ECG Updated

ECG Interpretation
ECG Basics
Course Objectives
• To recognize the normal rhythm of the

heart - “Normal Sinus Rhythm.”
• To recognize the 13 most common
rhythm disturbances.
• To recognize an acute myocardial
infarction on a 12-lead ECG.
Learning Modules
• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Impulse Conduction & the ECG
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
The “PQRST”
• P wave - Atrial
depolarization
• QRS - Ventricular
depolarization
• T wave - Ventricular
repolarization
The PR Interval
Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)
(delay allows time for

the atria to contract
before the ventricles
contract)
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.
The ECG Paper
• Horizontally
– One small box - 0.04 s
– One large box - 0.20 s
• Vertically
– One large box - 0.5 mV
The ECG Paper (cont)
3 sec 3 sec
• Every 3 seconds (15 large boxes) is

marked by a vertical line.
• This helps when calculating the heart
rate.
ECG Rhythm Interpretation
How to Analyze a Rhythm

Course Objectives

Learning Modules
• ECG Basics
Rhythm Analysis
• Step 1: Calculate rate.

• Step 2: Determine regularity.
• Step 3: Assess the P waves.
• Step 4: Determine PR interval.
• Step 5: Determine QRS duration.
Step 1: Calculate Rate
3 sec 3 sec
• Option 1
– Count the # of R waves in a 6 second
rhythm strip, then multiply by 10.
– Reminder: all rhythm strips in the Modules
are 6 seconds in length.
Interpretation? 9 x 10 = 90 bpm
R wave
• Option 2
– Find a R wave that lands on a bold line.
– Count the # of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes
- 100, 4 boxes - 75, etc. (cont)
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0
• Option 2 (cont)
– Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50
Interpretation? Approx. 1 box less than

100 = 95 bpm
Step 2: Determine regularity
R R
• 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
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
Step 4: Determine PR interval
• Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)
Interpretation? 0.12 seconds

Step 5: QRS duration
• Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)
Interpretation? 0.08 seconds

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
ECG Axis Interpretation
• Cardiac axis represents
the sum of
depolarisation vectors
generated by individual
cardiac myocytes.
Clinically it is reflected
by the ventricular axis,
and interpretation relies
on determining the
relationship between the
QRS axis and limb
leads of the ECG
ECG Axis Interpretation
• Since the left ventricle makes up
most of the heart muscle under
normal circumstances, normal
cardiac axis is directed downward
and slightly to the left:
• Normal Axis = QRS axis between
-30° and +90°.
• Abnormal axis deviation,
indicating underlying pathology, is
demonstrated by:
• Left Axis Deviation = QRS axis
less than -30°.
• Right Axis Deviation = QRS axis
greater than +90°.
• Extreme Axis Deviation = QRS
axis between -90° and 180° (AKA
“Northwest Axis”).
For more presentations www.medicalppt.blogspot.com
Methods of ECG Axis Interpretation
• There are several complementary

approaches to estimating QRS axis, which
are summarized below:
• The Quadrant Method – (Lead I and aVF)
• Three Lead analysis – (Lead I, Lead II and
aVF)
• Isoelectric Lead analysis
QUADRENT METHOD
• The most efficient way to
estimate axis is to look
at LEAD I and LEAD
aVF.
• Examine the QRS
complex in each lead and
determine if it is Positive,
Isoelectric (Equiphasic)
or Negative:
• A positive QRS in Lead
I puts the axis in roughly the
same direction as lead I.
• A positive QRS in Lead
aVF similarly aligns the axis
with lead aVF.
• Combining both coloured
areas – the quadrant of
overlap determines the axis.
So If Lead I and aVF
are both positive, the axis is
between 0° and +90° (i.e.
normal axis).
Summary
Normal Sinus Rhythm

Course Objectives

Learning Modules
• ECG Basics
Normal Sinus Rhythm (NSR)
• Etiology: the electrical impulse is formed

in the SA node and conducted normally.
• This is the normal rhythm of the heart;
other rhythms that do not conduct via
the typical pathway are called
arrhythmias.
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
Arrhythmia Formation
Arrhythmias can arise from problems in

the:
• Sinus node
• Atrial cells
• AV junction
• Ventricular cells
SA Node Problems
The SA Node can:

• fire too slow Sinus Bradycardia
• fire too fast Sinus Tachycardia
Sinus Tachycardia may be an appropriate

response to stress.
Atrial Cell Problems
Atrial cells can:

• fire occasionally Premature Atrial
from a focus Contractions (PACs)
• fire continuously Atrial Flutter

due to a looping
re-entrant circuit
Take a note….
• A re-entrant
pathway occurs
when an impulse
loops and results
in self-
perpetuating
impulse
formation.
Atrial Cell Problems
Atrial cells can also:
• fire continuously Atrial Fibrillation
from multiple foci
or
fire continuously Atrial Fibrillation
due to multiple
micro re-entrant
“wavelets”
Atrial tissue
Multiple micro re-
entrant “wavelets”
refers to wandering
small areas of
activation which
generate fine chaotic
impulses. Colliding
wavelets can, in turn,
generate new foci of
activation.
AV Junctional Problems
The AV junction can:

• fire continuously Paroxysmal
due to a looping Supraventricular
re-entrant circuit Tachycardia
• block impulses AV Junctional Blocks
coming from the
SA Node
Ventricular Cell Problems
Ventricular cells can:

• fire occasionally Premature Ventricular
from 1 or more foci Contractions (PVCs)
• fire continuously Ventricular Fibrillation
from multiple foci
• fire continuously Ventricular Tachycardia
due to a looping re-
entrant circuit
Sinus Rhythms and

Premature Beats
Course Objectives

Learning Modules
• ECG Basics
Arrhythmias
• Sinus Rhythms
• Premature Beats
• Supraventricular Arrhythmias
• Ventricular Arrhythmias
• AV Junctional Blocks
Sinus Rhythms
• Sinus Bradycardia
• Sinus Tachycardia
Rhythm #1
• Rate? 30 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.12 s
• QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
Sinus Bradycardia
• Deviation from NSR

- Rate < 60 bpm
Sinus Bradycardia
• Etiology: SA node is depolarizing slower

than normal, impulse is conducted
normally (i.e. normal PR and QRS
interval).
Rhythm #2
• Rate? 130 bpm

• Regularity? regular
• P waves? normal
Interpretation? Sinus Tachycardia
Sinus Tachycardia

- Rate > 100 bpm
Sinus Tachycardia
• Etiology: SA node is depolarizing faster

than normal, impulse is conducted
normally.
• Remember: sinus tachycardia is a
response to physical or psychological
stress, not a primary arrhythmia.
Premature Beats
• Premature Atrial Contractions

(PACs)
• Premature Ventricular Contractions
(PVCs)
Rhythm #3
• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2/7 different contour
• PR interval? 0.14 s (except 2/7)
Interpretation? NSR with Premature
Atrial Contractions
Premature Atrial Contractions

– These ectopic beats originate in the
atria (but not in the SA node),
therefore the contour of the P wave,
the PR interval, and the timing are
different than a normally generated
pulse from the SA node.
Premature Atrial Contractions
• Etiology: Excitation of an atrial cell

forms an impulse that is then conducted
normally through the AV node and
ventricles.
• When an impulse originates anywhere in
the atria (SA node, atrial cells, AV node,
Bundle of His) and then is conducted
normally through the ventricles, the QRS
will be narrow (0.04 - 0.12 s).
Rhythm #4
• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• QRS duration? 0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
PVCs

– Ectopic beats originate in the ventricles
resulting in wide and bizarre QRS
complexes.
– When there are more than 1 premature
beats and look alike, they are called
“uniform”. When they look different, they are
called “multiform”.
PVCs
• Etiology: One or more ventricular cells

are depolarizing and the impulses are
abnormally conducting through the
ventricles.
• When an impulse originates in a
ventricle, conduction through the
ventricles will be inefficient and the
QRS will be wide and bizarre.
Ventricular Conduction
Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
Acute Myocardial Infarction

Course Objectives

heart arrhythmias.
Learning Modules
• ECG Basics
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
The 12-Lead ECG
• The 12-Lead ECG sees the heart

from 12 different views.
• Therefore, the 12-Lead ECG helps
you see what is happening in
different portions of the heart.
• The rhythm strip is only 1 of these 12
views.
The 12-Leads
The 12-leads include:

–3 Limb leads
(I, II, III)
–3 Augmented leads
(aVR, aVL,
aVF)
–6 Precordial leads
(V1- V6)
Views of the Heart
Lateral portion
Some leads get a of the heart
good view of the:
Anterior portion
of the heart
Inferior portion
of the heart
ST Elevation
One way to
diagnose an
acute MI is to
look for
elevation of
the ST
segment.
ST Elevation (cont)
Elevation of the
ST segment
(greater than 1
small box) in 2
leads is
consistent with a
myocardial
infarction.
Anterior View of the Heart
The anterior portion of the heart is best

viewed using leads V1- V4.
Anterior Myocardial Infarction
If you see changes in leads V1 - V4

that are consistent with a myocardial
infarction, you can conclude that it is
an anterior wall myocardial infarction.
Putting it all Together
Do you think this person is having a
myocardial infarction. If so, where?
Interpretation
Yes, this person is having an acute anterior
wall myocardial infarction.
Other MI Locations
Now that you know where to look for an

anterior wall myocardial infarction let’s
look at how you would determine if the MI
involves the lateral wall or the inferior wall
of the heart.
Other MI Locations
First, take a look Lateral portion
again at this of the heart
picture of the heart.
Anterior portion
of the heart
Inferior portion
of the heart
Other MI Locations
Second, remember that the 12-leads of the ECG look at
different portions of the heart. The limb and augmented
leads “see” electrical activity moving inferiorly (II, III and
aVF), to the left (I, aVL) and to the right (aVR). Whereas, the
precordial leads “see” electrical activity in the posterior to
anterior direction.
Limb Leads Augmented Leads Precordial Leads
Other MI Locations
Now, using these 3 diagrams let’s figure where
to look for a lateral wall and inferior wall MI.

Anterior MI
Remember the anterior portion of the heart is
best viewed using leads V1- V4.
Lateral MI
So what leads do you think
the lateral portion of the Leads I, aVL, and V5- V6
heart is best viewed?

Inferior MI
Now how about the
inferior portion of the Leads II, III and aVF
heart?

Now, where do you think this person is
having a myocardial infarction?
Inferior Wall MI
This is an inferior MI. Note the ST elevation
in leads II, III and aVF.
How about now?
Anterolateral MI
This person’s MI involves both the anterior wall
(V2-V4) and the lateral wall (V5-V6, I, and aVL)!
Advanced 12-Lead Interpretation

Course Objectives

heart arrhythmias.
Learning Modules
• ECG Basics
The 12-Lead ECG
The 12-Lead ECG contains a wealth of
information. In previous slides you learned
that ST segment elevation in two leads is
suggestive of an acute myocardial
infarction. In this module we will cover:
– ST Elevation and non-ST Elevation MIs
– Left Ventricular Hypertrophy
– Bundle Branch Blocks
ST Elevation and
non-ST Elevation MIs
ST Elevation and non-ST Elevation MIs
• When myocardial blood supply is abruptly
reduced or cut off to a region of the heart, a
sequence of injurious events occur beginning
with ischemia (inadequate tissue perfusion),
followed by necrosis (infarction), and eventual
fibrosis (scarring) if the blood supply isn't
restored in an appropriate period of time.
• The ECG changes over time with each of

these events…
ECG Changes
Ways the ECG can change include:
ST elevation &
depression
T-waves
peaked flattened
Appearance inverted
of pathologic
Q-waves
ECG Changes & the Evolving MI
There are two Non-ST

Elevation
distinct patterns
of ECG change
depending if the
infarction is: ST
Elevation
–ST Elevation (Transmural or Q-wave), or

–Non-ST Elevation (Subendocardial or non-Q-wave)
ST Elevation Infarction
The ECG changes seen with a ST elevation infarction are:
Before injury Normal ECG
Ischemia ST depression, peaked T-waves, then T-

wave inversion
Infarction ST elevation & appearance of

Q-waves
Fibrosis ST segments and T-waves return to
normal, but Q-waves persist
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
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
Extra credit:
What is the
rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!
Here’s an ECG of an inferior MI later in time:
Now what do
you see in the
inferior leads?
ST elevation,
Q-waves and
T-wave
inversion
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
Non-ST Elevation Infarction
Here’s an ECG of an evolving non-ST elevation MI:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.
Question:
What area of
the heart is
infarcting?
Anterolateral
Left Ventricular Hypertrophy
Compare these two 12-lead ECGs. What stands
out as different with the second one?
Normal Left Ventricular Hypertrophy
Answer: The QRS complexes are very tall

(increased voltage)
Why is left ventricular hypertrophy characterized by tall
QRS complexes?
As the heart muscle wall thickens there is an increase in
electrical forces moving through the myocardium resulting
in increased QRS voltage.
LVH ECHOcardiogram
Increased QRS voltage
• Criteria exists to diagnose LVH using a 12-lead ECG.
– For example:
• The R wave in V5 or V6 plus the S wave in V1 or V2
exceeds 35 mm.
• However, for now, all

you need to know is
that the QRS voltage
increases with LVH.
Bundle Branch Blocks
Turning our attention to bundle branch blocks…
Remember normal
impulse conduction is
SA node 
AV node 
Bundle of His 
Bundle Branches 
Purkinje fibers
Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
So, depolarization of
the Bundle Branches
and Purkinje fibers are
seen as the QRS
complex on the ECG.
Therefore, a conduction
block of the Bundle
Branches would be Right
reflected as a change in BBB
the QRS complex.
With Bundle Branch Blocks you will see two changes
on the ECG.
1. QRS complex widens (> 0.12 sec).
2. QRS morphology changes (varies depending on ECG lead,
and if it is a right vs. left bundle branch block).
Why does the QRS complex widen?
When the conduction

pathway is blocked it
will take longer for
the electrical signal
to pass throughout
the ventricles.
Right Bundle Branch Blocks
What QRS morphology is characteristic?
For RBBB the wide QRS complex assumes a
unique, virtually diagnostic shape in those
leads overlying the right ventricle (V1 and V2).
V1
“Rabbit Ears”
Left Bundle Branch Blocks
What QRS morphology is characteristic?
For LBBB the wide QRS complex assumes a
characteristic change in shape in those leads
opposite the left ventricle (right ventricular
leads - V1 and V2).
Broad,
Normal deep S
waves
Don’t worry too much right now
about trying to remember all the
details. You’ll focus more on
advanced ECG interpretation in
your clinical years!
JAZAKALLAH &
THANKYOU

ECG Updated

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ECG Interpretation

• To recognize the normal rhythm of the

(delay allows time for

• SA Node - Dominant pacemaker with

• Every 3 seconds (15 large boxes) is

How to Analyze a Rhythm

• To recognize the normal rhythm of the

• Step 1: Calculate rate.

Interpretation? Approx. 1 box less than

• Look at the R-R distances (using a caliper or

• Are there P waves?

• Normal: 0.12 - 0.20 seconds.

Interpretation? 0.12 seconds

• Normal: 0.04 - 0.12 seconds.

Interpretation? 0.08 seconds

• Rate 90-95 bpm

• There are several complementary

Normal Sinus Rhythm

• To recognize the normal rhythm of the

• Etiology: the electrical impulse is formed

•Rate 60 - 100 bpm

Arrhythmias can arise from problems in

The SA Node can:

Sinus Tachycardia may be an appropriate

Atrial cells can:

• fire continuously Atrial Flutter

The AV junction can:

Ventricular cells can:

Sinus Rhythms and

• To recognize the normal rhythm of the

• Deviation from NSR

• Etiology: SA node is depolarizing slower

• Rate? 130 bpm

• Deviation from NSR

• Etiology: SA node is depolarizing faster

• Premature Atrial Contractions

• Deviation from NSR

• Etiology: Excitation of an atrial cell

• Deviation from NSR

• Etiology: One or more ventricular cells

Acute Myocardial Infarction

• To recognize the normal rhythm of the

• The 12-Lead ECG sees the heart

The 12-leads include:

The anterior portion of the heart is best

If you see changes in leads V1 - V4

Now that you know where to look for an

Limb Leads Augmented Leads Precordial Leads

Limb Leads Augmented Leads Precordial Leads

Limb Leads Augmented Leads Precordial Leads

Advanced 12-Lead Interpretation

• To recognize the normal rhythm of the

• The ECG changes over time with each of

There are two Non-ST

–ST Elevation (Transmural or Q-wave), or

Before injury Normal ECG

Ischemia ST depression, peaked T-waves, then T-

Infarction ST elevation & appearance of

B. Ischemia from coronary artery occlusion

C. Infarction from ongoing ischemia results in