SummaryofEKGInterpretationbyDHKim

1.Electrophysiology
Depolarization

Repolarization

Approachingtothelead:positivedeflection

Approachingtothelead:negativedeflection

2.EKGLeadReferenceSystem
Lead

Position

Limbleads(LA/RA/LL/RL)

Ineachextremity,atleast10cmfromtheheart

V1

4thintercostalspace,justtotherightofthesternum

V2

4thintercostalspace,justtotheleftofthesternum

V3

MidwaybetweenV2andV4

V4

Midclavicularline,5thintercostalspace

V5

Anterioraxillaryline,samelevelasV4

V6

Midaxillaryline,samelevelasV4andV5
HexaxialSystem

PrecordialSystem

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SummaryofEKGInterpretationbyDHKim
3.EKGWaveformsandIntervals

Waveforms/Intervals
Pwave

Meaning
Depolarizationofatria

NormalRange
0.080.11sec

SinusPwaveisuprightinIIandinvertedinaVR.
PRsegment

Depolarization of AV node, His bundle, bundle

branch,andthepurkinjesystem

PRinterval

Pwave+PRsegment

0.080.20sec

QRScomplex

Depolarizationofventricles

0.080.10sec

Qwave:thefirstnegativedeflectionafterPwave
Rwave:thefirstpositivedeflectionafterPwave
Swave:thefirstnegativedeflectionafterRwave

SignificantQwave:eitherofthefollowingcriteria
(1)Qwaveduration>0.04sec
(2)Qwaveheight>1/4ofthetotalheightoftheQRS

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SummaryofEKGInterpretationbyDHKim
STsegment

Electrically neutral period between depolarization

andrepolarizationofventricles

Twave

Repolarizationofventricles
NormalTwaveisasymmetric

QTinterval

QRScomplex+STsegment+Twave

QTc<0.44sec

Ventriculardepolarizationandrepolarization
CorrectedQT(QTc)(NormalQTc 0.44seconds)
=QTmeasured(sec)/SquarerootofRRinterval(sec)
Uwave

Drugs(Quinidine,Procainamide,Disopyramide)

Hypokalemia

4.EKGPaper
EKGpaperspeed=25mm/sec

The red line represents time ;

events that touch the red line
occurredsimultaneously.

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SummaryofEKGInterpretationbyDHKim
5.InterpretationofEKG
(1)Calibration

OneSmall

OneSmall

VerticalBox

HorizontalBox

A.Standard

0.1mV

0.04sec(25mm/sec)

B.Halfstandard

0.2mV

0.04sec(25mm/sec)

C.Doublespeed

0.1mV

0.02sec(50mm/sec)

(2)Rate:Useoneofthefollowingthreemethods
1500/(numberofmmbetweenbeats):onlyapplicabletoregularrhythm
Countoffmethod:300150100756050:onlyapplicabletoregularrhythm
Numberofbeatsin12secondstrip(theentireEKGlength)X5:applicabletoirregularrhythm

(3)Rhythm:Sinusrhythmispresent,if:
(1)eachPwaveisfollowedbyQRS
(2)eachQRSispreceededbyaPwave
(3)thePwaveisuprightinleadsI,II,&IIIandinvertedinleadaVR
(4)thePRintervalis0.120.20sec(35smallboxes)
(5)Ifrate60100:normalsinusrhythm;Ifrate>100:sinustachycardia;Ifrate<60:sinusbradycardia
Ifthesecriteriaarenotmet,determinethetypeofarrhythmia.

(4)Interval
Interval
PR

Normal

Decreasedin

0.120.20sec

Preexcitationsyndrome

(35smallboxes)

Junctionalrhythm

Increasedin
FirstdegreeAVblock
Bundlebranchblocks

QRS

0.10sec
(2.5smallboxes)

Ventricularectopicbeat

Toxicdrugeffect(e.g.,quinidine)
Severehyperkalemia
Hypocalcemia
Hypokalemia(dueto Uwave)

QT

QTc 0.44sec

Hypercalcemia

Hypomagnesemia

Tachycardia

Myocardialischemia
CongenitalprolongationofQT
Toxicdrugeffect(e.g.,quinidine)

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SummaryofEKGInterpretationbyDHKim
(5)MeanQRSAxis
NormalQRSaxis:30degreesto90degrees
IfQRSispositiveinleadsIandII,normalQRSaxis
Ifnot,(1)findtheisoelectriclead;(2)examinetheperpendicularleadtotheisoelectriclead.

Leftaxisdeviation

Rightaxisdeviation
Normalvariant(inchildrenandyoungadults)
RVH

LVH(sometimes)

AcuteorchronicRVoverload

Leftanteriorfascicularblock

(e.g.massivepulmonaryembolism)

InferiorwallMI

Leftposteriorfascicularblock

Normalvariant

LateralwallMI
Dextrocardia
Leftpneumothorax

(6)Pwave
Lookforatrialenlargement

LeadII

Normal

NoteslightlybiphasicPinV1

V1

Rightatrialabnormality(RAA)

Ppulmonale
PinleadII2.5mm

Pmitrale
Leftatrialabnormality(LAA)

BiphasicPinV1
Broad,oftennotchedPinleadII

(7)QRSComplex
Lookforventricularhypertrophy
Lookforbundlebranchblockandfascicularblock
Lookforinfarction
LookforpoorRwaveprogression

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SummaryofEKGInterpretationbyDHKim

V1

MainQRSvector

V6

Rightventricularhypertrophy
R SinV1
Rightaxisdeviation

Leftventricularhypertrophy
SinV1+RinV5orV6 35mm
RinV5orV6 25mm
RinI 15mm
RinaVL 1113mm

RinaVF 20mm

RinI+SinIII 25mm

Rightbundlebranchblock

Leftbundlebranchblock

1.QRS 0.12sec

1.QRS 0.12sec

2.Deep,slurredSwaveinIandV6

2.Broad,monomorphicRinI/V6,withnoQwaves

3.RSRpatterninV1

3.Broad,monomorphicSinV1

Leftanteriorfascicularblock
1.LADwiththeaxisat30to90
2.qRcomplexinI,aVL
3.rScomplexinII,III,aVF

Leftposteriorfascicularblock
1.RADwiththeaxisat90to180
2.rScomplexinI,aVL
3.qRcomplexinII,III,aVF
4.ExclusionofRAEand/orRVH

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SummaryofEKGInterpretationbyDHKim
AnatomicSite

ChangesonEKG

CoronaryArtery

Inferior

II,III,aVF

RCAorLCx

Anteroseptal

V1,V2

LAD

Anteroapical

V3,V4

LAD(distal)

Anterolateral

V5,V6,I,aVL

LCx

Posterior

tallRinV1,V2

RCAorLCx

AnteroseptalMI

AnteroseptalMIwithLateralExtension

LateralMI

InferiorMI

PosteriorMI

RV+InferiorMI

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SummaryofEKGInterpretationbyDHKim
EKGProgressioninMI

(8)STandTchanges
Baseline:TPsegment

STelevation:Injuryandischemia

STdepression:Ischemia

ExamplesofSTchanges

ExamplesofTchanges

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SummaryofEKGInterpretationbyDHKim
Conditions

EKGchange

Features
Tall,peakedandnarrowTwave
Wideningofintervals

Hyperkalemia

LossofPwave
Sinewavepattern
ProminentUwave
MildSTdepression

Hypokalemia

Hypercalcemia

FlattenedTwave
ShorteningofSTQTc

Hypocalcemia

ProlongationofSTQTc

Osbornwave:adistinctive

Hypothermia

convexelevationofJpoint

MarkedQTprolongation

Intracranialbleeds
(SAH)

Deep,wideTinversions

ShortenedQTinterval

Digoxin

ScoopingoftheSTTwave

Drugs(increase the duration of the action potential): Type IA

antiarrhythmics (quinidine, disopyramide, procainamide), TCAs,

ProlongationofQT

phenothiazines,typeIIIantiarrhythmics(amiodarone,sotalol)

REFERENCES
1.GarciaTB,HoltzNE.12leadECG:Theartofinterpretation.Sudbury,JonesandBarlettPublishers,2001
2.WagnerGS.Marriottspracticalelectrocardiography,10thedition.Philadelphia,LippincottWilliams&Wilkins,
2001
3.GoldbergerAL.Electrocardiography,inHarrisonsprinciplesofinternalmedicine,15thedition,EBraunwaldetal
(eds).NewYork,McGrawHill,2001
4. Lilly LS et al. The electrocardiogram, in Pathophysiology of heart disease, 2nd edition, Lilly LS et al (eds).
Philadelphia,LippincottWilliams&Wilkins,1997
5.ThalerMS.TheonlyEKGbookyoulleverneed,3rdedition.Philadelphia,LippincottWilliams&Wilkins,1999

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