Learning To Read An Electro-Cardiogram (ECG) : With Joseph S. Alpert, MD

Learning to Read an Electro-
cardiogram (ECG)
With Joseph S. Alpert, MD
risa septia, risaseptia1209@gmail.com

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An Early 20th Century ECG Machine
Willem Einthoven, PD-old, 1927

A Modern ECG Instrument
Bokskapet, PD
Reading ECGs
Reading ECGs is like examining a fine artwork, there are two phases to viewing:
1. The overall gestalt of the tracing R
2. The more careful, detailed analysis
• Take your time to check systematically P T

heart rate, timing intervals, and the
presence of P waves.
Q
• The computer is usually right about
S
intervals but often wrong about rhythm.

Reading ECGs
R
1 Heart rate = beats per minute
Intervals = the time taken for T

2 various components of the ECG
P
Q
P waves = electrical signal made by
3 depolarization of the atria S

ECG Waveforms and Intervals During Normal Cardiac Conduction
QRS
R 1 mm = 0.1 mV
PR
ST T
P
J U
1 mm = 0.04 s Q
5 mm = 0.2 s
S QT

Electrocardiogram (ECG)
P PR QRS ST T U
wave segment complex segment wave wave
• Shows the flow of electrical
R
depolarization current
through the heart
• Usually the first test done T

after the history and P
physical examination
• Simplest, cheapest, and

most easily obtained Q
S
cardiovascular test
PQ QT
Interval Interval

Electrocardiogram (ECG)
P PR QRS ST T U
wave segment complex segment wave wave
R
• Reasonable accuracy for a
variety of heart conditions
(e.g., arrhythmias or
T
myocardial infarction/heart
attack) P
• Many non-specific and

non-diagnostic patterns
Q
S
PQ QT
Interval Interval

Action Potential
1
0 2
3 4
Superior Vena cava
SA node
Atrium
Mitral valve 1 2
0 3
Tricuspid valve
4 4
Purkinje
Ventricle
R
An action potential from sinus
nodal cells with automaticity
causes sequential depolarization
of all excitable cardiac cells P T
© by Lecturio
QS
Ventricular Depolarization
Ventricular depolarization in the intact heart generates a changing

electrical field and QRS configuration over time.
© by Lecturio
Ventricular Depolarization
Ventricular depolarization in the intact heart generates a changing electrical field and QRS
configuration over time.
© by Lecturio
The 12-lead ECG Reference System
The 12-lead ECG reference system measures cardiac electrical forces

in frontal and transverse (precordial) planes.
The Frontal Plane ECG Leads (Electrical Vectors of the Heart)
3 unipolar limb leads
aVR aVL
+ +
aVR aVL
aVF
+ aVF

The Frontal Plane ECG Leads (Electrical Vectors of the Heart)
3 bipolar limb leads
I RA LA II RA LL
- + -
+
-
+ III LA LL

The Precordial ECG Lead System
Posterior
Right Left
6 precordial leads (electrical heart
vectors) create an anterior (V1 V2)
to lateral (V5 V6) reference V6 0°
system in the transverse plane.
V530°
V4 60°
V1 V2 V3
75°
ECG Interpretation Requires a Systematic Approach
6. Evaluate P wave morphology

1. Check voltage calibration
and/or voltage
7. Evaluate QRS morphology and/or

2. Determine rhythm
voltage
8. Evaluate ST segment and T wave

3. Calculate heart rate
morphology
4. Determine timing intervals 9. Compare with prior tracing(s) if

(PR, QRS, QTC ) available
5. Determine mean QRS axis

Step 1: Check Voltage Calibration
• Standard
10 mm = 1.0 mV
(or 1 mm = 0.1 mV)
• 1/2 Standard
5 mm = 1.0 mV
(or 1 mm = 0.2 mV)
This is a normal ECG!

Step 2: Determine Rhythm
Sinus rhythm is
present if:
• P waves are
present.
• All Ps are followed
by a QRS.
• Each QRS is
preceded by a P. If No to any, an
arrhythmia is present.
• Ps identical and
upright II and aVF.
Step 3: Calculate Rate
1. Counting the big

boxes between 2
and dividing
that number into
300.
2. Count the number

of in 3 s and
multiply by 20. 3 seconds
The normal heart rate is

between 60 100 beats
per minute.
Step 3: Calculate Rate
1. Counting the big

boxes between 2
and dividing
that number into
300.
2. Count the number

of in 3 s and
multiply by 20.
The normal heart rate is

between 60 100 beats
per minute.
Step 4: Calculate Timing Intervals
• Normal PR interval =
0.12 0.20 s
QTc 0.30 0.46 s
• Normal QRS interval
= less than 0.10 s
• Normal corrected
QT interval =
0.30 0.46 s
Each small box is 0.04 seconds and each large box is 0.20
seconds. There are 5 small boxes in each large box.

Step 5: Determine Mean QRS Axis
Axis is OK if the QRS is

upright in leads I and II.
Normal = -30° to +90° If not = axis deviation

Step 5: Determine Mean QRS Axis
The axis for the mean

frontal plane electrical
vector of the heart is
near the limb lead with
the tallest R wave and
perpendicular to the
lead where the size of
the upward deflection
(the R wave) and the
downward reflection
(the S wave) are equal.
Normal = -30° to +90° If not = axis deviation

Step 6: Check P-Wave Morphology and Voltage
LAE
Normal P wave:
• < 0.12 s duration
• Upright in lead I RAE

and II and negative
deflection less than
1 box wide and 1
box deep in V1

Step 7: Check QRS Morphology and Voltage
Normal:
• R wave
transition V3 V4
• Small Qs < 0.04 s

(but never V1 2)
• Normal voltage

Step 8: Check ST Segment for Depression or Elevation
Digoxin effect
Sagging of ST segment
Normal ST segment:
Isoelectric, but OK if:
-0.5 mm in limb leads
Ischemia
If ST depressed, consider: Flat or downsloping ST segment
Ischemia
Other: electrolyte
abnormality; digitalis effect
Hypokalemia
Mildly downsloping ST segment
with flattened T wave and a
U wave
Step 8: Check ST Segment for Depression or Elevation
Normal

ECG Case:
22-year-old Man with Anterior Chest
Pain

Case: 22-year-old Man with Anterior Chest Pain Test case
A 22-year-old male student who is the captain of his university

boxing team is referred to you for evaluation of anterior chest
pain. The discomfort occurs several times each day and lasts for
one to two hours. On physical exam, his sternal area is tender and
he admits to receiving a number of blows there during a recent
boxing match. His ECG is on the next slide.

A 22-year-old male student who is the captain of his university

boxing team is referred to you for evaluation of anterior chest Chest pain
pain. The discomfort occurs several times each day and lasts for
one to two hours. On physical exam, his sternal area is tender and
he admits to receiving a number of blows there during a recent Personal history of
boxing match. His ECG is on the next slide. thoracic trauma

Normal ECG

Diagnosis?
chest pain is
musculoskeletal in origin
and the result of trauma
suffered when he was
boxing.

Treatment?
• Non-steroidal anti-
inflammatory agent
such as Naprosyn
• No further testing is
required.

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Note: This document is copyright protected. It may not be copied, reproduced, used, or
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Learning to Read an Electro-

With Joseph S. Alpert, MD

risa septia, risaseptia1209@gmail.com

Willem Einthoven, PD-old, 1927

1. The overall gestalt of the tracing R

2. The more careful, detailed analysis

• Take your time to check systematically P T

risa septia, risaseptia1209@gmail.com

Intervals = the time taken for T

risa septia, risaseptia1209@gmail.com

risa septia, risaseptia1209@gmail.com

• Usually the first test done T

• Simplest, cheapest, and

risa septia, risaseptia1209@gmail.com

• Many non-specific and

risa septia, risaseptia1209@gmail.com

Ventricular depolarization in the intact heart generates a changing

The 12-lead ECG reference system measures cardiac electrical forces

3 unipolar limb leads

risa septia, risaseptia1209@gmail.com

3 bipolar limb leads

risa septia, risaseptia1209@gmail.com

6. Evaluate P wave morphology

7. Evaluate QRS morphology and/or

8. Evaluate ST segment and T wave

4. Determine timing intervals 9. Compare with prior tracing(s) if

5. Determine mean QRS axis

risa septia, risaseptia1209@gmail.com

This is a normal ECG!

1. Counting the big

2. Count the number

The normal heart rate is

1. Counting the big

2. Count the number

The normal heart rate is

This is a normal ECG!

Axis is OK if the QRS is

Normal = -30° to +90° If not = axis deviation

The axis for the mean

Normal = -30° to +90° If not = axis deviation

• < 0.12 s duration

• Upright in lead I RAE

This is a normal ECG!

• Small Qs < 0.04 s

This is a normal ECG!

risa septia, risaseptia1209@gmail.com

risa septia, risaseptia1209@gmail.com

A 22-year-old male student who is the captain of his university

risa septia, risaseptia1209@gmail.com

A 22-year-old male student who is the captain of his university

risa septia, risaseptia1209@gmail.com

risa septia, risaseptia1209@gmail.com

risa septia, risaseptia1209@gmail.com

risa septia, risaseptia1209@gmail.com

risa septia, risaseptia1209@gmail.com

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