ECG Interpretation

Definition

Test that records the electrical

activity of the heart
Measure:
Rate

and regularity of heartbeats

Size and position of the chambers
Presence of any damage to the
heart
Effects of drugs or devices used to
regulate the heart
Systemic condition that gives
effect to the heart

How does it work?

The heart is a muscle with wellcoordinated electrical activity, so

the electrical activity within the
heart can be easily detected from
outside of the body.

After the appropriate leads are

attached to the body, a heated
stylus moves upward with positive
voltage and downward for
negative voltage.

On the moving heat-sensitive

paper, voltage is traced out.

ECG lead

Electrodes used to measure

electrical activity of the hearts
2 basic types

Bipolar leads (standard limb leads)

utilize a single positive and a single
negative electrode between which
electrical potentials are measured.
Unipolar leads (augmented leads
and chest leads) have a single
positive recording electrode and
utilize a combination of the other
electrodes to serve as a composite
negative electrode.

Limb lead (bipolar)

-

+/-

II

III

Extremity lead (unipolar)

Menggunakan terminal sentral sebagai titik nol

Precordial lead

The Normal Conduction System

ECG Terminology

P wave : the sequential activation

(depolarization) of the right and left
atria
PR interval: time interval from onset
of atrial depolarization (P wave
QRS complex: right and left
ventricular depolarization (normally
the ventricles are activated
simultaneously)
QRS duration: duration of ventricular
muscle depolarization
PP interval: duration of atrial cycle (an
indicator or atrial rate)
RR interval: duration of ventricular
cardiac cycle (an indicator of
ventricular rate
QT interval: duration of ventricular
depolarization and repolarization

Normal ECG

P wave
Width < 0.12 s
Height < 0.3 milliVolt
Always positive in lead II, negative in
aVR
PR interval
From the start of P wave to the start of
QRS
Normal duration 0.12 0.20 s
QRS complex
Width 0.06 0.12 s (~ 0.10 s)
Length varies among leads
Q first negative deflection
R first positive deflection
S negative deflection after R
ST segment
From the end of S to the start of T
Normal : iso-electrical
T wave
Positive in lead I, II, V3 V6 and
negative in aVR

Normal ECG

Basic interpretation
Rate
Rhythm
Axis
P wave morphology
PR interval
QRS complex morphology
ST segment morphology
T wave morphology
U wave morphology
QTc interval

Determining the Heart Rate

Rule of 300

300/[number of large boxes between two R waves].

only works for regular rhythms !!

300/7.5 large boxes = rate 40

Six second methods

Count the number of R-R intervals in six seconds and multiply by 10

Useful for irregular rhythm average rate
There are 8 R-R intervals
within 30 boxes. Multiply 8 x
10 = Rate 80

Determining the Rhythm

Source of depolarization

Sino-atrial (SA) node: sinus rhythm

Depending on rate can be sinus bradicardi or sinus tachycardia

Non-sinus: atrial/ventricular rhythm (see arrhythmia section)

Sinus rhythm criteria

P wave always followed by QRS complex

Normal ECG

Axis

Defleksi positif

Defleksi negatif

ECG abnormalities
Hypertrophy
Ischemia/infarct
Arrhythmia

Hypertrophy

Right atrial enlargement

Tall,

peaked p wave

Left atrial enlargement

Widening

p wave, M-shape, notched

Deep, negative component p wave in V1

Ventricular Hypertrophy

LVH (sokolow, Lyon)

S

di V1 + R di V5 atau V6 > 35 mm
R di V5 atau V6 > 26 mm
R + S di lead precordial > 45 mm

RVH
R/S

di V1 > 1 atau R/S di V6 < 1

R in V5 > 26 mm

R/S in V1 > 1 or R/S in V6 < 1

Infarct / Ischemia

Evolution of MI

Hyperacute T wave changes increased T wave amplitude and

width; may also see ST elevation
Marked ST elevation with hyperacute
T wave changes (transmural injury)
Pathologic Q waves, less ST
elevation, terminal T wave inversion
(necrosis)
Pathologic Q waves, T wave inversion
(necrosis and fibrosis)
Pathologic Q waves, upright T waves
(fibrosis)

I, aVL, V5
V2-V4

Arrhythmia

Classification
Supraventrivular

Sinus pause or arrest, SA block, PAC, atrial flutter,

atrial fibrillation, etc

Ventricular

arrythmia

PVC, VT, torsade de pointes, VF, etc

AV

arrythmia

conduction abnormalities

AV block, WPW syndrome, etc

Rhythm

Rhythm Guidelines:
Check

the bottom rhythm strip for regularity, i.e. regular, regularly irregular, and irregularly irregular.
Check for a P wave before each QRS, QRS after
each P.
Check PR interval (for AV blocks) and QRS (for
bundle branch blocks). Check for prolonged QT.
Recognize "patterns" such as atrial fibrillation, PVC's,
PAC's, escape beats, ventricular tachycardia,
paroxysmal atrial tachycardia, AV blocks and bundle
branch blocks

Blocks

SA node block
Failure

of the SA node to transmit an impulse

Complete pause of 1 beat ("skipped beat")

AV node block
Block

which delays the electrical impulse as it

travels between the atria and the ventricles in the
AV node
Presented by PR interval

Blocks

1st degree AV block

PR interval greater than 0.2 seconds (200ms or 1 large box)

2nd degree AV block

Type I (Wenckebach) PR interval gets longer (by shorter

increments) until a nonconducted P wave occurs
Type II (Mobitz) PR intervals are constant until a
nonconducted P wave occurs

Blocks

3rd degree AV block

Complete

block of signals from the atria to the

ventricles complete dissociation between the
timing of the P-waves and the QRS complexes

Blocks

Bundle branch blocks

Blocks

within the ventricular bundles

Wide QRS complex
Consist of
Right ventricular bundle branch block
Left ventricular bundle branch block
Left anterior fasicular block
Left posterior fasicular block

RBBB
Complete

QRS duration > 0.12 s

rSR in lead V1-V2
Slurred S wave in lead I, aVL,
V5-V6
Down sloping of ST segment
and T wave inversion in lead
V1-V2

Incomplete
rSR complex in lead V1
QRS duration of 0.12 s or less
R or S waves are not broad or
slurred
Normal QRS axis

LBBB

Complete

QRS duration > 0.12 s

Bizarre, wide rS or QS complex in lead V1
Wide R wave in lead V6, sometimes plateu or Mshaped
Discordant T wave
Absence of normal septal Q wave in lead I, aVL, V6

LAFB

Criteria

QRS duration < 0.12

Left axis deviation more than -45 degrees
qR wave in leads I, aVL
Small rS complex in leads II, III, aVF

LPFB

Criteria
QRS

duration < 0.12 s

Right axis deviation > +110 degrees
Small r wave and large S wave in leads I, aVL
Small q waves in inferior leads
No other explanation for RAD (ex. RVH,
COPD, lateral myocardial infarction)

Supraventricular Arrythmia

Premature atrial contraction

Single or repetitive, unifocal or multifocal

Atrial fibrillation

Atrial activity is poorly defined; may see course or fine

undulations or no atrial activity at all
Ventricular response is irregularly irregular

Supraventricular

Atrial flutter

Regular atrial activity with a "clean" saw-tooth appearance

The ventricular response may be 2:1, 3:1 (rare), 4:1, or
irregular

Paroxysmal supraventricular tachycardia

Arise from structure above his bundle

Reciprocating tachycardias because they
utilize the mechanism of reentry

Ventricular Arrythmia

Premature ventricular contraction

May be unifocal, multifocal or multiformed

Occur as isolated single events or as couplets, triplets, and salvos (46 PVCs in a row ~ brief VT)
R-on-T PVCs vulnerable to ventricular tachycardia or fibrillation

Ventricular tachycardia
Sustained (lasting >30 sec) vs. nonsustained

Monomorphic (uniform morphology) vs. polymorphic vs. Torsade-depointes

Ventricular

Ventricular fibrillation
Chaotic,

wide, ventricular tachyarrythmia with

grossly irregular morphology
No consistent identifiable QRS complexes