Approach To 12 Lead ECG’s

Prepared by Dr. Jason Waechter

Depts of Critical Care and Anesthesiology

This is an outline only. For further details and explanations, please refer to “12 Lead ECG: The
Art of Interpretation” by Tomas Garcia. If you understand why and how the ECG findings occur,
they will be a lot easier to remember. To actually learn ECG’s, you need to practice, practice
practice. After about 500 ECG’s, you be able to do them without forgetting major details.
Questions or comments are always welcome: jwaech@yahoo.ca

Overview:
1. Determine the rhythm I aVR V1 V4
2. Determine the axis
3. Identify bundle branch blocks II aVL V2 V5
4. Identify chamber enlargement (all 4 chambers) III aVF V3 V6
5. Search for ischemia or infarction The 12 leads
6. Miscellaneous (metabolic and others)

Further details:
1. Determine the rhythm
 rate, rhythm, P waves, PR interval, QRS width -90°

2. Determine the axis

Extreme LAD
a) which quadrant is the axis in?
i) use leads I and aVF
b) which lead is isoelectric?
RAD Normal
i) the axis is 90 degrees to this lead
c) shortcut for normal axis:
i) leads I and II both positive = normal +90°
ii) defines the range from +90° to –30°
d) shortcut for LAD:
i) lead I positive and lead II negative (defines –30 to –90 degrees)

3. Identify bundle branch blocks

a) RBBB: QRS > 0.12 sec + RSR’ in V1/V2 (note R:S ratio > 1) + slurred S wave in I and V6
b) LBBB: QRS > 0.12 sec + smooth wide S in V1 + smooth wide R in I and V6
• Sinus rhythm + wide QRS that does not meet above criteria: think ↑ K+ !
• LBBB will change the ST segment, causing diagnostic interference for
infarct/ischemia, and often changes the voltage size, interfering with the dx of LVH.
c) LAHB (left anterior hemiblock): normal QRS width + LAD
d) LPHB (left posterior hemiblock): normal QRS width + RAD (not very common)

4. Identify chamber enlargement P

 P waves are seen best in leads II and V1 → → → P
a) LAE (left atrial enlargement, aka “P mitrale”)
i) M shaped and > 0.12 sec (3 squares wide) in II
(M for mitrale)
ii) biphasic, with big inverted second half in V1
b) RAE (right atrial enlargement, aka “P pulmonale”)
i) 2.5 mV tall (2.5 little squares) in II

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4. Identify chamber enlargement (continued)
c) LVH
 at least 1 “voltage criteria” is required:
i) biggest S in V1/V2 + biggest R in V5/V6 > 35
ii) biggest QRS in V1 through V6 > 45
iii) R > 12 in I ⎫ 12
iv) R > 11 in aVL ⎬ (in diagram form) → 11
v) R > 20 in aVF ⎭ 20
vi) plus a “strain pattern”, greatest where voltage is greatest
d) RVH
i) R > S in V1 (also called R:S ratio > 1)
ii) RAD
iii) RV “strain pattern”
iv) S1Q3T3 pattern (S in lead I, Q in lead III, inverted T in lead III)
v) evidence of RAE
• Note that the “strain pattern” can mimic ischemia or infarct

5. Search for ischemia and infarction

a) ensure no LBBB L S A
b) ST depression (usually ischemia) I L S L
c) ST elevation (usually infarct) I I A L
d) peaked, inverted or biphasic T waves
e) symmetrical T waves L = lateral S = septal
f) Q waves (old or late MI I = inferior A = anterior
g) poor R wave progression (V1 through V6)
Special infarcts:
i) RV infarct:
1. ST elevation in inf. leads
2. ST elevation in V1
3. ST elevation in RV4 (an extra right-sided lead, same as V4)
4. ST elevation is greater in III>II
ii) Posterior infarct:
1. ST elevation in inf. leads
2. ST elevation in V7,8,9 (extra posterior leads, also called “15 lead ECG”)
3. ST depression V1-4 (depression because posterior is mirror image)
4. R:S > 1 in V1
5. “pathological R wave” in V1,2. (Look at ECG upside down and mirror
image to see that R wave is really a Q wave).

6. Miscellaneous
a) R:S ratio > 1 in V1: Ddx = RVH, RBBB, Posterior infarct, WPW, children
b) Pericarditis: ST elevation in all leads, PR interval depression, “notched” QRS
c) ↑ K+: peaked T waves, wide QRS, flat/absent P waves, “sine wave” QRS
d) Hypothermia: Osborn (J) waves, bradycardia
e) ↓ Ca++: long QT interval
f) ↓ K+: U waves
g) Digoxin toxicity: scooped ST segments, bradycardia
h) “Low voltage”: Ddx = obesity, COPD, pericardial effusion, hypothyroid, big MI

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 12 Lead ECG Worksheet – Axis Calculation

When the axis is toward a lead, the QRS deflection is positive. When the axis is away from a lead,
the QRS deflection is negative. Shade in the following diagrams:

QRS positive in I QRS negative in I

QRS positive in aVF QRS negative in aVF

positive in I + positive in aVF negative in I + positive in aVF

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 12 Lead ECG Worksheet– Axis Calculation

The isoelectric lead is 90

degrees to the axis.

The 6 limb leads are at

30 degree intervals:

Determine the axis in the following examples:

Lead I Lead aVF Isoelectric lead Axis?

+ - aVR
+ + III
- + aVR
+ iso aVF
iso + I

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 12 Lead ECG Worksheet– Axis Calculation

Shortcut #1: positive in I and postive in II ↑

is a normal axis: ↑

+ =

↑
Shortcut #2: Positive in I and negative in II ↓
is LAD:

+ =

↓
Shortcut #3: Negative in I is RAD
or extreme LAD. Always abnormal.

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