Approach to ECG

interpretation
Jifunze Medics
Systemic examination of ECG
• Rate • QRS complex
• Rhythm • Axis
• Elect, position
• Intervals • Rotation
• PR
• Amplitudes
• QRS
• Q- wave
• QT
• ST segment
• P wave
• T wave
• U wave
• Conclusions
Rhythm
• Regular: RR intervals equal

• Irregular: RR intervals not equal

Rate
• Regular rhythm
• Count number of large boxes or small boxes in between RR intervals
• If you counted large boxes (300 ÷ number of large boxes)
• If you counted small boxes (1500 ÷ number of small boxes)
• Irregular rhythm
• Count the number of QRS complexes on a 10s strip ECG and multiple the
answer by 6.
Intervals (PR)
• Prolonged (more than 0.20s) • Decreased (less than 0.12s)
• 1st degree AV block • Junctional rhythm
• Rheumatic fever • WPW syndrome
• Coronary artery diseases
• Digitalis
• Hyperkalemia/
hypermagneseamia
QRS Interval
• Increased (More than 0.12 sec)
• LV hypertrophy
• BBB
• Hyperkalemia
• Hypercalcemia
• Hypermagneseamia
• Quinidine
• Procaine amide
QT interval
• Increased • Decreased
• Acute carditis • Hypercalcemia
• Hypocalcemia • Digitalis
• Myocardial infarction • Hyperthermia
• CCF • Vagal stimulation
• Quinidine
• CVA
• Hypomagnesaemia
• Congenital
• Hypokalemia
• Hypothermia
P wave
• Inverted in AVR
• Upright in Standard Lead: 1,2 AVF, V2-6
• Variable in lead: 3, AVL
• May be biphasic in lead V1

• Normal wave
• Height 2.5 mm; Width 0.11 sec
• Peaked P wave: Right atrial enlargement (P pulmonale)
• Broad and notched biphasic p wave: left atrial enlargement (p mitrale)
QRS complex (Axis)
• Axis
• We look at lead 1 and AVF
• Left axis deviation: left leaves (If the QRS complexes opposes each other is
LAD)
• Right axis deviation: Right reaches (if the QRS complexes comes together is
RAD)
• LAD differentials
• Myocardial infarction
• Coronary artery disease
• Long standing LVH
• Cardiomyopathy
QRS complex (BBB)
• Right BBB
• Look at lead V1 nad V6
• Use MARROW
• Look for M patern in V1
• QRS more than 0.10 sec
• Differentials
• Maybe normal
• Transitory acute PE
• Partial ASD
• RV diastolic overload
• Rheumatic heart disease
• Left BBB
• Look at V1 and V6
• Use WILLIAM
• Look for M patern in V6
• QRS more than 0.12s
• Differentials
• Always pathological
• Coronary heart diseases
• Hypertrophic heart disease
• Rheumatic heart disease
• Quinidine
• Procaineamide
• Hyperkalemia
• Tumor/ gumma
S-T segment
• Elevation differentials
• Acute pericarditis
• Myocardial injury
• Normal healthy African
• Acute pericarditis
• Concave upwards
• No pathological Q waves
• No reciprocal changes
• Slight changes over large areas
• Myocardial injury
• Convex upwards
• Pathological Q wave
• Depression
• Types of depression
• Junctional (maybe normal)
• Plane horizontal trough (ischemia)
• Strain (systolic overload)
• Digitalis effects
• Differentials
• MI (reciprocal changes)
• Myocardial ischemia
• Myocardial strain
• Digitalis effects
• Hypo/hyperkalemia
• Hypothermia
Localization of infarction

• Lead 2, 3, aVF (inferior wall)

• Lead 1, aVL, V5, V6 (lateral wall)
• Lead V1, V2 (Septal wall)
• Lead V3, V4 (Anterior wall)
T waves
• Tall T wave • Inverted T waves
• Myocardial ischemia
• Myocardial infarction
• Hyperkalemia
• Hypermagneseamia
• Ischemia/ infarction
• Ventricular hypertrophy
• Myocarditis
• Digitalis
• Anaemia
• Hypokalemia/hypocalcemia
• Constrictive pericarditis
• Hyper/hypothyroidism
• Amyloid and other infiltrates
• Beri beri