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ECG Rhythm Interpretation
Module VII a
Reading 12-Lead ECG’s

Course Objective
• To systematically analyze a 12-lead

ECG.

Learning Modules
• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
• Reading 12-Lead ECG’s
Reading 12-Lead ECGs
• The 12-Lead ECG contains information that will assist
you in making diagnostic and treatment decisions in your
clinical practice. In previous modules you learned how to
read and interpret parts of the ECG. Now, we will bring all
that you have learned together so that you can
systematically read and interpret a 12-lead ECG.
• The information will be divided into two modules, VII a

and VII b.

The best way to read 12-lead ECGs is to develop a step-
by-step approach (just as we did for analyzing a rhythm
strip). In these modules we present a 6-step approach:
1. Calculate RATE
2. Determine RHYTHM
3. Determine QRS AXIS
4. Calculate INTERVALS
5. Assess for HYPERTROPHY
6. Look for evidence of INFARCTION

Rate Rhythm Axis Intervals Hypertrophy Infarct
• In Module II you learned how to calculate the

rate. If you need a refresher return to that module.
• There is one new thing to keep in mind when

determining the rate in a 12-lead ECG…

If you use the rhythm
strip portion of the
12-lead ECG the total
length of it is always
10 seconds long. So
you can count the
number of R waves
in the rhythm strip
and multiply by 6 to
determine the beats
per minute. Rate? 12 (R waves) x 6 = 72 bpm

• In Module II you learned how to systematically

analyze a rhythm by looking at the rate, regularity,
P waves, PR interval and QRS complexes.
• In Modules III, IV and V you learned how to

recognize Normal Sinus Rhythm and the 13 most
common rhythm disturbances.
• If you need a refresher return to these modules.

Tip: the rhythm strip portion of the 12-lead ECG is a good

place to look at when trying to determine the rhythm
because the 12 leads only capture a few beats.
Rhythm?
Atrial
1 of 12 leads fibrillation
Lead II
Rhythm strip

Axis refers to the mean QRS axis (or vector) during ventricular
depolarization. As you recall when the ventricles depolarize (in a
normal heart) the direction of current flows leftward and downward
because most of the ventricular mass is in the left ventricle. We like
to know the QRS axis because an abnormal axis can suggest
disease such as pulmonary hypertension from a pulmonary
embolism.

The QRS axis is determined by overlying a circle, in the frontal
plane. By convention, the degrees of the circle are as shown.
The normal QRS axis lies between -30o and +90o.
A QRS axis that falls between -30o -90o
and -90o is abnormal and called left -120o -60o
axis deviation.
-150o -30o
A QRS axis that falls between +90o
and +150o is abnormal and called 180o 0o
right axis deviation.
150o 30o
A QRS axis that falls between +150o
and -90o is abnormal and called
60o
superior right axis deviation. 120o
90o

We can quickly determine whether the QRS axis is

normal by looking at leads I and II.
QRS negative (R < Q+S)
If the QRS complex is
overall positive (R > Q+S)
in leads I and II, the QRS
axis is normal.
In this ECG what leads

have QRS complexes
that are negative?
equivocal?
QRS equivocal (R = Q+S)

How do we know the axis is normal when the QRS

complexes are positive in leads I and II?

The answer lies in the fact that each frontal lead

corresponds to a location on the circle.
Limb leads
-90o
I = +0o -120o -60o
II = +60o avR -150o -30o avL
III = +120o
Augmented leads
180o 0o II
avL = -30o 30o
150o
avF = +90o
60o
avR = -150 o 120o
III 90o II II
avF
Since lead I is orientated at 0o a wave of depolarization directed towards it
will result in a positive QRS axis. Therefore any mean QRS vector
between -90o and +90o will be positive.
-90o
-120o -60o
-150o -30o
180o 0o I
150o 30o
o 60o
120
90o

Similarly, since lead II is orientated at 60o -90o
a wave of depolarization directed towards -120o -60o
it will result in a positive QRS axis.
-150o -30o
Therefore any mean QRS vector between
-30o and +150o will be positive.
180o 0o I
150o 30o
o 60o
120
90o
II

Similarly, since lead II is orientated at 60o -90o
a wave of depolarization directed towards -120o -60o
it will result in a positive QRS axis.
-150o -30o
Therefore any mean QRS vector between
-30o and +150o will be positive.
180o 0o I
Therefore, if the QRS complex is positive
in both leads I and II the QRS axis must 150o 30o
be between -30o and 90o (where leads I
and II overlap) and, as a result, the axis 60o
120o
must be normal. 90o
II

Now using what you just learned fill in the following table. For example, if
the QRS is positive in lead I and negative in lead II what is the QRS axis?
(normal, left, right or right superior axis deviation)
QRS Complexes -90o
I II Axis -120o -60o
+ + normal -150o -30o

+ - left axis deviation
180o 0o I
150o 30o
o 60o
120
90o
II

… if the QRS is negative in lead I and positive in lead II what is the QRS
axis? (normal, left, right or right superior axis deviation)
QRS Complexes -90o

+ + normal -150o -30o

- + right axis deviation 180o 0o I
150o 30o
o 60o
120
90o
II

… if the QRS is negative in lead I and negative in lead II what is the QRS
axis? (normal, left, right or right superior axis deviation)
QRS Complexes -90o

+ + normal -150o -30o

- + right axis deviation 180o 0o I
- - right superior 150o 30o

axis deviation
o 60o
120
90o
II

Is the QRS axis normal in this ECG? No, there is left axis
deviation.
The QRS is
positive in I
and negative
in II.

To summarize:
– The normal QRS axis falls between -30o and +90o because ventricular
depolarization is leftward and downward.
– Left axis deviation occurs when the axis falls between -30o and -90o.
– Right axis deviation occurs when the axis falls between +90o and +150o.
– Right superior axis deviation occurs when the axis falls between between
+150o and -90o.
– A quick way to determine QRS Complexes
the QRS I II Axis
axis is to look at the QRS + + normal
complexes in leads I and II. + - left axis deviation
- + right axis deviation
- - right superior
axis deviation
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
To summarize VII a:
1. Calculate RATE
2. Determine RHYTHM
– Normal
– Left axis deviation
– Right axis deviation
– Right superior axis deviation

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
In VII b we will cover the next 3 steps:

1. Calculate RATE
2. Determine RHYTHM
4. Calculate INTERVALS
5. Assess for HYPERTROPHY
6. Look for evidence of INFARCTION

End of Module VII a

Proceed to Module VII a Practice
Quiz on WebCT

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Reading 12-Lead ECG’s

• To systematically analyze a 12-lead

For more presentations www.medicalppt.blog

• The information will be divided into two modules, VII a

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• In Module II you learned how to calculate the

• There is one new thing to keep in mind when

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• In Module II you learned how to systematically

• In Modules III, IV and V you learned how to

• If you need a refresher return to these modules.

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Tip: the rhythm strip portion of the 12-lead ECG is a good

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We can quickly determine whether the QRS axis is

In this ECG what leads

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How do we know the axis is normal when the QRS

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The answer lies in the fact that each frontal lead

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+ + normal -150o -30o

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QRS Complexes -90o

+ + normal -150o -30o

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QRS Complexes -90o

+ + normal -150o -30o

- - right superior 150o 30o

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In VII b we will cover the next 3 steps:

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Reading 12-Lead ECGs

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