Electrocardiogram Examination

Introduction
1. This is the ECG of Mr./ Mrs./ Ms. [name]
2. Done on the [time] [date]
3. This is the [ordinal number] of a series of [number] ECGs
4. Before you begin interpreting ask yourself:
a. Is the ECG properly calibrated?
i. Paper speed is 25mm/s (1mm represents 0.04s)
ii. 10mm equals to 1mV (1mm represents 0.1mV)
b. Are the leads properly placed?
i. aVR should have a negative p wave, negative QRS complex
and negative T wave.

Rate
1. What is the rate?
1500
a. RR interval in number of small boxes
300
b. RR interval in number of big boxes
c. If patient is in atrial fibrillation, take the number QRS complexes
over 10 seconds or 50 large boxes and multiply by 6.
2. Tachyarrhythmia
3. Bradyarrhythmia

Rhythm
1. What is the rhythm?
a. Regular (AVRT/ AVNRT/ SVT)
b. Regularly irregular (sinus rhythm)
c. Irregularly irregular (atrial fibrillation)

Axis
1. What is the axis?
Normal axis Right Axis Left Axis
Deviation Deviation
Leads I + - +
Leads II + - -
Leads III - + -
a. Left axis deviation
i. LEFT ventricular hypertrophy
ii. LEFT bundle branch block
iii. Left anterior fascicular block (LARP-Left anterior right
posterior)
1. Frontal plane axis between -45° and -90°
 2. qR in lead aVL
3. R peak time in lead aVL ≥45ms
4. QRS duration <120ms
iv. PRIMUM ASD (LPRS-LAD primum RAD secundum)
b. Right axis deviation
i. RIGHT ventricular hypertrophy
ii. RIGHT bundle branch block
iii. Left posterior fascicular block (LARP-Left anterior right
posterior)
1. Frontal plane axis between 90° and 180°
2. rS in leads I and aVL
3. qR in leads III and aVF
4. QRS duration <120ms
iv. SECUNDUM ASD (LPRS-LAD primum RAD secundum)

P waves
1. Normal:
a. Duration <0.12s (<3small boxes)
b. Amplitude <0.25mV (<2.5 small boxes)
c. Notched in limb leads and biphasic in V1
2. Abnormalities
a. Right atrial enlargement
i. P pulmonale: narrow p wave with increased amplitude
ii. P wave >2.5mm in lead II
iii. P wave >1.5mm in V1 or V2
iv. P wave axis right ward
v. Right atrium maybe large and spread to the left causing P
inversion in V1.
b. Left atrial enlargement
i. P mitrale: notched with enlargement of the terminal
portion of the p wave.
ii. Interpeak interval >0.04s
iii. Negative phase of p in V1 >0.04s or >1mm
c. Multifocal atrial tachycardia
i. Discrete p waves with at least 3 different morphologies
ii. >100 beats per minute
iii. P waves which return to baseline
iv. P-P intervals, P-R intervals and R-R intervals, which vary.
d. Wandering atrial pacemaker
i. MAT with heart rate <100 bpm
e. Atrial fibrillation
i. Irregularly irregular
ii. No obvious P waves seen
f. Atrial flutter
i. Rate of 240 to 340
ii. Sawtooth pattern (F waves) in II, III, and aVF
PR interval
1. Normal:
a. 0.12 to 0.2s (3 to 5 small boxes)
2. Abnormalities
a. Lown-Ganong-Levine pattern (bundle of James/ Brechnemacher
fibers bypasses AV node)
i. PR interval short ≤60msec
ii. Narrow QRS complex
iii. 1:1 conduction between atrium and His bundle
b. Wolff-Parkinson-White syndrome (bundle of Kent [atria to
ventricle])
i. PR interval short ≤120msec
ii. Delta wave (slurred and broad upstroke of QRS complex
iii. QRS wide and bizarre ≥120msec
iv. Type A
1. Left sided bypass tract
2. Tall R waves in V1 to V3
v. Type B
1. Right sided bypass tract
2. QS waves in V1 to V3
c. Atrioventricular block
i. First degree (PR>0.2sec)
ii. Second degree
1. Mobitz type I (Wenckebach)
a. Progressively prolonging PR until one P is not
transmitted
2. Mobitz type II
a. No change in PR interval prior to dropped
beat
3. 2:1 AV block
a. Every other beat is dropped
b. Not able to say if Type I or Type II
4. High grade AV block
a. More than 2 consecutives P waves not
conducted
iii. Third degree
1. Non-conduction of P waves resulting in escape
rhythm
2. Intrinsic rhythm of ventricle slower than atrial
intrinsic rhythm
3. More P waves than QRS complexes
4. P-P intervals do not vary
5. R-R intervals do not vary

QRS complex
1. Lower case letters such q, r, and s used for amplitude <0.05mV
2. Normal duration is 0.06 to 0.10s (1.5 to 2.5 small boxes)
3. Q wave criteria for abnormality (indicating prior MI):
 a. V2 and V3: ≥0.02s or QS complex
b. Any other 2 leads in contiguous grouping: ≥0.03s, ≥0.1mV (1mm)
or QS complex
4. Leads III, aVF, aVL, aVR and V1 may normally display moderate to large Q
wave and/or T inversion in otherwise healthy adults. They are usually in
isolation.
5. R wave abnormality (indicating prior MI):
a. R wave ≥0.04s (1 small box) in V1 and V2.
b. R/S ≥1 with a concordant positive T wave.
c. V1 to V3: posterior wall MI
6. Abnormalities:
a. Left bundle branch block
i. ≥120ms (3 small boxes)
ii. Broad notched or slurred R wave in leads I, aVL, V5 and V6.
iii. RS occasionally in V5 and V6.
iv. Q wave absent in leads I, aVL, V5 and V6 in the absence of
myocardial pathology a narrow q wave may be present in
lead aVL.
v. R peak time greater than 60ms (1.5 small boxes) in V5 and
V6 but normal in leads V1 to V3.
vi. ST and T waves are usually opposite in direction to QRS
complex.
vii. Depressed ST segment and negative T waves with negative
QRS indicate ischaemia.
b. Incomplete left bundle branch block
i. QRS duration 100ms to 120ms
ii. QRS morphology like complete LBBB
c. Left ventricular hypertrophy
i. Sokolow and Lyon: S wave in V1+R wave in V5 or V6
(whichever is taller) ≥35mm
ii. Cornell: R wave in aVL+S wave in V3 >28mm for men,
>20mm for women
iii. Roberts: QRS in all leads >175mm to 225mm
iv. Scott:
1. Limb leads:
a. R wave in lead I + S wave in Lead III >25mm
b. R wave in aVL >11mm or >18mm if left axis
deviation
c. R wave in aVF >20mm
d. S wave in a VR >14mm
2. Chest leads:
a. S wave in V1 or V2 + R wave in V5 or V6
>35mm
b. R wave in V5 or V6 >26mm
c. R + S in any V lead >45mm
v. Romhilt-Estes scoring system
1. 3 points
a. Any limb R wave or S wave ≥20mm
b. S wave in V1 or V2 ≥30mm
 c. R wave in V5 or V6 ≥30mm
d. ST-T wave changes when not taking digitalis
e. P wave terminal force in V1 is 1mm or more in
depth with a duration of 40ms
2. 2 points
a. Left axis deviation ≥-30°
3. 1 point
a. ST-T wave changes when taking digitalis
b. QRS duration ≥90ms
c. Intrinsicoid (beginning of QRS complex to
peak of R) deflection in V5 or V6 ≥50ms
4. ≥5 points = definite LVH
5. ≤4 points = probable LVH
d. Right ventricular hypertrophy
i. Right axis deviation >+90°
ii. R wave in V1 >6mm
iii. R wave in V1 + S wave in V5 or V6 >10.5mm
iv. R/S ratio in V1 >1
v. S/R ratio in V6 >1
vi. Late intrinsicoid deflection in V1 >0.035s
vii. Incomplete right bundle branch block
viii. ST-T wave abnormalities in inferior leads
ix. Right atrial hypertrophy
x. S >R in leads I, II and III
e. Right bundle branch block
i. QRS duration ≥120ms
ii. Rsr’, rsR’ or rSR’ in leads V1 or V2
iii. R’ or r’ usually wider than the initial R wave
iv. S wave >40ms or greater than R wave in leads I and V6
v. Normal R peak time in V5 or V6 but >60ms in leads V1
vi. St segments and T waves discordant to the QRS
f. Incomplete right bundle branch block
i. QRS duration <120ms
ii. Fulfilling other criteria
g. Bifascicular block
i. Right bundle branch block and left posterior fascicular
block
ii. Right bundle branch block and left anterior fascicular block
iii. Complete left bundle branch block
h. Trifascicular block
i. Alternating right bundle branch block and left bundle
branch block
ii. Bifascicular block with first degree heart does NOT always
indicate trifascicular block
i. Intraventricular conduction delay
i. Duration of 0.11s to 0.12s
ii. No classical features of left bundle branch block or right
bundle branch block
j. Ashman’s phenomenon
 i. Commonly in atrial fibrillation
ii. Abrupt change in rate from slow to rapid
iii. This causes the depolarization to encounter areas of
refractoriness
iv. Left bundle branch block or right bundle branch block
pattern will be seen

ST segment
1. PQ junction up to the J point.
2. Elevation:
a. Criteria:
i. New ST elevation at the J point.
ii. 2 anatomically contiguous leads.
iii. For leads I, II, III, aVL, aVF, aVR, V1, V4 to V6: ≥ 0.1mV
(1mm)
iv. For leads V2 and V3:
1. Females: ≥0.15mV (1.5mm)
2. Males <40: ≥0.2mV (2mm)
3. Males ≥40: ≥0.25mV (2.5mm)
b. ST elevation in:
i. aVR+widespread ST depression or ≥V1 ST elevation:
1. Left main stem disease
2. 3 vessel disease
3. Severe proximal left anterior descending artery
disease
ii. V1 to V6: Anterior MI; location of occlusion
1. Proximal to both first septal perforator and diagonal
branch: aVL ST elevation+ ST depression>1mm in II,
III, and aVF.
2. Proximal to first septal perforator:
a. aVR ST elevation
b. Complete right bundle branch block
c. V5 ST depression
d. V1 ST elevation>2.5mm
3. Distal to first septal perforator: Q waves in V4 to V6
4. Proximal to first diagonal branch: Q wave in aVL
5. Distal to first diagonal branch: ST depression in aVL
6. Anterior and inferior MI: wrap around LAD
iii. V1 to V3:
1. Apical MI
2. Anteroseptal MI
iv. V4 to V6: Anterolateral MI
v. II, III, aVF: Inferior MI (proceed to right side and posterior
ECG)
1. III >II+ I and aVL ST depression
a. Proximal right coronary artery occlusion
b. Mid portion right coronary artery occlusion
2. II=III+V1 to V3 ST depression
 a. Left circumflex artery occlusion
vi. V3R to V4R: Right ventricular MI
1. Occlusion of proximal right coronary artery
vii. V7 to V9: Posterior MI
viii. aVL+
1. ST depression V1 to V4, II, III, aVF: posterolateral
STEMI
2. ST depression II, III, aVF: isolated high lateral STEMI
3. ST elevation if leads I, V2 and ST depression of lead
III (South Africa Flag sign): high lateral infarct
c. Early repolarization:
i. Notched J point (fish hook)
ii. Concave ST segment
iii. Symmetrical T wave
iv. No reciprocal ST depression
d. Hypothermia
i. Elevated J point
3. Depression
a. Horizontal or down-sloping
i. ≥0.05mV (0.5mm)
ii. 2 anatomically contiguous leads
b. ST depression in:
i. V1 to V3: Posterior MI
ii. I and aVL+III>II ST elevation: right coronary artery
occlusion
iii. V1 to V3+II=III ST elevation: left circumflex artery occlusion
iv. II, III, and aVF:
1. +aVL: isolated high lateral STEMI
2. +aVL, V1 to V4: posterolateral STEMI
v. “Strain pattern”: down-sloping and T inversions
c. Upsloping:
i. V1 to V6 with hyperacute T waves: de Winter’s T waves
(LAD sub-occlusion)
4. Other abnormalities
a. Sgarbossa criteria:
i. In the presence of left bundle branch block
ii. ST elevation≥1mm concordant to the QRS=5
iii. ST depression≥1mm in V1 to V3=3
iv. ST/QS or rS≥0.25=2
v. Significant score is≥3
b. Brugada Syndrome
i. Type I
1. ST segment elevation ≥2mm in V1 and V2
2. Descends in upward convexity
3. T inversion
ii. Type II
1. ST segment ≥2mm in V1 and V2
2. Saddleback 1mm above baseline
3. Biphasic or positive T wave
 c. Arrhythmogenic Right Ventricular Dysplasia
i. QRS>110ms in V1 to V6 without RBBB
ii. S wave upstroke ≥55ms
iii. Epsilon wave (small wave post QRS before T wave)
iv. T inversions V1 to V3.
d. Ventricular aneurysm
i. Persistent ST elevations
ii. No ischaemic symptoms
iii. T inversions indicating old infarct
e. Pericarditis
i. Stage 1
1. Diffuse ST elevation (concave up)
2. ST depression aVR and V1.
3. PR elevation in aVR (opposite from ST segment)
4. PR depression in other leads (opposite from ST
segment)
ii. Stage 2: ST and PR normalization
iii. Stage 3:
1. Normal ST and PR
2. T inversions
iv. Stage 4:
1. Normalization
f. Digitalis toxicity
i. Concave upwards
ii. ST depression

T wave
1. Normal T wave:
a. Mean T wave vector same as the mean QRS vector
b. Asymmterical: upstroke slow, downstroke rapid
c. Normal variant:
i. Persistent juvenile T wave pattern
1. T inversions in V1 to V3
ii. Black athlete T wave variant
1. Dome-shape ST elevations V1 to V4
2. T inversions V1 to V4
3. Asymptomatic, no family history, no physical
abnormality.
2. Leads III, aVF, aVL, aVR and V1 may normally display moderate to large Q
wave and/or T inversion in otherwise healthy adults. They are usually in
isolation.
3. Inversion:
a. ≥0.1mV (1mm)
b. 2 anatomically contiguous leads
c. Prominent R waves of R/S>1
4. Tall T waves:
a. Hyperkalaemia
i. >10mm in precordial leads
 ii. >5mm in limb leads
iii. Tented or peaked
5. Abnormalities:
a. Wellen’s syndrome
i. R wave preservation
ii. Presence of ischaemic symptoms
iii. QTc>0.425s
iv. Deep T wave inversions V1 to V6 (may start only in 1 lead).
1. Biphasic Type A
2. Symmetrical Type B
b. De Winter’s T waves
i. Upsloping ST depression in V1 to V6
ii. hyperacute T waves
c. Pseudonormalization:
i. Previous abnormal T waves
ii. Chest discomfort
iii. Normalization of T waves during ischaemia
d. T wave inversion in aVL may indicate midsegment lesion of the left
anterior descending artery.

QT interval
1. The QT interval consists of the duration of the QRS complex, ST segment
and T waves.
𝑄𝑇 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
2. Corrected QT =
√𝑅𝑅 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
3. Measures the depolarization and repolarization of the ventricles.
4. Normal:
a. Male: ≤0.44s
b. Female: ≤0.45 to 0.46
5. Causes of long QT interval:
a. Jervell and Lange-Nielsen syndrome ( sensorineural deafness)
b. Romano-Ward syndrome
c. The hypos:
i. Hypokalaemia
ii. Hypomagnesaemia
iii. Hypocalcaemia
iv. Hypothyroidism
v. Hypothermia
d. Amiodarone
e. Macrolides
f. Formoterol
6. Causes of short QT interval:
a. Digitalis
b. Acidosis
c. Catecholamines
d. The hypers:
i. Hyperkalaemia
ii. Hypercalcaemia
iii. Hyperthermia
U wave
1. Seen in V2 to V4
2. Amplitude <0.2mV
3. Amplified by:
a. Hypokalaemia
b. Bradycardia
c. QT shortened by:
i. Digoxin
ii. Hypercalcaemia

Tachyarrhythmias
1. Narrow QRS complex (<120ms/3 small boxes):
a. Normal-looking p waves:
i. Sinus tachycardia
ii. Inappropriate sinus tachycardia
1. Delayed response to vasovagal maeouvre
iii. Sinoatrial reentrant tachycardia
1. Diagnosis requires electrophysiological study
2. P wave rate between 100 to 150 beats per minute
3. P wave looks like normal sinus rhythm P wave
4. Responds abruptly to vasovagal maneouvre
b. Retrograde p wave
i. Atrioventricular nodal reentrant tachycardia
1. Typical AVNRT
a. P wave maybe buried inside QRS or fused
b. Pseudo R in V1
c. Pseudo S in inferior leads
2. Atypical AVNRT
a. RP>PR
ii. Atrioventricular reentrant tachycardia (pre-excitation in
sinus rhythm)
1. Orthodromic
a. Rate=150 to 250
b. Narrow QRS complex
c. Inverted p waves
d. RP less than one half of RR
e. Constant RP interval regardless of RR cycle.
2. Antidromic
a. Rate=150 to 250
b. Wide QRS complex
c. Inverted p waves
d. RP less than one half of RR
e. Constant RP interval regardless of RR cycle.
iii. Difficult to differentiate the two without sinus rhythm strip
c. Abnormal P wave
i. Focal atrial tachycardia
1. P wave morphology different from the sinus p wave.
ii. Multifocal atrial tachycardia
 1. Heart rate>100 beats per minute
2. 3 distinct P wave morphology
iii. Intraatrial reentrant tachycardia
1. If from right atrium V1 positive, aVL negative
2. If from left atrium V1 negative, aVL positive
iv. Atrial flutter
v. Atrial fibrillation
vi. Junctional rhythm
1. Escape (40-60bpm)
2. Accelerated junctional rhythm (60-100bpm)
3. Junctional tachycardia (>100bpm)
4. P wave just before, during or after the QRS
5. Short PR interval.
6. Inverted in II, III and aVF (retrograde P wave going
away from the base of the heart)
7. Upright V1 and aVR (p wave heading towards the
right and front)
2. Widened QRS complex (≥120ms/3 small boxes):
a. Ventricular tachycardia (regular, never irregular)
i. Monomorphic
1. Regular
ii. Polymorphic
1. Typical
a. Changing QRS morphology
b. Torsades de Pointes
2. Bidirectional
a. Digoxin poisoning
iii. Accelerated idioventricular tachycardia is a VT that is 40-60
bpm.
b. Supraventricular tachycardia with:
i. Aberrant conduction
ii. Pre-excitation
1. AVRT
a. Orthodromic
i. Rate=150 to 250
ii. Narrow QRS complex
iii. Inverted p waves
iv. RP less than one half of RR
v. Constant RP interval regardless of RR
cycle.
b. Antidromic
i. Rate=150 to 250
ii. Wide QRS complex
iii. Inverted p waves
iv. RP less than one half of RR
v. Constant RP interval regardless of RR
cycle.
iii. Activation of ventricular pacing
c. Differentiating VT with SVT with aberration
 i. Absence of typical LBBB or RBBB
ii. Extreme axis deviation e.g. “Northwest deviation” (positive
aVR)
iii. QRS complexes >160ms
iv. AV dissociation
v. Capture beats
vi. Fusion beats
vii. Negative or positive concordance in V1 to V6
viii. Brugada’s sign (onset of QRS to S nadir >100ms)
ix. Josephson’s sign (notching prior to S nadir)
x. Marriot’s sign (Taller left rabbit ear in V1)
xi. qR in V6.

Bradyarrhythmia
1. Types:
a. Heart block
i. First degree (PR>0.2sec)
ii. Second degree
1. Mobitz type I (Wenckebach)
a. Progressively prolonging PR until one P is not
transmitted
2. Mobitz type II
a. No change in PR interval prior to dropped
beat
3. 2:1 AV block
a. Every other beat is dropped
b. Not able to say if Type I or Type II
4. High grade AV block
a. More than 2 consecutives P waves not
conducted
iii. Third degree
1. Non-conduction of P waves resulting in escape
rhythm
2. Intrinsic rhythm of ventricle slower than atrial
intrinsic rhythm
3. More P waves than QRS complexes
4. P-P intervals do not vary
5. R-R intervals do not vary
b. Wandering atrial pacemaker rhythm
i. 60 to 100 bpm.
ii. 3 distinct p wave morphology
c. Sick sinus syndrome
i. Periods of severe bradycardia <50bpm
ii. Alternating bradycardia and tachycardia
iii. Sinus pause
iv. No junctional escape rhythm.
d. Junctional escape rhythm
 i. 60-100 bpm
ii. Narrow QRS complex
iii. P wave just before QRS complex
e. Ventricular escape rhythm
i. 60-100 bpm
ii. Wide QRS complex
iii. Slow VT.

Miscellaneous
1. Electrical alternans
a. Pericardial effusion
b. Severe aortic regurgitation
c. Severe cardiomegaly and left ventricular dysfunction
2. Low voltage (limb leads<5mm, precordial leads<10mm)
a. Pericardial effusion
b. Amyloidosis
c. Obesity
d. Anasarca
e. Lung disease

Summary
1. Rate
2. Rhythm
3. Axis
4. Components of ECG
a. Waves & complexes
i. P waves
ii. QRS complex
iii. ST segment
iv. T waves
v. U waves
b. Intervals
i. PR interval
ii. QT interval
5. Is it an arrhythmia?
a. Tachycardia?
i. P wave normal-looking, abnormal-looking or none.
ii. RP and PR interval
b. Bradycardia?
i. QRS complex narrow or wide
ii. Pause?
iii. P wave morphology?
iv. PR interval
c. Normal heart rate?