Interpretation of the ECG

 ECG is recorded on a special grid divided into lines spaced 1 mm apart in both the horizontal and vertical
directions ( each fifth line is made heavier to facilitate measurement)
 Vertical Axis  measures voltage, 1 small square represents 0.1 mV
 Horizontal axis  measure time, 1 small square represents 0.04 seconds ( the recording speed of the machine is
25 mm / sec)
 The pacemaker activity and transmission by the conducting system are generally not seen on the ECG; these
events simply do not generate sufficient voltage to be recorded by surface electrodes.
 The wave on ECG have 3 chief characteristics :
o Duration, measured in fraction of seconds
o Amplitude, measured in millivolts (mV)
o Configuration, a more subjective criterion referring to the
shape of and appearance of a wave

 There is commonly followed sequence of analysis, followed by a description of each :

1. Check voltage calibration
2. Heart rhytym
3. Heart rate
4. Intervals (PR, QRS, QT)
5. Mean QRS axis
6. Abnormalities of the P wave
7. Abnormalities of the QRS (hyperthrophy, bundle branch block, infarction)
8. Abnormalities of the ST segment and T wave

Calibration
 ECG machine usually inscribe a 1.0 mV vertical signal at the beginning or end of each 12-lead tracing to document
the voltage calibration of the machine, so it would be 10 mm tall.
 In patients with markedly increased voltage of the QRS complex (e.g., some patients with leftventricular
hypertrophy or bundle branch blocks), the very large deflection do not fit on the standard tracing. To facilitate
interpretation in such case, the recording is often purposely made a half the standard voltage ( 1 box = 0.2 mV ),
so the calibration signal would be 5 mm tall.

Heart Rhythm
 The normal cardiac rhythm, initiated by depolarization of sinus node, is known as sinus rhythm and is present
o Every P wave is followed by a QRS
o Every QRS is preceded by a P wave
o The P wave is upright in leads I, II, II
o The PR interval is greater than 0.12 second (3 small boxes )
 If heart rate in sinus rhythm is between 60 and 100 bpm  normal sinus rhythm, if is below 60 bpm  sinus
bradycardia, if greater than 100 bpm  sinus tachycardia

Heart Rate

 simply “count off” the number of large boxes between 2 consequtives QRS complexes using : 300—150—100—
75—60—50
 When the rhythm is irregular, the heart rate may be approximated by counting the number of complexes during 6
sec of the recording and multiplying that number by 10. ECG also has time markers every 3 second so just count
the number of complexes and multiply by 20

Intervals
 PR interval  from the onset of P wave to
onset of QRS
 QRS interval  from the beginning to the
end of the QRS complex
 QT interval  from tje beginning of the
QRS to the end of T wave
 Because the QT interval varies with the
heart rate ( the faster the heart rate the
shorter QT ), the corrected QT interval is
determined by dividing the measured QT
by the square root of the R-R interval.
 When the heart rate is normal, a rapid
visual rule can be applied; if the QT
interval is less than half the interval between 2 consequtive QRS complexes, then the QT interval is within the
normal limit

Mean QRS Axis

 Mean QRS axis represents the average of the instantaneous electrial forces generated during the sequence of
ventricular depolarization as measured in the frontal plane.
 The normal value is between -30 degree and +90 degree
 If more negative that -30 degree  left axis deviation, if greater than +90 degree  right axis deviation.
 The mean QRS axis is calculated as follows
o Inspect the limb leads I and II. If the QRS is primarily upward in both, then the axis is normal and you are done.
o If not both, inspect the six limb leads and determine which one contains the QRS that is most isoelectric. The
mean axis is perpendicular to that lead.
o Inspect the lead that is perpendicular to the lead containing the isoelectric complex. If the QRS in that
perpendicular is primarily upward, then the mean axis points to the (+) pole of that lead. If primarily negative,
then the mean QRS points to the (-) pole of that lead.

P wave Abnormalities
 To inspect the P wave in leads II and V1 for left and right atrial
enlargement
Abnormalities of the QRS complex
 Inspect for left and right ventricular hypertrophy

 Inspect for Bundle Branch Blocks

  Inspect for Fascicular Blocks

 Inspect for pathologic Q waves

ST Segment or T wave Abnormalities

 Inspect for ST elevation
 Inspect for ST depressions or T wave inversions