How to read ECG

ECG
Representation of Electrical activity of heart

ECG Leads
12 lead ECG 6 limb leads: Lead I, II, III
aVL, aVR, aVF

6 Chest Leads: V1, V2,V3, V4, V5, V6

ECG paper
Speed 25mm/s 1 large square= 5 small square [5mm] Voltage 10mm =1mV

Appearance of waves
Positive deflection [upward] If electrical impulses flowing towards that lead

Negative deflection [downward]

If electrical impulses flowing away from that lead

Origin of waves

P wave PR interval

Atrial depolarization

Atrial depolarization to start of ventricular depolarization QRS complex Ventricular depolarization

T wave
QT interval U wave

Ventricular repolarization
Ventricular depolarization & repolarization ? Interventricular septal repolarization

Systematic approach
The following 14 points should be analyzed carefully in every ECG: Standardization Heart rate Rhythm P waves PR interval QRS voltages QRS interval QT interval Mean QRS axis Precordial R-wave progression Abnormal Q waves ST segments T waves U waves

Standardization

Heart Rate
1500/RR

If HR is irregular Count no. of QRS complexes in 30 large squares= 6 sec Multiply it with 10 HR [per min]

Rate calculation
Memorize the number sequence: 300, 150, 100, 75, 60, 50

 ECG machines: print out HR

DO NOT RELY ON IT!!!! Always Calculate yourself.

Bradycardia: <60/min
Tachycardia: >100/min

Rhythm
Rhythm strip: prolonged recording of Lead II Sinus rhythm ? Each QRS complex preceded by P wave

Regular/ irregular?

Regular Sinus rhythm

Irregular

QRS AXIS
Indicator of overall direction that wave of depolarization takes when passing through ventricles Also called ANGLE Measured in degrees

 Photo

 Right axis deviation [RAD] Beyond +90

Left Axis Deviation [LAD]

Beyond -30

Method 1
Most precise method Use of vectors Measure overall height of QRS in lead I & aVF Plot in graph paper Measure the ANGLE of vector

Method 2
Quick method

Identify limb lead in which QRS complex

is isoelectric

[with equal positive & negative

deflection]

Implies: electric flow is at Right angle to

this lead

Method 3
For quick assessment Look at QRS complexes in lead I & II

 Predominantly
positive QRS in

lead I
Axis between

-90 to +90
Excludes RAD

 Predominantly positive QRS in lead II Axis between -30 to +150 Excludes LAD

Lead I
QRS Positive QRS Positive

Lead II
QRS Positive

Cardiac Axis
Normal Axis

QRS Negative Left Axis Deviation Right Axis Deviation

QRS Negative QRS Positive

 LAD WPW syndrome LBBB Inferior wall MI

RAD RVH WPW syndrome Anterolateral MI Dextrocardia

P wave
Present or not? Sinus rhythm If completely absent
Atrial Fibrillation

Hyperkalemia

If intermittently absent
Sinus arrest

 Inverted P waves?

Incorrect positioned electrodes

Dextrocardia

Abnormal atrial depolarization

 Height of P waves

> 2.5 mm: tall

Indicative of Right Atrial enlargement P Pulmonale

P PULMONALE

P MITRALE

 Width of P waves >2mm width: abnormal Bifid P wave

Indicates Left Atrial enlargement

P Mitrale

PR Interval
From start of P wave to start of R wave Normally Not <3 small squares Not > 5 small squares Consistent

Short PR Interval
AV junctional rhythm WPW syndrome

Lown Ganong-Levine syndrome

Long PR Interval
Denotes delay in conduction through AV node First Degree Block PR prolonged, constant

Second degree Block Mobitz Type I PR progressively increase until one P

wave fails to produce QRS complex

 Mobitz Type II
PR interval normal & fixed, But occasional P waves fail to produce QRS

 Third Degree Block [Complete AV Block] No relationship between P waves & QRS complex

 2:1 Block Alternate P waves are not followed by QRS complex

Q WAVE
First negative deflection in QRS complex ? Pathological Q waves If >2 small squares deep >1 small square wide >25% of height of the following R wave in depth

QRS complex
Appearance of QRS Complex vary from lead to lead

 Width: Narrow/ wide

Wide QRS:

> 3 small squares

Bundle branch block Ventricular arrhythmia

 Size of QRS complex Small: Pericardial effusion

?incorrect calibration

 Big QRS complex

Ventricular hypertrophy: R/L

WPW syndrome

Progression of R wave
V1: small R wave , large S wave, Gradually R wave increases, S wave decreases

V6: small Q wave, large R wave

V3 and V4 : located midway between V1 and V6, QRS complex nearly isoelectric in one of these leads

Progression of R wave

Left ventricular Hypertrophy

R Wave in V5 or V6 >25mm S Wave in V1 or V2 > 25mm Sum of R wave in V5 Or V6 & S wave in V1 or V2 >35mm

LVH

Right Ventricular Hypertrophy

Right axis deviation Deep S Waves in leads V5 & V6 R>S in V1 RBBB

RBBB
Right Bundle Branch Block Broad QRS complex Small r wave in V1, small Q wave in V6 S wave in V1, R wave in V6 R wave in V1, S wave in V6

LBBB
Left Bundle Branch Block Broad QRS Small Q wave in V1, Small r wave in V6 R wave in V1, S wave in V6

S wave in V1, R wave in V6

 WILLIAM MORROW William: W in V1 & M in V6: LBBB

Morrow: M in V1 & W in V6: RBBB

 LBBB Ischemic Heart Disease Cardiomyopathy LVH

RBBB
Ischemic heart

disease
Cardiomyopathy

ASD
Massive pulmonary

Fibrosis

embolism

ST Segment
From end of S wave to start of T Wave Normally: Isoelectric ? Depressed/ elevated

 Elevated ST segment Acute MI Prinzmetals angina Pericarditis LV aneurysm High take off

 Depressed ST segment Myocardial ischemia Posterior MI Ventricular hypertrophy with Strain Drugs: Digoxin

Ventricular Hypertrophy with strain pattern

Tall R waves Deep S waves ST segment depression T wave inversion

T Wave

T wave
Inverted? Normal in aVR V1,V2, III Size Normal: not > size of preceeding QRS complex Too small? Too large?

Tall T waves
Hyperkalemia Acute MI

Too small T Waves

Hypokalemia Pericardial effusion

hypothyroidism

Inverted T waves
Normal in few leads: aVR, V1, V2, III MI Myocardial ischemia Ventricular hypertrophy with strain Digoxin toxicity

QT Interval
From start of QRS complex to end of T wave Varies with HR

Corrected QT interval
QTC QTC =QT/RR Normal: 0.35-0.43 sec

Prolonged QTc
If 0.44 sec Hypocalcemia Acute myocarditis Torsades de pointes

U waves
Mostly in anterior chest leads Difficult to identify clearly

 Prominent U Waves Hypoklemia Hypercalcemia

Hyperthyroidism

Common ECG Problems

ACUTE MI

Ischemia

HYPERKALEMIA

LVH WITH STRAIN

PERICARDITIS