Basic ECG Interpretation

Christopher Wenger, DO
August 2012
The Conduction System
The conduction system
http://www.unm.edu/~lkravitz/EKG/ekgdepolmyocyte.html
Nomenclature
Nomenclature
http://cal.vet.upenn.edu/projects/lgcardiac/ecg_tutorial/heartrate.htm
Waves
-P wave
-T wave
-U wave

Complex
-QRS

Segments
-PR segment
-ST segment

Intervals
-PR interval
-QT interval

Point
-J point
Putting it all together
(Conduction system + Nomenclature)
Atrial depolarization
(P wave)
Time lag of impulse from
atrial depolarization to
onset of ventricular
depolarization
(PR segment)
Ventricular
depolarization
(QRS complex)
Plateau phase of
repolarization
(ST segment)
Ventricular
repolarization
(T wave)
Systole: QRS complex to end of T wave
Diastole: End of T wave to QRS complex
Timing of the ECG Paper

Timing of the ECG paper
1 little box = 0.04 seconds (or 40 msec)
1 big box = 0.2 seconds (or 200 msec)
5 little boxes = 1 big box
5 big boxes = 1 second

http://www.unm.edu/~lkravitz/EKG/ekgpaper.html
Timing of the ECG paper
2012 UpToDate, Inc. All rights reserved
Timing of the ECG paper
Full standard: ECG was not reduced in size in order to fit on the paper
(10 mm/mV)
Half standard: ECG was reduced in size by 1/2 in order to fit on the paper (all
(5 mm/mV) deflections should be multiplied by two for proper interpretation)
Full/Half standard: The limb leads are in full standard, however the chest (precordial)
(10/5 mm/mV) leads are in half standard.
Phase I: Rate, Rhythm, Axis
In what order do you read an ECG?
1
st
: What is heart rate (HR)?
Normal, bradycardic, tachycardic
2
nd
: What is the QRS axis?
Normal, left, right, extreme right (aka northwest)
3
rd
: What is the rhythm?
Sinus, supraventricular, junctional, ventricular
Although there is no absolute particular order, YOU MUST
ALWAYS BEGIN YOUR ECG INTERPRETATION WITH THE
ABOVE 3 ASSESSMENTS!!!
Step 1: Heart Rate (defined)
Normal
60 - 100 bpm

Bradycardia
<60 bpm

Tachycardia
>100 bpm
Step 1: Heart Rate (how to calculate)
4 ways to calculate HR:
1
st
: Memorize incremental box counts:






2
nd
: Divide 1500 by the # little boxes between RR interval
Example (above): 1500 / 20 little boxes = 75 beats/minute

3
rd
: Divide 300 by the # big boxes between RR interval
Example (above): 300 / 4 big boxes = 75 beats/minute

4
th
: Count # R waves on entire ECG strip and multiply by 6
Use this method when the rhythm is irregular
Step 2: QRS Axis (defined)
Normal axis
0 to 105
-30 to 0 (normal variant)
Right axis deviation
+105 to +/-180
Left axis deviation
-90 to -30
Extreme right axis deviation (aka Northwest axis)
+/- 108 to -90
Step 2: QRS Axis
http://www.unm.edu/~lkravitz/EKG/qrsaxisdetermine.html
Step 2: QRS Axis (how to determine)
Lead I:
Is R wave > S wave?
Lead aVF:
Is R wave > S wave?
Normal axis
Normal variant or Left
axis deviation
Lead II:
Is R wave > S wave?
Normal variant Left axis deviation
Right axis deviation
YES
YES
NO YES
NO
NO
Hkjhkjhjhkjhkj
jhkh
Step 3: Rhythms
Sinus rhythm
Premature beats
Supraventricular arrhythmias
Junctional rhythms
Ventricular rhythms
Step 3: Rhythms
Sinus rhythms
Normal sinus rhythm
Sinus bradycardia/tachycardia
Sinus arrhythmia
Premature beats
Supraventricular arrhythmias
Junctional rhythms
Ventricular rhythms
Sinus rhythm
Normal sinus rhythm
What makes a rhythm sinus?
-P wave axis is positive in the inferior leads (II, III, aVF)
-P wave morphology is the same
-Cadence is regular

Sinus rhythm is not strictly defined as a P wave before every QRS
Sinus rhythm
Sinus bradycardia
Sinus tachycardia
Heart rate is < 60 beats per minute (bpm)
-In this example, the HR is 55 bpm
(1500 / 27 = 55) or (300 / 5.3 = 56 bpm)
Heart rate is > 100 bpm
-In this example, the HR is 107 bpm
(1500 / 14 = 107) or (300 / 2.8 = 107 bpm)
Sinus rhythm
Sinus arrhythmia
-Normal P wave morphology and axis
-Phasic change in P-P interval, usually in response to breath cycle
-Longest and shortest P-P intervals vary by >0.16 seconds or 10%
Sinus rhythm with sinus arrhythmia
*This rhythm is typically seen with respiration due to fluctuations in
parasympathetic vagal tone
*Treatment is not usually required unless symptomatic bradycardia is present
Rhythms
Sinus rhythm
Premature beats
Premature atrial contraction (PAC)
Premature ventricular contraction (PVC)
Fusion beat
Supraventricular arrhythmias
Junctional rhythms
Ventricular rhythms
Sinus rhythm (with premature beats)
Premature atrial contraction (PAC)
-P wave is abnormal in configuration and premature relative to the normal P-P interval
-QRS complex is usually similar in morphology to the QRS complex present during
sinus rhythm
Sinus rhythm with PACs
Sinus rhythm (with premature beats)
Premature ventricular contraction (PVC)
-A wide, notched or slurred QRS complex that is:
~premature relative to the normal R-R interval, and
~not preceded by a P wave
-Note: a PVC contains a QRS that is almost always >0.12 seconds
-Note: Initial direction of the QRS is often different from the QRS during sinus rhythm
Sinus rhythm with PVCs
If the above telemetry strip had..
-2 PVCs in a row = Sinus rhythm with a couplet
-3 PVCs in a row = Sinus rhythm with a triplet

-PVCs occurring every second beat = Sinus rhythm with bigeminy
-PVCs occurring every third beat = Sinus rhythm with trigeminy
Sinus rhythm (with premature beats)
Fusion beat
-Occurs when a supraventicular & ventricular impulse coincide to create a hybrid complex
~indicative of two foci of pacemaker cells firing simultaneously:
1. a supraventicular pacemaker (e.g. the sinus node), and
2. a competing ventricular pacemaker (source of ventricular ectopic activity)
Sinus rhythm with PVC and fusion beat
http://www.lex-co.com
Rhythms
Sinus rhythm
Premature beats
Supraventricular arrhythmias
Atrial fibrillation
Atrial flutter
Multifocal atrial tachycardia
Wandering atrial pacemaker
Supraventricular tachycardia
Junctional rhythms
Ventricular rhythms
Supraventricular rhythms: Atrial fibrillation
Atrial fibrillation (AF)
-P waves absent (no organized atrial depolarization)
~impulses are not originating from the sinus node
-Atrial activity is totally irregular and represented by fibrillatory waves of varying
amplitude, duration and morphology, causing random oscillation of the baseline
-The AV node allows some of the impulses to pass through at variable intervals
~ventricular rhythm is typically irregularly irregular
~ventricular rate is usually 100-180 bpm


Conditions that can mimic atrial fibrillation:
-Atrial flutter
-Multifocal atrial tachycardia (MAT)
Atrial fibrillation
Supraventricular rhythms: Atrial flutter
Atrial flutter
-Rapid regular atrial undulations (flutter waves)
~forms a classic sawtooth pattern
-Atrial rate of 250-350 bpm
-Ventricular rate depends on conduction via the AV node to the ventricles
~the reentrant pathway in the right atrium with every 2
nd
, 3
rd
, or 4
th
impulse
generates a QRS (while the others are blocked in the AV node as the node
repolarizes
Atrial flutter
Supraventricular rhythms: Multifocal atrial
tachycardia & Wandering atrial pacemaker
Multifocal atrial tachycardia (MAT)
-P waves with 3 morphologies (each originating from a separate atrial focus)
-Atrial rate typically 100-150 bpm
-Irregular rhythm with varying PP and PR intervals
-Isoelectric baseline between P waves (i.e. no flutter waves)
-P waves may be blocked (i.e. not followed by a QRS complex)
Multifocal atrial tachycardia
Wandering atrial pacemaker (WAP)
- P waves with 3 morphologies (just like MAT, however HR is <100 bpm)
Wandering atrial pacemaker
Supraventricular rhythms: SVT
SVT
-Regular rhythm
-HR >100 bpm
-QRS duration is normal
-P wave often buried in QRS complex or preceding T wave
-Impulses stimulating the heart are not being generated by the sinus node, but instead
are coming from a collection of tissue around and involving the AV node

SVT
Rhythms
Sinus rhythm
Premature beats
Supraventricular arrhythmias
Junctional rhythms
Junctional rhythm
Accelerated junctional rhythm
Junctional tachycardia
Ventricular rhythms
Junctional rhythms: Junctional rhythm
Junctional rhythm
-P wave may proceed, be buried in, or follow the QRS complex
-QRS is narrow; RR interval is usually regular
-HR 40-60 bpm
~if HR 60-100 bpm, then the rhythm is called Accelerated junctional rhythm
~if HR >100 bpm, then the rhythm is called Junctional tachycardia
Junctional rhythm
Junctional rhythms: Accelerated junctional
rhythm/Junctional tachycardia
Accelerated junctional rhythm
-Same as Junctional rhythm, however HR is now 60-100 bpm
Accelerated junctional rhythm
Junctional tachycardia
Junctional tachycardia
-Same as Junctional rhythm, however HR is now >100 bpm
Rhythms
Sinus rhythm
Premature beats
Supraventricular arrhythmias
Junctional rhythms
Ventricular rhythms
Accelerated idioventricular rhythm (AIVR)
Ventricular tachycardia (VT)
Ventricular fibrillation (VF)
Torsade de pointes
Ventricular rhythms: Accelerated idioventricular
rhythm (AIVR)
Accelerated idioventricular rhythm (AIVR)
-Regular or slightly irregular ventricular (wide complex) rhythm
-HR of 60-110 bpm
-QRS morphology similar to PVCs

*Tip: Think of this rhythm as a slow ventricular tachycardia (VT)
[however unlike VT, AIVR is not associated with an adverse prognosis]
Accelerated idioventricular rhythm
Ventricular rhythms: Ventricular tachycardia (VT)
Ventricular tachycardia (VT)
-Rapid succession of 3 ventricular premature complexes at a rate >100 bpm
-This rhythm originates in the ventricles (thus no P waves and wide QRS)
-R-R interval is usually regular
-Abrupt onset and termination of arrhythmia is evident
-AV dissociation is common

*This is a lethal arrhythmia!
Ventricular tachycardia
Ventricular rhythms: Ventricular fibrillation (VF)
Ventricular fibrillation (VF)
-Extremely rapid and irregular ventricular rhythm demonstrating:
~chaotic and irregular deflections of varying amplitude and contour
~Absence of distinct P waves, QRS complexes, and T waves

*This is a lethal arrhythmia!
Ventricular fibrillation
Ventricular rhythms: Torsade de pointes (TdP)
Torsade de pointes (TdP)
-Type of polymorphic ventricular tachycardia (VT)
~initiated in the presence of a long QT interval
-HR 240-300 bpm
-progressive reduction of QRS amplitude with reversal that occurs cyclically
~creates an oscillating apperance around the isoelectric line
-AV dissociation present

*This is a lethal arrhythmia!
Ventricular tachycardia
Phase II: Conduction Blocks
Conduction Blocks
Sinoatrial exit blocks
1
st
degree SA block
2
nd
degree SA block
Type (Mobitz) I SA block
Type (Mobitz) II SA block
3
rd
degree SA

AV blocks
1
st
degree AV block
2
nd
degree AV block
Type (Mobitz) I or Wenckebach AV block
Type (Mobitz) II AV block
3
rd
degree AV block (Complete heart block)

Bundle branch blocks
Right bundle branch block (RBBB)
Left bundle branch block (LBBB)
Left anterior fasicular block (or left anterior hemiblock)
Left posterior fasicular block (or left posterior hemiblock)
Conduction Blocks
Sinoatrial exit blocks
1
st
degree SA block
2
nd
degree SA block
Type (Mobitz) I SA block
Type (Mobitz) II SA block
3
rd
degree SA

AV blocks

Bundle branch blocks
Conduction blocks: Sinoatrial exit blocks
1
st
degree SA block
-Delay between impulse generation and transmission to the atrium
-Not detectable on a surface ECG
2
nd
degree SA block, Type (Mobitz) I
-P wave morphology and axis consistent with a sinus node origin
-Group beating with:
~progressive shortening of PP interval up to pause
~constant PR interval
~PP pause <2x the normal PP interval
-Progressive lengthening of the interval between impulse generation and transmission,
culminating in failure
~the gradually lengthening transmission interval pushes successive P waves
closer together which results in grouping of the P-QRS complexes
2
nd
degree SA block, Type (Mobitz) I
Conduction blocks: Sinoatrial exit blocks
3
rd
degree SA block
-No sinus impulses are conducted to the right atrium (complete sinoatrial failure)
~complete absence of P waves
~rhythm may be maintained by a junctional escape rhythm
~indistinguishable on ECG from sinus arrest
2
nd
degree SA block, Type (Mobitz) II
-Constant PP interval followed by a pause that is a multiple (e.g. 2x, 3x, etc.) of the normal
PP interval
~pause may be slightly less than 2x the normal P-P interval (usually within 0.10 seconds)
2
nd
degree SA block, Type (Mobitz) II
Conduction Blocks
Sinoatrial exit blocks

AV blocks
1
st
degree AV block
2
nd
degree AV block
Type (Mobitz) I or Wenckebach AV block
Type (Mobitz) II AV block
3
rd
degree AV block (Complete heart block)

Bundle branch blocks
Atrioventricular (AV) blocks
1
st
degree AV block
-PR interval 0.20 seconds
-Each P wave is followed by a QRS complex


*Remember: the PR interval represents the time from the onset of atrial depolarization to the
onset of ventricular repolarization
1
st
degree AV block
Atrioventricular (AV) blocks
2
nd
degree AV block, Type (Mobitz) I
-Progressive prolongation of the PR interval and progressive shortening of the RR interval
until a P wave is blocked
~RR interval containing the nonconducted P wave is less than 2 PP intervals

*This type of block occurs at the level of the AV node, thus has narrow QRS complex
2
nd
degree AV block, Mobitz I
Atrioventricular (AV) blocks
2
nd
degree AV block, Mobitz II
2
nd
degree AV block, Type (Mobitz) II
-Regular rhythm with intermittent nonconducted P waves and no evidence for atrial
prematurity
-PR interval in the conducted beats is constant
-RR interval containing the nonconducted P wave is equal to two PP intervals

*This type of block typically occurs below the bundle of His, thus has wide QRS complex
(80% of cases)
Atrioventricular (AV) blocks
3
rd
degree AV block
-Atrial impulses consistently fail to reach the ventricles, resulting in atrial and ventricular
rhythms that are independent of each other
-PR interval varies
-PP and RR intervals are constant
-Atrial rate >> Ventricular rate
-Ventricular rhythm is maintained by a junctional or idioventricular escape rhythm or a
ventricular pacemaker

*Note: If Atrial rate << Ventricular rate, then the rhythm is called AV dissociation
3
rd
degree AV block
Conduction Blocks
Sinoatrial exit blocks

AV blocks

Bundle branch blocks
Right bundle branch block (RBBB)
Left bundle branch block (LBBB)
Left anterior fasicular block (or left anterior hemiblock)
Left posterior fasicular block (or left posterior hemiblock)
Bundle branch blocks
http://www.cvphysiology.com
Bundle branch blocks
Right bundle branch block (RBBB)
-Prolonged QRS duration (0.12 seconds)
-Secondary R wave (R) in leads V1 and V2 (rsR or rSR) with R usually taller than the initial
R wave
-Typically have wide slurred S wave in leads I, V5, and V6

*Incomplete RBBB = when RBBB criteria are met, but the QRS duration is 0.10-0.12 seconds
R wave
r wave
S waves
Bundle branch blocks
Left bundle branch block (LBBB)
-Prolonged QRS duration (0.12 seconds)
-Broad monophasic R waves in leads I, V5, V6 that are usually notched or slurred
-Secondary ST & T wave changes opposite in direction to the major QRS deflection
-rS or QS complex in right precordial leads

*Incomplete LBBB = when LBBB criteria are met, but the QRS duration is 0.10-0.12 seconds
Broad monophasic R waves rS complex
Bundle branch blocks
Left anterior fascicular block (hemiblock)
-Left axis deviation with mean QRS axis between -45 and -90
-qR complex (or an R wave) in leads I and aVL
-rS complex in lead III
-No other factors responsible for left axis deviation
qR complex
rS complex
Bundle branch blocks
Left posterior fascicular block (hemiblock)
-Right axis deviation with mean QRS axis between +100 and +180
-Q waves in lead III
-S waves in lead I
-No other factors responsible for right axis deviation

*Compared to the left anterior fascicule, the left posterior fascicle is shorter, thicker, and receives
dual blood supply (from the LAD and RCA ); thus more rare
*CAD is the most common cause of LPFB; when it develops during AMI, MV-CAD and extensive
infarction are typically present and prognosis is poor




Q wave
S wave
Right axis
deviation
Phase III: Intervals,
Hypertrophy, Infarction
Intervals
Length of PR interval

Length of QRS complex

Length of QT interval
Intervals: PR
< 0.12 seconds 0.12 0.20 seconds >0.20 seconds
Pre-excitation
(i.e. Wolff-Parkinson-White)
Normal AV nodal blocks
Intervals: QRS
0.10 seconds 0.10 0.12 seconds >0.12 seconds
Normal Incomplete bundle branch
block
Bundle branch block
PVC
Ventricular rhythm
Pictured: Incomplete RBBB
Pictured: Sinus rhythm with PVC
Intervals: QT
Proportional to heart rate:
Slower HR = Longer QT interval
Faster HR = Shorter QT interval

To calculate accurate QT interval (taking into account HR),
you must calculate the corrected QT interval (QTc):
Bazetts formula:
QTc = QT / square root of R-R interval

Quick tip: Instead of calculating a QTc, you can perform a quick
estimate to determine if the QT interval is normal or
prolonged:
A QT interval > half of the R-R interval is probably prolonged

Intervals: QT
0.44 seconds > 0.44 seconds
Normal Prolonged QT interval
Pictured: Prolonged QT interval
Pictured: Torsade de Pointes
Hypertrophy
Types:
Right atrial abnormality (RAA)
Left atrial abnormality (LAA)
Right ventricular hypertrophy (RVH)
Left ventricular hypertrophy (LVH)

Note:
To determine atrial abnormality, analyze the P waves
To determine ventricular hypertrophy, analyze the QRS
complex
We use the term abnormality instead of enlargement when
referring to the atria since an ECG reflects augmentation of
electrical current only (and not necessarily the actual size of the
chamber)
Hypertrophy: RAA
Diagnostic criteria:
1. Lead II, III, and aVF: P wave >2.5 mm, or
2. Lead V1 or V2: P wave >1.5 mm
*Remember: 1 small box = 1 mm
Alpaslan, Dr. Mete. doktorekg.com
Hypertrophy: LAA
Diagnostic criteria:
1. Lead V1: P wave 1 mm deep and 0.04 seconds in duration
(1 small box deep and one small box wide), or
2. Lead II, III, or aVF: Notched P wave with duration of 0.12 seconds
(P-mitrale)
Alpaslan, Dr. Mete. doktorekg.com
Hypertrophy: RVH
Diagnostic criteria:
1. Right axis deviation
2. Dominant R wave:
R/S ratio in V1 or R/S ratio in V5 or V6 1
R wave in V1 7 mm
R wave in V1 + S wave in V5 or V6 >10.5 mm

Lifeinthefastlane.com. Aug 2012
Hypertrophy: LVH
Diagnostic criteria (any of the following):
1. Cornell Criteria (most accurate):
R wave in aVL + S wave in V3: >28 mm (male), >20 mm (female)
2. Maximum R wave + S wave in precordial leads >45 mm
3. R wave in V5 >26 mm
4. R wave in V6 >20 mm
Lifeinthefastlane.com. Aug 2012
Infarction
When assessing for infarction, take note of the
following:
Abnormal Q waves
ST segment deviation (elevation or depression)
Peaked, flat, or inverted T waves

Acute MI ECG diagnostic criteria:
ST segment elevation or depression of 1 mm in 2
contiguous leads
Infarction (Q waves)
http://www.medicine-on-line.com
Normal (non-pathologic) Q wave: note that the Q
wave is both shallow and brief
Pathologic Q waves: >40 ms or deeper than 1/3 the
height of the entire QRS complex
http://www.medicine-on-line.com
*Tip: Pathologic Q waves = infarction (however they
do not tell you if the infarct is acute, sub-acute, or old!
(the timing is determined by the ST segment)
Infarction (ST segments)
Transmural MI = Q wave MI = STEMI
(note Q wave and ST segment elevation
>1 mm)

Subendocardial MI = Non-Q wave MI = NSTEMI
(note absence of Q waves; ST segment
depression >1 mm)

http://www.medicine-on-line.com
http://www.medicine-on-line.com
Infarction (ST segments)
Acute inferior wall STEMI
Infarction (T waves)
Hyperacute (tall positive) T waves:
-T waves may precede ST segment elevation (A), or
-T waves may be seen with ST elevation during the acute
phase (B)


http://www.medicine-on-line.com
Infarction (coronary artery
distribution)
Peter J. Zimetbaum, M.D., and Mark E. Josephson, M.D. Use
of the Electrocardiogram in Acute Myocardial Infarction N
Engl J Med 2003; 348:933-940March 6, 2003
Infarction (Timing)
Emerg Med Clin N Am 2006; 24:53-89
Abnormal Q waves.
-with ST segment elevation/depression = acute MI
-without ST segment changes and normal T wave = old MI
-without ST segment changes and inverted T wave = MI of undetermined age