Understanding the ECG

Andrew C Rankin
Professor of Medical Cardiology
BHF-Glasgow Cardiovascular Research Centre University of Glasgow & Glasgow Royal Infirmary

The 12-lead ECG

6 - Limb leads
3 bipolar 3 unipolar

6 - Chest Leads

The Physics
Bipolar leads Measures the potential difference between two points Unipolar Leads Effectively measures the potential variation at a single point (reference = Wilsons Central Terminal)

Bipolar leads

Unipolar Leads

The Physics
Bipolar leads Leads I, II and III Unipolar Leads aVR, aVL, aVF (a = augmented) V1 V6

Limb leads

Chest leads

ECG leads & the heart

II, III, aVF = Inferior V1-V6 = Anterior

I, aVL, V6 = Lateral

Lateral

Inferior

Anterior

Cardiac Cycle and the ECG

R

P Q S

V1 r q V6

V1 S R V6

A systematic approach to the ECG

R Rate Rhythm T wave P regular or irregular? P waves Q S specific rhythm diagnosis Intervals and durations PR, QRS, QT QRS complexes (axis and morphology) ST segment / T wave changes

Rate

Rate?
Normal? Fast? Slow?

Reading ECG Squares

Intervals and Timing
Paper speed = 25mm/sec 5 large squares per second Each large square = 200 ms Each small square = 40 ms

Rate
Paper speed = 25mm/sec 5 large squares per second

Heart rate 60 bpm = 1 beat per second RR interval of 1 second = 60 bpm RR interval of 5 large squares = 60 bpm

Rate = 300 divided by the number of large squares between each QRS complex

Rate
300 divided by the number of large squares between each QRS complex
1 square - 300/min 2 squares - 150/min 3 squares - 100/min 4 squares - 75/min 5 squares - 60/min 6 squares - 50/min

OR - 1500 divided by the number of small squares between each QRS complex

Rate
How fast is this rhythm?

RR interval = 2 squares Rate = 300/2 = 150 bpm

Rhythm

Regular? or Irregular?

Rhythm

Rhythm P waves?
Regular? or Irregular?

Sinus Bradycardia

Sinus Arrest

First -Degree AV Block First-Degree

PR interval > 200 ms (1 large square) Delayed conduction through the AV Node
- Example shows PR Interval = 320 ms

Second-Degree AV Block type I

Known as Wenckebach Block

Progressive prolongation of the PR interval until there is failure to conduct and a ventricular beat is dropped

Second-Degree AV Block type II

Dropped beats with constant preceding PR interval

Third-Degree AV Block

No impulse conduction from the atria to the ventricles

Premature Atrial Contraction

Premature Ventricular Contraction

Atrial Fibrillation (AF)

Irregular rhythm Absence of P waves Fibrillatory wave

Supraventricular tachycardia

Narrow complex tachycardia Regular

Ventricular Tachycardia

Broad complex tachycardia Regular

Ventricular Fibrillation

Rapid irregular ventricular rhythm Cardiac arrest

Intervals & durations

Reading ECGs
Intervals and Timing
PR Interval QRS Complex QT Interval Normal Ranges in seconds: 0.12 0.2 s 0.06 0.1 s 0.36 0.44 s

Reading ECGs
Intervals and Timing
Upper Normal Ranges in squares: PR Interval <1 large square QRS Complex < 3 small squares QT Interval <12 small squares

QRS complexes

Cardiac axis
Normal axis is towards cardiac apex (-30 to 90) aVR I + II positive = normal I +ve, II -ve I -ve, II +ve = LAD = RAD
III aVF II aVL

http://www.blaufus s.org

Left anterior hemiblo

Left anterior hemi-fascicle

Left posterior hemi-fascicle

Wide Complex Tachycardia

Wide-complex tachycardia

Bundle branch block

SVT

OR

VT ?

Left Bundle Branch Block

V1 V6

LBBB

WiLLiaM

Right Bundle Branch Block

V1 V6

RBBB

W?

MaRRoW

ST segment

ST elevation

Acute Myocardial Infarction

Current of injury ST elevation

Old Myocardial Infarction

Myocardial window

Q wave

Pathological Q wave >0.04

ST depression

Left Ventricular Hypertrophy

ECG criteria for LVH e.g. SV1 + RV5 > 3.5 mV (35 mm)

A systematic approach to the ECG

Rate Rhythm regular or irregular? P waves specific rhythm diagnosis Intervals and durations PR, QRS, QT QRS complexes (axis and morphology) ST segment / T wave changes