ECG INTERPRETATION

Normal Conduction System

Sinoatrial node

Internodal
pathway

AV node

Bundle of

His

Bundle
Branches
 Pacemakers o f 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.
Prerequisites before E C G
I n te r p r e t atio n

STANDARD CALLIBRATION
Speed = 25mm/s
Amplitude = 0.1mV/mm
• 1 large square: 0.2s(200ms)
1 small square: 0.04s
(40ms)
• 1mV: 10mm high
• 0.1 mV amplitude
READ THE PT DETAILS
callibratio
n
The best way to interpret an E C G is
to do it step-by-step
Step 1: Rate
Step 2: Rhythm +
Regularity Step 3: P- wave
Step 4: PR - interval
Step 5: QRS
Complex
Step 6: ST Segment and T waves
Step 7: QT interval (Include T and U
wave)
Step 8 : Cardiac Axis
Step 9: Other ECG signs
STEP 1:
RATE
CALCULATING RATE

• As a general interpretation, look at lead II at the bottom part of the ECG

strip This lead is the rhythm strip which shows the rhythm for the whole
time the ECG is recorded. Look at the number of square between one R-R
interval

• To calculate rate, use any of the following formulas:

300
Rate =
the number of BIG SQUARE between R-R interval

OR

1500
Rate =
the number of SMALL SQUARE between R-R interval
 CALCULATING RATE Tips for
calculation:in
For example: extreme tacycardia

300
Rate = or Rate =
3
1500
15
Rate = 100 beats per minute
 CALCULATING RATE

• If you think that the rhythm is not regular, count the number of electrical
beats in a 6-second strip and multiply that number by 10.(Note that some
ECG strips have 3 seconds and 6 seconds marks) Example below:

16x10=160

There are ? R waves in this 6-seconds strip.

(30 big boxes)

Rate = (Number of R waves in 6-second strips) x 10

= ? x 10
= ? bpm
Sinus
Bradycardia

• Rate < 60bpm, otherwise normal

Sinus
Tachycardia
Rate >100bpm

• Rate > 100bpm, otherwise normal

 STEP 2:
RHYTHM
RHYTHM

• If in doubt, use a paper strip to map out consecutive beats and see whether
the rate is the same further along the ECG.

• Measure ventricular rhythm by measuring the R-R interval

• Is the rhythm regular or irregular?
INTERPRETATION
• Sinus rhythm: Each P is followed by QRS
complex
• Absent P wave: Rhythm is junctional or
ventricular in origin
 RHYTHM

Normal Sinus Rhythm

• ECG rhythm characterized by a usual rate of anywhere between 60-99 bpm,

every P wave must be followed by a QRS. Normal duration of PR interval is 3-5
small squares. The P wave is upright in leads I and II.
 STEP 3:
P- WAVE
P -WAVE

Normal P- wave
• 3 small square wide, and 2.5 small square
high
• Always positive in lead I and II in NSR
• Always negative in lead aVR in NSR
• Commonly biphasic in lead V1
P wave

1. Are P waves present?

2. Is there 1 P for each QRS complex?
3. Are the P waves smooth, rounded and upright in appearance
except inverted P waves in lead aVR?
4. Do all P waves look similar?
P -WAVE

P pulmonale
• Tall peaked P wave
• Generally due to enlarged right atrium-
commonly associated with congenital
• heart disease, tricuspid valve disease, pulmonary
hypertension and diffuse lung disease

Biphasic P wave
• It’s terminal negative deflection more than 40
ms wide and more than 1 mm deep is an ECG
sign of left atrial enlargement

P mitrale
• Wide P wave, often bifid, may be due to
mitral stenosis or left atrial enlargement
 STEP 4:
PR-INTERVAL
PR INTERVAL

NORMAL PR
INTERVAL

Long PR interval
may indicate
heart block

Short PR
interval may
disease like
PR-Interval 3-5 small square (120-200ms) Wolf-Parkinson-
White
 PR-INTERVAL

Wolff–Parkinson–White
Syndrome Wolf Parkinson White Syndrome

• One beat from a rhythm strip in V2

demonstrating characteristic findings
in WPW syndrome

• Note the characteristic:

• Delta wave (above the blue bar),
the short PR interval (red bar) of
0.08 seconds, and the long QRS
complex
(green) at 0.12 seconds
• Accessory pathway (Bundle
of Kent) allows early
activation of the ventricle (delta
wave and short PRI)
 STEP 5:
QRS-
COMPLEX
 QRS COMPLEX

Q wave amplitude less

than 1/3 QRS
amplitude(R+S) or
< 1 small square

QRS complex< 3 small square (0.10 sec)

Prolonged indicates hyperkalemia or BBB
INTERPRETATO
N
• Narrow complexes (QRS <100 ms) are supraventricular in
origin.
• Broad complexes (QRS >100 ms) may be either:
– Ventricular in origin
– Due to aberrant conduction e.g. due to bundle branch
block
– Electrolytes imbalance e.g. Hyperkalaemia
– Ventricular paced rhythm
STEP 6: ST-
SEGMENT
and T WAVE
ST
SEGMENT
T
wave
• T wave is the positive
deflection after each QRS
complex
• It represents
ventricular
repolarisation
• Upright in all leads except
aVR and V1
• Amplitude
– < 5mm in limb leads
– <15mm in precordial leads
Step 7: QT-
INTERVAL
QT- INTERVAL

RR interval
• QT interval decreases when heart rate increases
• As a general guide the QT interval should be 0.35- 0.45 s,(<2 large square)
and should not be more than half of the interval between adjacent R
waves (R-R interval)
QT
interval

< 2 large square

LONG QT SYNDROME

• LQT is a rare inborn heart condition

in which repolarization of the heart
is delayed following a heartbeat
• Example: drug toxicity
 STEP 8:
CARDIAC
AXIS
CARDIAC AXIS

• To determine cardiac axis look at QRS complexes of lead I , II,

III.
Axis Lead I Lead II Lead III
Normal Positive Positive Positive/Negative

Right axis. Negative Positive Positive

deviation
Left axis Positive Negative Negative
deviation
• Remember, positive(upgoing) QRS complex means the
impulse travels towards the lead.
• Negative means moving away
CARDIAC AXIS

Positive

Positive

Positive

Normal Axis
Deviation
CARDIAC AXIS

Negative

Positive

Positive
Right Axis
Deviation
 CARDIAC AXIS

Positive

Negative

Negative

Left Axis
Deviation
 I I

aVF
EXTREME LEFT AXIS aVF
RIGHT AXIS DEVIATIO
DEVIATION N

(180º) I (0º)

RIGHT AXIS NORMAL AXIS

DEVIATION
I
I

aVF

aVF (+90º)
STEP 9: OTHER
ECG SIGNS
Left ventricular hypertrophy
• To determine LVH, use one of the following:
(LVH)
Sokolow
Criteria & Lyon Criteria: S (V1) + R(V5 or V6) > 35mm
:
Cornell Criteria: S (V3) + R (aVL) > 28 mm (men) or > 20 mm (women)
Others: R (aVL) > 13mm

Example:

LVH!

S (V1) + R(V5) = 15 + 25 = 40mm

S(V3) + R (aVL)= 15 + 14 =29mm
R(aVL) =14 mm
Let’s see another example of
LVH

LVH strain pattern

• Tall R waves in V4 and V5 with down sloping ST segment depression and T wave
inversion are suggestive of left ventricular hypertrophy (LVH) with strain
pattern
• LVH with strain pattern usually occurs in pressure overload of the left ventricle
as in systemic hypertension or aortic stenosis
Right ventricular hypertrophy
(RVH)
Right axis deviation (QRS axis >100o) V1(R>S), V6 (S>R)
Right ventricular strain T wave inversion
Example
:

So, it’s RVH!

 Common Causes of LVH and
LVHRVH RVH
• Hypertension (most • Pulmonary hypertension
common cause) Aortic • Tetralogy of Fallot
stenosis • Pulmonary valve stenosis
• Aortic regurgitation Mitral • Ventricular septal defect (VSD)
regurgitation • High altitude
• Coarctation of the aorta • Cardiac fibrosis COPD
• Hypertrophic • Athletic heart syndrome
cardiomyopathy
 E C G RULES
• Professor Chamberlains 10 rules of a normal ECG, a foundation to
ECG interpretation used all over the world to this date
 10 RULES OF A NORMAL ECG
Rule 1 Rule 2
PRI should be 120 to 200ms (3 to 5 small QRS complex width should not exceed
squares) 120ms (<3 small squares)

Rule 3 Rule 4
QRS complex should be QRS and T waves tend to have
dominantly upright in lead 1 and the same direction in the limb
II leads

Rule 5 Rule 6
All waves are negative in lead R wave must grow from V1 to v4
AVR and
S wave must grow from V1 to V3
and disappear in V6

Rule 7 Rule 8
ST segment should start P waves should be upright in I,II
isoelectric except V1 and V2 and V2 to V6
(maybe elevated)

Rule 9 Rule 10
No Q wave or only a small q wave (<0.04 in T wave must be upright in 1,II, V2- V6
width) in I,II,V2 to V6
THANK YOU