Basic ECG Interpretation

Our ECG Interpretation Training and Reference Guides provide basic lessons for ECG analysis
as well as a quick reference guide for over 40 types of ECG tracings. The arrhythmia drills
and quizzes allow you to practice ECG interpretation.
What is ECG Interpretation?
An electrocardiogram or ECG, records electrical activity in the heart. An ECG machine
records these electrical signals across multiple heart beats and produces an ECG strip that is
interpreted by a healthcare professional.
How Electrocardiograms Work - ECG Strips
To briefly summarize the components of a normal ECG tracings, it consist of waveform
components which indicate electrical events during one heart beat. These waveforms are
labeled P, Q, R, S, T and U.
P wave is the first short upward movement of the ECG tracing. It indicates that the atria are
contracting, pumping blood into the ventricles.
The QRS complex, normally beginning with a downward deflection, Q; a larger upwards
deflection, a peak (R); and then a downwards S wave.
The QRS complex represents ventricular
depolarization and contraction.
The PR interval indicates the transit time for the
electrical signal to travel from the sinus node to the
ventricles.
T wave is normally a modest upwards waveform
representing ventricular repolarization.

ECG Training - Introduction

The focus of this introductory ECG course is to provide a tutorial about the main features of
ECGs along with a method for analyzing ECGs. This method includes assessment of rhythm,
calculating heart rate, observing P-wave forms, measurement of intervals and segments and
the evaluation of other relevant waves.
ECG practice exercises serve to reinforce the lesson content.
ECG Training
EKG Basics
EKG Course Introduction
This short course reviews the main features of EKG tracings. A method for analyzing EKGs is also
presented. This method includes assessment of rhythm, calculating heart rate, observing P-wave
forms, measurement of EKG intervals and segments and the evaluation of other relevant waves.

Table of Contents

1 EKG Paper 3 EKG Interpretation

2 EKG Nomenclature 4 Rhythm
5 Heart Rate
9 T Wave
6 P Wave
10 QT Interval
7 PR Interval
11 ST Segment
8 QRS Complex
 EKG Paper

ECG tracings are recorded on grid paper. The horizontal axis of the
EKG paper records time, with black marks at the top indicating 3 second intervals.
Each second is marked by 5 large grid blocks. Thus each large block equals 0.2 second. The
vertical axis records EKG amplitude (voltage). Two large blocks equal 1 millivolt (mV). Each
small block equals 0.1 mV.
Within the large blocks are 5 small blocks, each representing 0.04 seconds.
 EKG Nomenclature
Normal EKG tracings consist of waveform components that indicate
electrical events during one heart beat. These waveforms are labeled P, Q,
R, S, T and U. The following descriptions are with respect to Lead II.
P wave is the first deflection and is normally a positive (upward) waveform.
It indicates atrial depolarization.
QRS complex follows the P wave. It normally begins with a downward
deflection, Q; a larger upward deflection, R; and then a downward S wave.
The QRS complex represents ventricular depolarization and contraction.
T wave is normally a modest upward waveform, representing ventricular
repolarization.
U wave indicates the recovery of the Purkinje conduction fibers. This wave
component may not be observable.

EKG Interpretation
EKG interpretation should be performed using a standard procedure. For this course, we are
using an eight step procedure:
 Rhythm
 Rate
 P Wave
 PR Interval
 QRS Interval
 T Wave
 QT Interval
 ST Segment
Rhythm
For ventricular rhythms, examine the R to R intervals on the EKG strip. Calipers or paper
marks can be used to fix the distance for one R-R interval and then this distance can be
compared to other R-R pairs. Within this web site, you will also be able to use virtual
calipers.
Are they regular, meaning that each heart beat's R-R interval is equal? Small variations of up
to 10% are considered equal. Is the rhythm regularly irregular? For example is there a
pattern, such as increasing R-R durations? Or perhaps groups of similar intervals as
illustrated on the right? Or are R-R intervals completely irregular?
For atrial rhythm, observe the P-P intervals. Are they regular (minor variations can be
caused by the breath cycle)? If P-P intervals are irregular, is there a pattern?

Heart Rate
There are several methods for determining heart rate. Our first method is simple. Count the
number of QRS complexes over a 6 second interval. Multiply by 10 to determine heart rate.
This method works well for both regular and irregular rhythms. In the first image, we can
count 7 QRS complexes, so the heart rate is 70.
The second method uses small boxes. Count the number of small boxes for a typical R-R
interval. Divide this number into 1500 to determine heart rate. In the second image, the
number of small boxes for the R-R interval is 21.5. The heart rate is 1500/21.5, which is
69.8.
 P Wave
The P wave represents atrial depolarization. In a normal EKG, the P-wave precedes the QRS
complex. It looks like a small bump upwards from the baseline. The amplitude is normally
0.05 to 0.25mV (0.5 to 2.5 small boxes). Normal duration is 0.06-0.11 seconds (1.5 to 2.75
small boxes). The shape of a P-wave is
usually smooth and rounded.
P-wave questions:
 Are they present?
 Do they occur regularly?
 Is there one P-wave for each QRS
complex?
 Are the P-Waves smooth,
rounded, and upright?
 Do all P-Waves have similar
shapes?
 PR Interval
The PR Interval indicates AV conduction time.
In this step you should measure the interval from where the P wave begins until the
beginning of the QRS complex. Calipers, marked paper or counting small boxes methods can
be used to determine PR Intervals. Normally this interval is 0.12 to 0.20 seconds (3 to 5
small boxes) in adults, longer in elderly people. This interval shortens with increased heart
rate.
Also evaluate if PR Intervals are constant or varying across the EKG strip. If they vary,
determine if the variations are a steady lengthening until the point where an expected QRS
does not appear.
PR Interval questions to address:
 Does the PR-Interval fall within the norm of 0.12-
0.20 seconds?
 Is the PR-Interval constant across the ECG tracing?

QRS Complex
The QRS complex indicates ventricular depolarization. Depolarization triggers contraction of
the ventricles.
Because of the larger tissue mass, the QRS complex is larger than the P wave. While the
prototypical QRS complex consists of three wave components, one or two of these
components may be missing.
In this step, measure the QRS interval from the end of the PR interval to the end of the S
wave. Use calipers, marking paper or by counting small boxes. Normally this interval is 0.08
to 0.10 seconds.
QRS questions:
Does the QRS interval fall within the range of
0.08-0.10 seconds?
Are the QRS complexes similar in appearance
across the ECG tracing?
 T Wave
The T wave indicates the repolarization of the ventricles. It is a slightly asymmetrical
waveform that follows (after a pause), the QRS complex. Take note of T waves that have a
downward (negative) deflection or of T waves with tall, pointed peaks.

The U-wave is a small upright, rounded bump.

When observed, it follows the T-wave.

QT Interval
The QT interval represents the time of ventricular activity including both depolarization and
repolarization.
It is measured from the beginning of the QRS complex to the end of the T wave. Normally,
the QT interval is 0.36 to 0.44 seconds (9-11 boxes).
The QT interval will vary with patient gender, age
and heart rate. Another guideline is that normal QT
Intervals is less than half of the R-R Interval for heart
rates below 100 bpm.

ST Segment
The ST segment represents the early part of ventricular repolarization.
The ST segment is the line that from the end of the QRS complex to beginning of the T wave.
Normally the ST segment is flat relative to the baseline.
ECG Interpretation Tutor
Use our online ECG 'Workbook' to practice your ECG analysis skills and to learn over 40 different types of ECG
tracings. After your analysis is completed, our ECG tutor presents an analysis from an ECG expert.

ECG Interpretation Tutor

Arrhythmia Drills
Using multiple choice questions and answers, users are asked to identify arrhythmia tracings. Digital calipers are
available to assist in analyzing each ECG practice strip. Feedback is provided after each response.

Arrhythmia Practice Drills

ECG Guide
Our ECG training guide provides information about many types of arrhythmias. For each ECG arrhythmia we provide
multiple electrocardiogram tracings. Electrocardiogram analysis is provided using a concise summary of the ECG's key
features. Tracing features can be measured using our digital calipers.

ECG Guide