ECG Interpretation

Rate
RR interval Heart rate
Rhythm
PP interval P wave - width, height, shape, etc.
PR interval
QRS - width (and height), axis, R wave progression, abnormal Q waves
ST segment
T waves
QT interval
U waves
An electrical current in the direction towards the
positive end of a bipolar electrode causes a positive
deflection of EKG


An electrical current in the direction away from the
positive end of a bipolar electrode causes a negative
deflection of EKG
The Normal ECG



Normal = normal sinus rhythm
Rate
1. R-R interval
Is it regular?


2. What is the heart rate?
300, 150, 100, 75, 60, 50
300 / (# of large boxes)
1500 / (# of small boxes)
Count the number of cardiac cycles in 10 seconds and multiple by
6.
Rate
Bradycardia
less than 60 bpm



Tachycardia
greater than 100 bpm
Rate
3.P-P interval
Rhythm

4.P wave
5.PR interval
6.QRS
4. P Wave
Lead II and aV
R

Positive in II
Negative in aV
R
< 2.5 mm in amplitude
< 0.12 sec. in width
Normal P Wave
Normal direction of atrial
depolarization
aVR?
II?
Normal P Wave
Normal direction of right and left atrial
depolarization = physiologic
difference right left = 0.02 sec
aVR?
II?
V1
V2
V5
V6
Abnormal P Wave
aVR?
II?
Direction of atrial depolarization
with junction rhythm
This is an example of
a retrograde
conduction
Atrial depolarization
Axa P=+30-+60
0

0
90
SA
nod
e
AV
nod
e
Step 1: right atrial depolarization vector cranio-caudal, right left, postero-anterior
(goes to V1-V2)

Step 2: left atrial depolarization horizontal vector orizontal, right - left, antero-posterior
(goes to V5-V6)
AD
AS
V
1
V
2
V
5
V
6
P
P
Characteritics of atrial depolarization
Biphasic P wave in V1-V2
Positive P wave in V5-V6
P wave:
A
P
= +30-+60
0


+ in DI, DII, aVF, aVL
certainly negative in aVR
anyway in DIII
Width : 0,10 0,12 sec
Amplitude: <2,5 mm
P wave
The same direction as QRS
Only one P wave in front of QRS
Do all the P waves look alike?
5. PR interval
0.12 - 0.20 seconds
6. QRS Complex
What is the width? (less than 0.10 seconds)
Do all the QRS waves in the same lead look alike?
R wave progression
Axis
Abnormal Q waves (infarction)
QRS Complex
Q waves
Normal QRS
Three phases


brief phase; depolarization of ventricular septum

longer phase; depolarization of both ventricles but the
left is larger

brief phase; depolarization posterior basal small
segment left ventricle
First Phase
Depolarization of
ventricular septum
DI, aVL,
V5, V6
r
S
V1, V2
Second Phase
Depolarization of both
ventricles but the left is
larger
DI, aVL,
V5, V6
r
S
V1, V2
Third Phase
brief phase;
depolarization posterior
basal small segment left
ventricle

r
S
DI, aVL,
V5, V6
V1, V2
Precordial Leads
V1
V6
Normal QRS
V
1
?
V
1
?
V
6
?
V
6
?
Fig. 4-6
Normal QRS
V1
V6
Normal QRS
Septal r wave
Septal q wave
Depolarizarea V si geneza cx QRS
1. The depolarizes from the
inside out and the resulting
depolarization wave moves
away from the electrode
recording Lead II
septum
2. The rest of the
depolarizes counter-clockwise
from the inside out and creates
the (large arrow)
which is essentially, the algebraic
sum of all of the small depolarization
vectors (including the small
contribution from the )
. In a normal heart, this vector
is always moving directly
toward Lead II, generating a
mostly positive QRS complex

left ventricle
main cardiac vector
right ventricle
Lead II electrode
60 downward
rotation angle
from the horizontal 0
o
o
Note: compared to
the left ventricle, the
right ventricle is much
smaller and contributes
little to the overall main
vector of depolarization
60
o
1
2
3
V1
V2
r
V5
V6
q
s
6. QRS Complex




R wave progression
Normal R Wave Progression
Transition Zone?
R Wave Progression
Transition Zone?
Transition Zone

Early & Delayed Transition
Figure 4-7
V1 V2 V3 V4 V5 V6
6. QRS Complex
What is the electrical axis?
normal
left axis deviation
right axis deviation
extreme axis deviation
7. ST Segment



ST segment elevation or depression

8. T Wave
Normally positive where QRS wave is positive
V
3
- V
6
and II,

but negative in aV
R
Abnormally tall T waves




10 ECG rules

Rule 1
PR
interval
M
i
l
l
i
v
o
l
t
s

Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
P
R
T
Q
S
PR interval should be 120 to 200
milliseconds or 3 to 5 little squares

PR interval is the time from initiation of
depolarisation of the atria to initiation of the
depolarisation of the ventricles

A longer PR may imply a block in
conduction and a shorter interval indicates
a vulnerability to arrhythmias.


Rule 2
M
i
l
l
i
v
o
l
t
s

Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
QRS
P
R
T
Q
S
The width of the QRS complex
should not exceed 110 ms, less than
3 little squares

QRS complex is due to depolarisation of
the ventricles

A wider QRS is sometimes seen in
healthy people, but may represent an
abnormality of intraventricular
conduction.


Rule 3
I II III aVR aVL aVF
The QRS complex should be dominantly
upright in leads I and II


Rule 4
I II III aVR aVL aVF
QRS and T waves tend to have the same
general direction in the limb leads
Rule 5
P
Q
T
S
All waves are negative in lead aVR



aVR represents electrical activity as
seen from the right shoulder. The
sinus node is placed top right in the
heart nearest the right shoulder, and
the electrical activity is moving
downwards and leftwards towards
the left ventricle.

Rule 6
V
1

V
2

V
3

V
4

V
5

V
6

The R wave in the precordial leads must grow from V1 to at least V4
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Rule 7
The ST segment should start isoelectric except in V1 and V2 where it may
be elevated
Rule 8
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The P waves should be upright in I, II, and V2 to V6
Rule 9
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
There should be no Q wave or only a small q less than 0.04 seconds in
width in I, II, V2 to V6
Rule 10
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The T wave must be upright in I, II, V2 to V6
Normal
Not normal PR interval -
Mobitz Type II block
Not normal
LAD, R wave progression
RBB w/inferior MI
Not normal -
First degree block, left atrial enlargement, left bundle branch
block, & inferior MI
Not normal
Atrial fibrillation
Normal
Not normal
Junctional rhythm
Not normal
LAD, late R wave progression
Acute MI
Normal
Not normal
Second degree AV block - type II
Not normal
Third degree AV block
Not normal
Right bundle branch block. Note the wide QRS waves
Normal
Not normal
Left bundle branch block. Note the wide QRS waves
a. yes
b. vertical
c. V3
d. yes
e. yes
f. yes
2. No. Although there are P waves, they are negative.
negative P waves indicate a retrograde conduction likely
coming from the AV junction.