ECG interpretation

*Use rhythm strip unless otherwise stated

1 small square=0.04s; 1 large square=0.2s

Demographics

Patient name, DOB, any symptoms (e.g. chest pain)

ECG date and time and which in series
Check calibration (paper speed) 25mm/s

Rate and rhythm

Rate: 300 / number of large squares between R peaks

o bradycardia <60 e.g. athletes; hypothermia; hypothyroidism; SA node disease; B-blockers
o tachycardia >100 e.g. exercise; pain; anxiety; PE; hypovolaemia; fever; anaemia; thyrotoxicosis; shock
Rhythm
1. Regularity: mark 4 R peaks on plain piece of paper and move along to confirm
2. Sinus: look for a P wave before each QRS complex (no P waves and irregular QRS = AF; sawtooth baseline = atrial
flutter)

Axis

Short method: QRS in lead I and II normally predominantly positive.

o If R waves point away from each other i.e. QRS predominantly positive in lead I and negative in lead II (legs apart)
there is left axis deviation (LV strain/ hypertrophy e.g. left anterior hemiblock; inferior MI; WPW)
o If R waves point towards each other (legs together - right!) there is right axis deviation (RV strain/ hypertrophy e.g. PE;
anterolateral MI)

P wave

Height 2 small squares (increased in right atrial enlargement e.g. pulmonary hypertension; tricuspid stenosis)
Morphology
o Bifid (left atrial hypertrophy e.g. mitral stenosis)
o Peaked (right atrial hypertrophy)

PR interval

Length 3-5 small squares

o Decreased: accessory conduction pathway
o Increased:
st

1 degree heartblock: PR >5 small squares and regular

nd

Mobitz T1 (Wenkebach) 2 degree heartblock: PR elongates over ECG then regular failure of conducted atrial
beat
nd

Mobitz T2 2 degree heartblock: constant prolonged PR with occasional dropped beats; may be 2:1 block, 3:1
block (alternate conducted and non-conducted atrial beats P:QRS)
rd

3 degree heartblock: complete dissociation between p waves and QRS. Normal atrial contraction with a
ventricular escape rhythm (due to fibrosis around Bundle of His or post-MI)

QRS complex

Normally should get R wave progression *Check in all V leads as well systematically
Length <3 small squares
o Increased

RBBB: QRS in V1 has M pattern, in V6 has W pattern (MarroW) e.g. PE (with tachycardia); normal variant; cor
pulmonale

LBBB: QRS in V1 has W pattern, in V6 has M pattern (WilliaM) e.g. ischaemia; cardiomyopathy; hypertension
Height <4 big squares *Check as below
o Left ventricular hypertrophy = R wave in V5/V6 >25mm, or sum of R in V5/V6 and S in V1/V2 >35mm
o Right ventricular hypertrophy = dominant R in V1, T inversion V1-V3, deep S in V6
Q wave *Check as below
o Normal if: width <0.04s and depth <2mm in V5/V6/aVL/I (reflects normal septal depolarisation)
o Pathological Q waves (deeper than 2mm): full thickness acute MI; may persist post-MI

2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students finals OSCE revision

ST segment *Check in all leads systematically

Elevation 1 small square (infarction see table; pericarditis or tamponade if in every lead)
Depression 1 small square (ischaemia; posterior infarction reciprocal change)
Morphology
o Saddled (pericarditis; tamponade)
o Upward sloping (normal variant)
o Downward sloping (digoxin toxicity)

Inferior MI
Anteroseptal
MI
Anterolateral
MI

V1-V4

Lateral MI

I, aVL V5-6

Posterior MI

Tall R V1-2, ST
depression

T wave

Leads
II, III, aVF

V4-V5, I, aVL

Artery
Right
coronary
L.A.D.
L.A.D. or
left
circumflex
Left
circumflex
Left
circumflex
or right
coronary

Inversion *Check as below

o V1-V3, aVR: normal variant (especially in black, afrocarribean); PE; RBBB
o V4-V6, I & II: ALWAYS pathological subendocardial (partial) infarct; MI; angina; LVH; old ischaemia
Morphology
o Tented (hyperkalaemia)
o Flat (hypokalaemia)

Common pathologies

Sinus rhythm: P waves (positive in II, III, aVF) followed by QRS complex
AF: absence of P waves, irregular baseline, irregular QRS complexes. May be tachycardic if not rate controlled. QRS complexes
should be narrow, unless co-existent BBB. If QRS complexes are regular, it is unlikely to be AF.
Atrial flutter: saw-tooth baseline, classically at 300bpm, with 2:1 block giving a QRS rate of 150bpm.
Nodal rhythm: regular QRS complexes but P waves are absent, or occur within or after QRS complexes.
Ventricular rhythm: broad QRS complexes with P waves following them.
VF: No discernible P waves/ QRS complexes.
VT: broad complex tachycardia is VT until proven otherwise.
Acute MI: ST elevation in >2mm in 2 adjacent chest leads, or ST elevation > 1mm in 2 adjacent limb leads
Ischaemia: Inverted T waves, pathological Q waves, ST depression
PE: Sinus tachycardia, RAD, RBBB, SIQIIITI pattern (rare)

Metabolic

Digoxin: ST Depression, inverted T waves V5-V6, reverse tick sign

Hyperkalaemia: low flat P waves, wide bizarre QRS, slurring into ST segment, tall tented T waves
Hypokalaemia: small flattened T waves, prolonged PR, depressed ST, prominent U wave
Hypercalcaemia: short QT
Hypocalcaemia: prolonged QT

2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students finals OSCE revision