Basic ECG Reading

1. Determine Rate
2. Determine Rhythm
3. Measure Intervals
(PR interval, QRS interval, QT interval)
4. Determine QRS electrical axis
5. Check for chamber enlargements
6. Check for ST and T wave changes
7. Check for miscellaneous ECG findings
 STEP 1: Determine Rate
For Regular Rhythm
Heart Rate= 1500/ # of small squares from R to R

Heart Rate= 1500/ 20 = 75 beats per minute

Tachycardia: HR >100 beats per minute
Bradycardia: HR <60 beats per minute
 STEP 1: Determine Rate
For Irregular Rhythm
Heart Rate= # of QRS complexes within 30
large boxes x 10
1 2 3 4 Heart Rate=
8 QRS complexes
within 30 large
5 6 7 8
boxes x 10 =
80 beats per minute
 STEP 2: Determine Rhythm
A. Regular Sinus Rhythm
- Rhythm is normally determined by the sinus node,
which fires at 60-100 beats per minute.
-P wave is normally upright in Lead II (and usually in
leads I, AVL and AVF)
-Each p wave is followed by a QRS complex and
each QRS complex is preceded by a p wave
-The distance between the R-R intervals should be
equal
 STEP 2: Determine Rhythm
A. Regular Sinus Rhythm
 STEP 2: Determine Rhythm
B. Sinus Arrhthymia
- Sinoatrial node discharges irregularly (sinus
node rate varies with the respiratory cycle)
-Rate: normal (still within 60-100 bpm)
-Rhythm: variation in the P-P interval or R-R
interval >/= 120 msecs (or the shortest and
longest of these intervals differs by more than
10%)
-P waves, PR Interval and QRS: Normal
 STEP 2: Determine Rhythm
B. Sinus Arrhthymia
 STEP 2: Determine Rhythm
C. Junctional (Atrioventricular) Rhythm
-Pacemaker: AV junction with a ventricular rate
of 40 to 60 bpm
-Pwave: may appear before, after or buried
within the QRS complex
- Rhythm (R-R interval): regular
-QRS complex: narrow(</=0.12 sec)
 STEP 2: Determine Rhythm
C. Junctional (Atrioventricular) Rhythm
 STEP 2: Determine Rhythm
D. Idioventricular Rhythm
-Pacemaker: His Purkinje system (HPS) with a
ventricular rate between 20 to 40 bpm)
-P wave: absent
- Rhythm (R-R interval): regular
-QRS complex: wide (>0.12 sec)
 STEP 2: Determine Rhythm
D. Idioventricular Rhythm
 STEP 3: Measure Intervals
(PR interval, QRS interval, QT interval)
Wave/ Interval Description Normal Values
P wave Atrial depolarization ≤120 msec
(≤3 small squares wide)

PR interval Conduction delay within ≤200 msec

the AV node (≤5 small squares wide)

QRS duration Ventricular depolarization ≤110 to 120 msec

(≤3 small squares wide)

QT interval(corrected, Ventricular depolarization ≤440 to 450 msec

QTc) and repolarization (in general)
Upper limit:
-460 msec in women
-450 msec in men
 STEP 3: Measure Intervals
(PR interval, QRS interval, QT interval)
 STEP 3: Measure Intervals
(PR interval, QRS interval, QT interval)
Corrected QT interval using Bazett’s Formula
-Done to adjust for abnormal heart rates
(HR<60 or >100 bpm)
Corrected QT interval=
QT actual in sec/
 STEP 3: Measure Intervals
(PR interval, QRS interval, QT interval)

R-R interval

QT actual
QT actual= 12 small boxes x 0.04 sec/small box= 1.68 sec
R-R interval= 29 small boxes x 0.04 sec/small box= 1.16 sec
Corrected QT interval= QT actual in sec/
Corrected QT interval= 0.4/ = 0.37 sec
 STEP 4: Determine QRS electrical axis
INTERPRETATION VALUE
Normal Axis -30⁰ TO 90⁰
Moderate Right Axis 90⁰ TO 120⁰
Deviation

Marked Right Axis 120⁰ TO 180⁰

Deviation
Moderate Left Axis -30⁰ TO -45⁰
Deviation

Marked Left Axis -45⁰ TO 90⁰

Deviation
Extreme Axis -90⁰ TO 180⁰
Deviation
STEP 4: Determine QRS electrical axis
A. Computation of Frontal Axis
- Deduct negative deflections from positive
deflections in QRS complexes to derive the values
for leads I and AVF
-If lead I is negative integer, subtract the computed
axis from 180 to get the final axis
-Note that the value for AVF in the denominator is
the absolute value, while that in the numerator
takes the sign (positive or negative) into
consideration.
Axis= 90 x AVF / (I) + (AVF)
STEP 4: Determine QRS electrical axis

• I= 1 -8= -7 (negative integer) ; aVF=9

• 90*9-=810; 7+9=16; 810/16= 50
• AXIS= 180-50= +130
STEP 4: Determine QRS electrical axis
STEP 4: Determine QRS electrical axis

• I= 3-10= -7; aVF=7-4= 3

• 90*3=-270; -7+3=-4; 270/-4= -67.5
• AXIS= -67.5
STEP 4: Determine QRS electrical axis
STEP 4: Determine QRS electrical axis
B. Quadrant Method
 STEP 4: Determine QRS electrical axis
C. Three- Lead Analysis
INTERPRETATION LEAD I LEAD II LEAD AVF

Normal Axis + + +/-

Left Axis Deviation + - -
Right Axis Deviation - + +
Extreme Axis - - -
Deviation
STEP 4: Determine QRS electrical axis

• Lead I = POSITIVE
• Lead II = POSITIVE
• aVF = POSITIVE
• This puts the axis in
the left lower
quadrant (LLQ)
between 0° and +90°
– Normal Axis
STEP 5: Check for chamber enlargements
A. Atrial Enlargement
Right Atrial Enlargement:
-peaked P-waves with amplitudes in lead II of
>0.25Mv (“P pulmonale”)
-Prominent initial positivity in lead V1 or V2
>0.15 MV (1.5 at usual gain)
-Increased area under initial positive portion of
the p wave in lead V1 to >0.06 mm sec
STEP 5: Check for chamber enlargements
Right Atrial Enlargement:
STEP 5: Check for chamber enlargements
Left Atrial Enlargement:
-prolonged P-wave (≥120ms or ≥3 small boxes) in
lead II
-prominent notching of P wave, usually most
obvious in lead II, with the interval between
notches of >0.04 msec (“P mitrale”)
-ratio between the duration of the p wave in lead II
and duration of the PR segment >1.6
-increased duration and depth of terminal negative
portion of p wave in lead V1 (P terminal force) so
that area subtended by it is >0.04 mm sec
STEP 5: Check for chamber enlargements
Left Atrial Enlargement:
STEP 5: Check for chamber enlargements
Right and Left Atrial Enlargement:
STEP 5: Check for chamber enlargements
B. Left Ventricular Hypertrophy
Sokolow + Lyon
• (S in V1)+ (R in V5 or V6) > 35 mm or R in AVL
>11mm
Cornell criteria
• S in V3 + R in aVL > 28 mm in men
• S in V3 + R in aVL > 20 mm in women
STEP 5: Check for chamber enlargements
Sokolow + Lyon
STEP 5: Check for chamber enlargements
Cornell criteria

S in V3= 17mm; R in AVL= 15 mm

STEP 5: Check for chamber enlargements
C. Right Ventricular Hypertrophy
• Right axis deviation (>90 degrees)
• R in V1 ≥0.7MV
• QR in V1
• R/S in V1 >1 with R >0.5MV
• R/S in V5 OR V6 <1
• S in V5 or V6 >0.7MV
• R in V5 or V6 ≥ 0.4MV with S in V1 ≤0.2 MV
• S1-Q3 pattern
• S1-S2-S3 pattern
• P pulmonale
STEP 5: Check for chamber enlargements

C. Right Ventricular Hypertrophy

STEP 6: Check for ST and T wave changes
A. The Contiguous Leads
LEADS Walls Represented
II, III, aVF Inferior wall
I, aVL High lateral wall
V1, V2 Septal wall
V3, V4 Anterior wall
V5, V6 Lateral wall
V1 – V3 Anteroseptal wall
V3– V6, I, aVL Anterolateral wall
V5, V6, II, III, aVF Inferolateral wall
Almost ALL leads Diffuse, massive
V3R, V4R Right ventricular wall
ST segment depression of >1mm; deep T wave inversions of >5mm
STEP 6: Check for ST and T wave changes
A. The Contiguous Leads
STEP 6: Check for ST and T wave changes
B. Variability of ECG Patterns with Acute
Myocardial Infarction
PATHOLOGY
Subendocardial Ischemia
(Non-infarcted)
Transmural Ischemia
(Non-infarcted)
Non ST elevation Myocardial
Infarction
ST elevation Myocardial Infaction
POSSIBLE ECG FINDINGS
Transient ST depressions
Transient ST elevations or
paradoxical T wave normalization
Sometimes followed by T wave
inversions
ST depressions
T wave inversions
No Q waves
Hyperacute T waves and ST
elevations
T wave inversions
Dveleopment of Q waves
STEP 6: Check for ST and T wave changes
STEP 6: Check for ST and T wave changes
C. Criteria for ECG Manifestations of Myocardial
Infarction
Manifestation Criteria
ST Depression -New horizontal or downsloping ST depression
≥0.05mv in two contiguous leads
-ST depression ≥0.1mv in one or more surface
leads + ST elevation in AVR and /or V1 suggestes
left main (or equivalent) obstruction
T wave inversion T wave inversion ≥0.1mv in two contiguous leads
with a prominent R wave or R/S ratio >1
ST elevation (in absence of CLBBB) -New St segment elevation at J point in 2
contiguous leads with the following cut points:
-All leads (except V2-V3):≥0.1MV elevation
-Leads V2-V3: Men≥40 years ≥0.2mv elevation;
Men <40 years ≥0.25mv elevation; Women
≥0.15mv elevation
-For inferior wal MI: right precordial leads are
needed to identify concomitant RV infarction
-For ST depression in V1-V3: ST
elevation(≥0.5mm)in leads V7-V9 signifies a
posterior wall MI
STEP 6: Check for ST and T wave changes
C. Criteria for ECG Manifestations of Myocardial
Infarction
Manifestation Criteria
ST elevation (in setting of CLBBB or RV Sgarbossa’s criteria to identify AMI in a
pacing) patient with complete LBBB or RV pacing:
-ST elevation ≥1 mm in a lead with a
positive QRS complex - 5 points
-concordant ST depression ≥1 mm in lead
V1, V2, or V3 - 3 points
-ST elevation ≥5 mm in a lead with a
negative (discordant) QRS complex - 2
points
≥3 points = 90% specificity of STEMI
(sensitivity of 36%)

Pathologic Q waves ->0.04sec(1mm) wide

>0.2mv(2mm)deep
>25% of QRS complex amplitude
STEP 6: Check for ST and T wave changes

D. Timing of STEMI