THE NORMAL

ELECTROCARDIOGRAM
 Medical problems can be
diagnosed with an ECG
Cardiac chamber enlargement
Hypertrophy of cardiac muscle
Cardiac arrhythmias
Insufficient coronary blood flow
Death of heart muscle and its location (ischemia,
injury, infarction)
Electrolyte imbalance
Miscellaneous
Cardiac conduction system
Cardiac conduction system
Recording Electrodes & Leads

aVF I aVR

RA LA
ICS4

II III ICS5

RSM LSM

MCL
RL LL AAL MAL

aVF
 Calibration & Paper Speed

Paper speed
25 mm/second
50 mm/second
 Reading the
Electrocardiogram
Electrocardiogram
 Electrocardiogram

Identity : Name, age, sex, (race), date,

time
Paper speed
Calibration
Electrode placement
Artifact
 Electrocardiogram

The ECG machine is very accurate at measuring interval and duration

 Electrocardiogram

ECG machine DIAGNOSIS is not always accurate

 ECG interpretation
Rhythm
Rate & regularity
P wave morphology
PR interval
QRS complex morphology
ST segment morphology
T wave morphology
U wave morphology
QTc interval
 Regularity
P waves and QRS complex are used to
determine cardiac rate and regularity

Regular : constant P-P interval or R-R interval

Irregular : not constant P-P interval or R-R
interval
Regularity

Regular
 Heart rate

Regular rhythm
Memorize the number sequence Mathematical method

_________300__________
large boxes between R-R

_________1500_________
small boxes between R-R

Speed 25 mm/second
 Heart rate
Irregular rhythm
6 second method : R-R interval ( R waves) X 10
6 second = 30 large boxes

6 second = 8 R-R interval

Heart rate 1 minute = 8 X 10 = 80 X/minute
 The P wave
Contour : smooth and monophasic
(entirely negative/positive) in all leads
except V1, or occasionaly V2
Configuration :
Positive (upright) : I, II, aVL, aVF, V4V6
Negative (downward) : aVR
Positive / negative : III
Duration : 0.12 sec
Amplitude : 0.2 mV
P wave
 PR interval
The time required for an electrical impulse to
travel from the atrial myocardium adjacent to
the SA node to the ventricular myocardium
adjacent to the fibers of the Purkinje network
Duration : 0.11 0.20 seconds (3-5 small
boxes)
PR interval varies with the heart rate. The
faster the heart rate, the shorter the PR
interval
 PR interval
Abnormal PR interval : first degree AV block
 QRS complex
Q R S
QRS complex
 QRS complex
The Q wave
The presence of Q waves in lead V1, V2, and
V3 should be consider abnormal
The absence of small Q waves in lead V5 and
V6 should be consider abnormal
A Q wave of any size is normal in lead III and
aVR
 QRS complex
The Q wave
In all others leads, a normal Q wave would be
very small (less than 0.04 second and its
voltage is less than 25% of the R wave)
QRS complex
Abnormal Q waves
 QRS complex
The R wave
The positive R wave normally increases in
amplitude and duration from lead V1 to V4 or
V5
Loss of normal R wave progression is
considered abnormal
 QRS complex
R wave progression
 QRS complex
The S wave
S wave should be large in V1 and then
progressively smaller to V6

Ratio R/S
Ratio of R/S amplitude in V1 and V2 is
normally less than 1
R in V5/V6 + S in V1/V2 is not more than 35
mm
 QRS complex
S wave regression
 QRS complex

RV1/SV1 > 1
 QRS complex
Transitional zone = Rotation
Clockwise rotation
Counter clockwise rotation
QRS complex
QRS complex
 QRS complex
J point
Junction between end of QRS complex and
beginning of ST segment
Where QRS stops and makes a sudden sharp
change of direction
 QRS complex
Duration of the QRS complex (QRS interval)
0.07-0.11 second (less than 0.12 second)
The QRS interval has no lower limit that indicates
abnormality
Amplitude of QRS complex
There is no arbitrary upper limit for normal voltage of
the QRS complex
An abnormality low QRS complex when the amplitude
is no more than 0.5 mV in any limb leads and no more
than 1.0 mV in any of the precordial leads
 QRS complex

Abnormal QRS interval

 QRS complex
The Axis of QRS complex
Normal :
-300 - +900
Left Axis Deviation (LAD) :
-300 - -1200
Right Axis Deviation (RAD) :
+900 - +1800
Extreme RAD :
- 900 - +1800
 QRS complex
The Axis of QRS complex (Lead I + Lead aVF)
Normal :
Lead I (+) Lead aVF (+)
Lead I (+) Lead aVF (-) Lead II (+)
Left Axis Deviation (LAD) :
Lead I (+) Lead aVF (-) Lead II (-)
Right Axis Deviation (RAD) :
Lead I (-) Lead aVF (+)
Extreme RAD :
Lead I (-) Lead aVF (-)
 QRS complex
The Axis of QRS complex (Lead I, Lead II, Lead III)
 QRS complex
The Axis of QRS complex
 QRS complex
The Axis of QRS complex
 QRS complex
The Axis of QRS complex
QRS complex
QRS complex
 ST segment
The ST segment represent the period during
which the ventricular myocardium remains in
an activated or depolarized state
ST segment normally located at the same
horizontal level with the PR segment
Normal variations :
Slight upsloping, downsloping, or horizontal
depression
 ST segment
Early repolarization : displacement of ST segment
by as much as 0.1 mV in the direction of the
ensuring T wave
ST segment may be altered when there is
prolonged QRS complex
ST segment
ST segment
 T wave
The T waves are positively directed in all leads
except aVR (negative) and V1 (biphasic)
T waves do not normally exceed 0.5 mV in any
limb lead or 1.5 mV in any precordial lead
 U wave
U wave is either absent or present as a small
wave following the T wave and is usually most
prominent in leads V1 and V2.
Increased prominence of the U wave indicates
the possibility of hypokalemia.
 QT interval
The QT interval measures the duration of
electrical activation and recovery of the
ventricular myocardium
The QT interval decreases as the heart rate
increases and therefore should be corrected
for cardiac rate (QTc interval)
QTc= QT/RR interval (in seconds)
The upper limit of QTc is 0.46 second (slightly
longer in female)
 QT interval
QT interval varies among different leads. The
longest QT interval measured in multiple leads
should therefore be considered the true QT
interval
The QT interval should be measured in either
lead II or V5-6
The Normal Cardiac Rhythm :
The Sinus Rhythm
 Sinus Rhythm
The normal cardiac rhythm is called sinus rhythm
because it is produced by electrical impulses formed
within the SA node
Sinus rhythm, is essentially but not absolutely regular
The P wave axis of sinus rhythm is between 30o and
75o
An abnormal P wave axis is usually accompanied with
an abnormality short PR interval. However short PR
interval with in the presence of normal P wave axis
suggests an abnormal conduction pathway
SA node
Thank You