So the first step in reading an ECG is to look for the

presence and correctness of the standardization.

SUT AMS MEDICAL COLLEGE, TVM Only if it is so, the rest of the ECG is read.
House Surgeon’s Manual Chapter 8
ECG READING Result of Step 1: Standardization
I looked into the ECG, I found that there is a
standardization lead.
Introduction: It was looking like a rectangle. The height was
10mm. There were no half standardization leads
Step 01. Standardization: 1mv = 10sd
ECG may be read in 12 basic steps.
The basic steps are
Step 2: Calculation of Heart rate
If the rhythm is regular, count the number of big
Step 1. Standardization divisions between two adjacent R waves. Then
Step 2. Calculation of Heart rate divide the 300 with that value to get the heart rate.
Step 3. Rhythm of the Heart
Step 4. Electrical Axis Rest of it is calculated mentally
Step 5. P wave Only this amount of accuracy in calculating the
Step 6. PR Interval heart rate is required in most instances. Otherwise
Step 7. Q Wave divide 1500 by the number of small divisions
Step 8. QRS duration
Step 9. ST segment Heart Rate in Irregular Rhythm
Step 10. T wave If there is Atrial Fibrillation, count the number of
Step 11. RVH by voltage criteria QRS complexes within 6 seconds of ECG paper .
Step 12. LVH by voltage criteria Then multiply by 10 to get heart rate in 60 seconds

Step 3. Rhythm of the Heart

Step 1. Standardization
It is the first lead of the electrocardiogram, the
standard against which other leads are to be read.
It is the square waves seen at the beginning of the
ECG tracing.
What is Standardization?
When 1 millivolt of current is given by the machine
it produces a square wave deflection of 10 small
divisions. When ECG is recorded this amplitude is
applied as a standard.
What is half standardization?
Here even when 1 millivolt of current is applied
there is a deflection of only five small divisions. This
is made so, if the deflections are very tall.
Look for standardization in every ECG
Rhythm of heart is the regularity or irregularity of
the heart action. It has to be studied using a long
lead II or V1
Normal Sinus Rhythm
Normal sinus rhythm is said to be present if the
heart rate is between 60 and 100 and every P wave
is followed by a QRS complex and a T wave and
intervals normal
Result of Step 3: The Rhythm
The rhythm appeared to be regular. The heart rate
calculated was 75 per minute. Each P was followed
by a QRS and T. PR interval and QRS durations
were normal. The shape of QRS was normal
Step 03 – Rhythm of heart is normal sinus rhythm
Step 4. Electrical Axis
It is the net or ultimate direction of conduction of the
cardiac impulse from SA node to the ventricular
apex which can be represented as a straight line
vector
Determining Axis
Axis is determined by studying leads I and III alone.
If the net deflection is upright in these two leads,
the axis is considered as normal
Normal Electrical Axis
In the above ECG the lead I shows an upright wave
with net positive deflection and lead III shows a net
positive wave with upward deflection. Hence axis is
normal
Right Axis Deviation
In the above ECG the lead I shows a downward
wave with net negative deflection and lead III
shows a net positive wave with +ve deflection.
Hence axis is RIGHT
Left Axis Deviation
The lead I shows a positive wave with net positive
deflection and lead III shows a net negative wave
with negative deflection. Hence axis is LEFT
Result of Step 4: Electrical Axis of Heart
I looked into leads ! And III. In lead I there was a
positive and negative. But positive wave was more.
In lead I the net deflection was positive. In lead III
also the net deflection was positive
Step 04 - Electrical Axis: Normal
Step 5: P wave
The normal P wave is upward convex in shape and
prominently seen in leads II and V1
So look into leads II and V1 for the details
Normal P wave
The normal P wave is not more than 2.5 mm height
and not more than 2.5 mm in width
If it more than this it is abnormal
P Mitrale
When P wave is broad and notched it indicates Left
Atrial Enlargement and it is most often seen in
patients with Rheumatic Mitral Stenosis
P Pulmonale
When P wave is tall and peaked it indicates Right
atrial enlargement
It is most often seen in Chronic Corpulmonale
Result of Step 5: P wave
I studied the P wave dimensions. It was 2 mm wide.
It was 2.5 mm high. P wave shape was normal in
lead II. P was biphasic in V1 and terminal negative
Step 05 – P wave: Normal
Step 6: PR Interval
The physiological necessity, for the AV Nodal
delay, which causes the normal PR interval is that,
the same SA Nodal impulse has to activate, both
atria & ventricles
Normal PR Interval
The Normal PR Interval is 3-5 small divisions, when
measured from the beginning of P to beginning of
QRS
In other words it is 0.12 to 0.20 seconds
Prolonged PR Interval
Prolonged PR interval is said to be present if the
PR interval is equal to or more than 0.21 sec
It is seen in Acute Rheumatic Fever and I degree
HB
Short PR Interval
PR interval is said to be short when it is less than
0.12 seconds in duration
It is seen in WPW Syndrome and Junctional
Rhythm
ECG showing short PR interval
It is a sinus rhythm with short PR interval and
ventricular pre-excitation syndrome possibly due to
WPW
There is in addition a Delta wave
Result of Step 6: PR Interval
I looked at the PR segment. I measured the PR
interval. It was found to be 4 small divisions. It
meant that it is 0.16 seconds in duration. It is with in
the normal ranges
Step 06 – PR interval: Normal
Step 7: Q Wave
Q wave is defined as the first negative deflection of
the QRS Complex and it is normally present only in
a few leads viz. Lead III, II, V​5​ & V​6​ and they are
very small
There can be ‘no Q’ situation
But q waves are not always present in all the leads
of all persons, unlike the other waves
A small q may be present in some leads
Significance of Q waves
The presence of a significant Q wave is highly
suggestive of a transmural myocardial infarction
It also means that the coronary artery is totally
occluded
What is an insignificant ‘Q wave’?
When the ‘q wave’ is very small in size (less than
0.04mm in width) it is called an insignificant q wave
Then it is an isolated finding in one lead.
In which leads small ‘q’ waves are seen?
Small or insignificant q waves are seen usually in
leads III, II, V5 and V6, in normal persons. Rest of
the leads in a normal person does not show any
significant q wave
Pathological Q wave
A ‘significant Q’ or ‘pathological Q’ is one which is
more than 0.04mm in width. It may also be more
than 25% of the R wave height in the same lead
Why is Q very important?
Presence of significant Q wave indicates the
diagnosis of Myocardial infarction either acute or
old
It is usually preceded by the classical chest pain
Whether Acute MI or Old MI?
If it is, accompanied by other evidence of acute
Myocardial Infarction, like ST elevation or T wave
inversion it is acute; otherwise it is old
Anterior wall Infarction
In Anterior wall Myocardial Infarction the changes
of MI are seen in V2-V4
If V1 also shows changes the septum is involved
Inferior wall Infarction
In Inferior Wall Myocardial Infarction the changes of
MI are seen in II, III and aVF
If V1 also shows changes the septum is involved
Result of Step 7: Q wave
I looked for any q waves. Small q were present in
V5 and V6. Rest of the leads were not showing any
q. He q present were not wide. None of them >
0.04 second.
Step 07 – Q wave: Nil pathological
QRS Duration Measurement
QRS duration is measured from the beginning of
QRS to the end of QRS
Irrespective of the type and waves in the QRS
QRS Patterns
QRS patterns vary from individuall to individual and
from lead to lead
They don’t have much significance
Result of Step 8: QRS duration
I looked at the QRS complexes. They were looking
normal. The duration, I measured. It was 0.10
seconds. The pattern were numerous.
Step 08 – QRS Duration: Normal
Step 8: ST segment
ST segment is that portion of the base line from the
S wave to the beginning of T wave, Normally, it is
iso-electric ie. at the same level as that of the
baseline
ST segment elevation
ST segment elevation is the elevation of the
beginning of ST segment from the baseline, when
compared to the isoelectric line or the PR segment
What is J point?
J point is the point at which the S wave ends and
the ST segment begins
It is usually seen as a definite point of turn
Significance of ST elevation
Elevation of the ST segment is considered to be
due to myocardial injury in coronary artery disease
and it is the single most important criterion of
thrombolytic therapy
Pathophysiological Co-relation
The degree of ST elevation in the ECG directly
correlates with the pathophysiology of CAD
Hence it the indication for thrombolysis
Differential diagnosis of ST elevation
Pericarditis is characterized by the presence of ST
elevation with upward concavity, present almost in
all the leads and associated with PR segment
depression
Early Repolarization
It is a normal variant seen mostly in young males
characterized by J point elevation
To be differentiated from Acute MI and Pericarditis
Comparison of ECG changes
ST/T Ratio in V6 of <0.25 against Pericarditis and
less ST(equal to or less than 0.05mV) against
Acute Myocardial Infarction
Whether there is ST depression?
The ST segment is normally at the same level as
that of the iso-electric line/PR segment. When it is
depressed by1mm from the baseline, it is called ST
depression
What is ST depression due to?
ST depression in ECG is due to the presence of
Ischemia to the myocardium
It occurs in Angina
What is myocardial Ischemia?
Myocardial ischemia may result in temporary or
permanent damage to the myocardium
But usually not
Causes of ST depression
Down sloping ST elevation is usually due to
ventricular strain associated with a relative
ischemia, whereas, horizontal ST depression is due
to absolute ischemia
Result of Step 9: ST segment
I looked at the ST segment after each QRS. They
were flat and isoelectric. I compared them with the
P segments. They were at the same level. There
was no point elevation or depression
Step 09 – ST segment is isoelectric
Step 10. T wave
T wave is the upward convex wave following the
QRS complex and it represents ventricular
repolarization
Normal T wave
The normal pattern of T wave is upward and
convex in all the leads of the ECG except aVR and
V​1 ​; it is inverted in these leads
What is tall peaked T wave?
T wave is said to be tall and peaked when it is very
tall and equal to or more than the preceding R
wave and along with an elevated ST suggestive of
a acute MI
Significance of peaked T
Tall and peaked T waves along with ST elevation in
a set of ECG leads are the earliest evidence of
acute coronary syndrome called Hyperacute
Myocardial Infarction
Other important cause of tall peaked T
Peaked T, along with decreased p wave amplitude
and widening of QRS complex suggest
hyperkalemia
It is also a potentially fatal disorder
Types of T wave inversion
In Acute MI the terminal portion of the peaked T
wave is inverted resulting in a biphasic T wave; In
other forms of ischemia the T wave is usually
symmetrically inverted
ECG with T inversions
ST depression along with T wave inversions are
seen in leads II, III and aVF and the chest leads V4,
V5 and V6 suggesting ischemia of the inferior and
lateral walls
Result of Step 10: T wave
I looked at the T wave in all leads. They were
upright in all leads
With the exception of leads aVR and V1. T shape
was now inspected. There were no peaked or
inverted T waves.
Step 10 – T wave: Normal
Changes occurring in Acute MI
In normal persons ECG the q wave is absent or
insignificant, ST isoelectric and T upright in all
leads
There is no evidence of MI
ECG changes after Acute MI
After Acute Myocardial Infarction, q wave appears,
ST is elevated and the T wave is inverted in the
leads affected
The evidence of MI
Progressive changes during MI
Seen is the normal ECG followed by the
progressive changes in acute myocardial infarction
Peaked T, ST elevation, loss of R and T inversion
Progressive changes after MI
ECG changes in the post MI period
The ST elevation gets resolved, T inversion
gradually disappears and the Q waves if any persist
Anterior Wall MI
Changes of Acute MI , when seen in the anterior
chest leads, from V1 to V4 it is diagnostic of
Anterior Wall MI; if lead V1 is involved it is termed
anteroseptal MI
Coronary Occlusion
Anterior wall myocardial infarction means that the
left anterior descending branch of the left coronary
artery is occluded by a thrombus
Acute Anteroseptal MI
ST elevation and tall peaked T waves are seen in
the anterior precordial leads
No q waves have appeared
Antero-septal MI evolved phase
Here the ST is still elevated the T wave is upright in
the chest leads V1 to V4
Q waves have appeared in the same leads
Lateral Wall Infarction
Changes of Acute MI , when seen in the lateral
chest leads, from 1, aVL, V5 V6, it is diagnostic of
Lateral Wall Myocardial Infarction
Deep Circumflex occlusion
It is also inferred from this, that it is the deep
circumflex branch of the left coronary artery, is
occluded, either by a plaque or thrombus
Acute Myocardial Infarction
Diffuse ST elevation with reciprocal changes
Anterior lateral and inferior walls are involved and
there is atrial fibrillation also
Inferior Wall Infarction
Changes of Acute Myocardial Infarction, when seen
in the inferior chest leads, namely II, III and aVF is
diagnostic of Inferior Wall MI
Right coronary artery occlusion
It is also inferred from this, that it is the right
coronary artery, which supplies the inferior or
diaphragmatic surface, is occluded, either by a
plaque or thrombus
Acute Inferior Wall MI – Early stage
Changes are seen in the leads II, III and aVF;
hence it is Inferior wall MI
There is ST elevation and reciprocal changes also
Acute Inferior Wall MI in ECG
There is ST elevation, Upright and peaked waves
in II, II and aVF
It is acute Inferior wall MI
Antero-lateral Infarction
Changes of Acute MI are seen in all the anterior
chest leads, from V1 through V6
It is diagnostic of Antero-lateral Wall MI
Left Coronary Stem Occlusion
The left coronary artery, which supplies the whole
of the anterior wall of heart is occluded at the stem,
involving the area supplied by both the branches
True Posterior MI
Changes are in the V1 lead of ECG as mirror
image. These are Tall R instead of Q, ST
depression instead of ST elevation and upright T
instead of T inversion
Right Ventricular Infarction
The changes of myocardial infarction are visible in
the right ventricular leads, V3R & V4R
It is a right ventricular Infarction
ECG of RVMI
Right sided leads shown separately on the right
side of the panel shows ST elevation
The diagnosis is Inferior Wall MI + RV MI
Transmural and subendocardial
Previously, abnormal Q waves were considered to
be markers of trans-mural MI, while
sub-endocardial infarcts were thought not to
produce Q waves
Q waves are more important
Now we know that Trans-mural Infarcts may occur
without presence of Q waves and subendocardial
infarcts may produce Q waves
ECG in ACS
When a patient presents with acute onset of chest
pain, ECG is the first line of investigation
Depending upon ECG findings further assessment
made
Acute Coronary Syndrome
The algorithmic management of a patient with
Acute Coronary Syndrome is also now based on
the ECG
Cardiac markers assist the diagnosis
Step 11: Right Ventricular Hyprtrophy
Normally the R wave in lead V1 is less than S wave
in the same lead. If R wave height is found to be
more than S wave depth in lead V1 it is the voltage
criteria for RVH
Right Ventricular Hypertrophy
The height of the R wave in V1 and depth of the S
wave in V1 is measured and these are compared
The R wave in V1 is taller than the S wave in V1
Result of Step 11: RVH by voltage criteria
I looked at lead V1. Measured the height of r wave
– 4 mm. I looked at lead V1 again. Measured the
depth of S wave – 16 mm. The r wave height is less
than S wave depth
Step 11 – No RVH by voltage criteria
Step 12: S in V1 + R in V6
If the depth of S wave in lead V1 + R wave height
in V6 is more than 35mm, it satisfies the voltage
criteria for Left Ventricular Hypertrophy
Left ventricular hypertrophy
The depth of the S wave in V1 is measured and
added to the height of the R wave in V6
The total is more than 35 mm It is LVH
Result of Step 12: LVH by voltage criteria
I looked at lead V1. Measured the depth of S wave
– 12 mm.. I looked at lead V6. Measured the height
of R wave – 16 mm.. Added these two. The result
was 28 mm
Step 12 – No LVH by voltage criteria
Thus ECG is read simply
1. Std
2. Rate
3. Rhythm
4. Axis
5. P
6. PR
7. Q
8. QRS
9. ST
10. T
11. R/S in V1
12. SV1+RV6