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 well-
coordinated 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)

- I
+/-

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 arrythmia
Sinus pause or arrest, SA block, PAC, atrial flutter,
atrial fibrillation, etc
Ventricular arrythmia
PVC, VT, torsade de pointes, VF, etc
AV 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 M-
shaped
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 (4-
6 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-de-
pointes
Ventricular
Ventricular fibrillation
Chaotic, wide, ventricular tachyarrythmia with
grossly irregular morphology
No consistent identifiable QRS complexes