocks from baseline to
the highest or lowest point
ECG TRACING INTERPRETATION
Information Obtained from ECG include
Rhythm abnormalities, i.e arrhythmias
Conduction disorders
Ischaemia and myocardial infarction (MI)
Structural abnormalities such as chamber
hypertrophy, dextrocardia and cardiomyopathy.
Electrolyte imbalance
Inflammation of pericarditis and myocarditis
Hyperthermia, thyroid disease, malignance, drugs e.g.
digoxin
Abnormalities in ECG measurement
I. Heart Rate -60bpm and below = bradycardia, 90bpm
and above = tachycardia.
II. PR interval (0.12-0.2 seconds=3-5 small squares)
III. QRS Duration (0.12 seconds = 3 small squares)
IV. QT interval
V. QRS Axis
QRS Complexes
Normal Cardiac axis Lead II has the most positive deflection compared to lead
I&III
 Right axis deviation
Lead III has the most positive deflection & lead I should
be negative. This is commonly seen in RVH
 Left axis deviation
Lead I has the most positive deflection & Lead II & III are negative. This is seen in heart
conduction defects
 Atrial fibrillation
P-waves are absent & there is an irregular rhythm
Prolonged P-R interval (0.12-0.2=3-5small squares) A prolonged

P-R interval may suggest the presence of heart block

 Shortened P-R interval
A shortened P-R interval may suggest the presence of Wolf Parkinson White (WPW)
Syndrome
 ST Elevation
If > 1mm (1 small square) in relation to the baseline. Commonly caused by acute myocardial
infarction. The morphology of the ST elevation differs depending on how long ago the MI occurred
 ST Depression
Significant when it is >1mm in relation to the baseline

• Can be caused by anxiety, tachycardia, digoxin toxicity,

haemorrhage,hypokalaemia, myocarditis,coronary artery insufficiency, MI.
It must therefore be interpreted in the context of the patient.
 T Waves inversion – are one of the most
common abnormalities found on ECG
They lack specificity & should not be used alone to form a diagnosis. Can be
caused by smoking, anxiety, tachycardia, haemorrage, & shock,
hypokalaemia, pericarditis, MI (new & previous), bundle branch block
(BBB),WPW syndrome.
 Tall T Waves
(>5mm in the standard leads, 10mm in the precordial leads)
Exercise ECG Test

Indication
 Diagnosis of chest pain
 Risk stratification in stable angina
 Risk stratification after myocardial infraction
 Assessment of exercise induced arrhythmias
 Assessment of the need for a permanent
pace-maker
 Assessment of exercise tolerance
 Assessment of the patient’s repose to
treatment
Exercise ECG test Risks and
contraindication
Morbidity of 2.4/10,000 and a mortality of
1/10,000. You must take good history and
perform a careful clinical examination
before embarking on the procedure.
Absolute Contraindications
MI within previous 7 day
Unstable angina-rest pain within the previous 48hrs
Severe aortic stenosis or hypertrophic obstructive
cardio-myopathy
Acute myocarditis
Acute pericarditis
Uncontrolled hypertension >250/120mmHg
Uncontrolled heart failure
A recent thromboembolic episode
Acute febrile illness
SUMMARY
Electrocardiogram (ECG) must be recorded meticulously to obtain a
correct and accurate reading.
 An incorrect ECG tracing can lead to wrong assessment of the patient.
 Wrong interpretation of the ECG tracing may lead to improper
management.
 There are ECG artefacts which are avoidable.
 Interpretation of ECG should based on individual patient’s clinical
picture
 Remember that a cardiologist is highly skilled in interpreting ECG, you
should remember to send his patient to him!
 Self reading automated ECG machines are now available for your quick
assessment and decision. They are affordable.
 S HA L OM !