Medicine, Nursing and Health Sciences

Cardiovascular Investigations
and Interpretation
THE ELECTROCARDIOGRAM

Dr NADIDA KACHKOUCHE
Year 1 Clinical Skills Coordinator
Monash University
Department of General Practice
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Do not remove this notice.

2
What Is An ECG ?

An ECG is a graphical
recording of the electrical
activity of the heart
More precisely, it is a
graphical recording of the
difference in potential
between electrodes
placed on the body
surface
3
 The Electrocardiogram/ ECG

The conduction of electrical signals through the heart reflects the order of
the cardiac cycle to ensure the correct sequence of contraction of the
heart muscle. When an impulse travels along a nerve, or when a muscle
contracts, there is the passage of charged ions (principally Na+, K+, Ca++
and Cl-) across the cell membrane. These movements of ions create very
small differences in potential at various parts of the body which can be
detected by a sensitive potentiometer via electrodes. The resulting record
is called an electrocardiogram

4
 How Will ECG Interpretation Be Taught ?

 Online ECG tutorial

 Practical tutorial

 Online quiz

5
 ECG INTERPRETATION
Although ECGs can be very confusing, the aim of this online tutorial is
to make ECG interpretation as simple and as clear as possible

6
 The ECG Online Tutorial

This ECG online tutorial is made up of three parts in this tutorial and it is
important that they be read in the order in which they are presented

7
 PART 1
At the end of this part of the tutorial and its related activities you are
expected to be able to:

• Explain normal electrical conduction through the heart

• Describe the purpose and the function of the ECG
• Describe the indications for performing an ECG

8
 INTRODUCTION
Clinical ECG interpretation requires basic knowledge from
several fields of medicine including cardiac anatomy,
physiology, and electrophysiology. Hence in preparation for
this tutorial a review of the cardiac anatomy and the
electrophysiological concepts that are necessary to
understand the ECG is important
Please answer the questions on the next slide
These will help you understand;
- Elements of cardiac anatomy that are relevant to ECG
interpretation
- Aspects of cardiac electrophysiology and pathophysiology
that are relevant to ECG interpretation
9
 Revision Questions
• Describe the location of the sinus node
• Name the two branches of the left main coronary artery
• Name the artery that supplies blood to the right ventricle
• Explain the phases of the cardiac cycle
• Name the valve that separates the right atrium from the right ventricle
• Name the valve that prevents back flow to the right ventricles
• Name two functions of the AV node
• Beginning in the SA node, diagram the normal sequence of cardiac
activation
• Explain the phases of the cardiac action potential
• Explain the difference between depolarisation and repolarisation
10
 The Cardiac Cycle
Bickley L S. BATES’ Guide to Physical Examination And History Taking. Tenth Edition(2009)

11
The Arterial Supply Of The Heart

12
 Properties of Myocardial Cells

The generation and transmission of the electric impulse

relies on the following properties of the myocardial cells:
• Automaticity refers to the ability to generate an electrical
impulse (self-excitation)
• Excitability refers to the ability for the myocardial cells to
respond
• Conductivity refers to the ability of myocardial cells to
transmit the impulse
• Contractility refers to the ability of myofibrils to contract
• Refractoriness refers to the inability to respond to a
premature impulse during depolarisation
13
 Pacemakers Of The Heart
• The sinoatrial (SA) node is the primary pacemaker of the heart. It is
located near the junction of the superior vena cava and the right atrium
and has an an intrinsic rate of 60 - 100 beats/ minute
• Other subsidiary pacemakers are found in/around the atrioventricular
(AV)node and in the purkinje fibres. These are also capable of
generating automatic activity when the atria and/or the AV node fail to
initiate a cardiac rhythm
• The AV node has an intrinsic rate of 40 - 60 beats/minute
• The Purkinge system has an intrinsic rate of 20 – 40 beats/minute

Remember that the fastest focus suppresses the activity of all other foci

14
 The Normal Conduction Pathway

SA node → atrial muscle

→ AV node → bundle of
His → Left and Right
Bundle Branches →
Ventricular muscle

Bickley L S. BATES’ Guide to Physical Examination

And History Taking. Tenth Edition(2009)

15
 ECG Purpose And Function
Clinical diagnosis depends mainly on the patient’s history and to a lesser
extent on examination. Investigations like ECGs support a diagnosis and
can be crucial in patient management.
The ECG is a fast, cheap and non-invasive test that can provide
information regarding:
• The electrical orientation of the heart in three-dimensional space
• The relative size of the cardiac chambers
• The presence of conduction defects
• Cardiac arrhythmias
• Electrolyte disturbances (e.g.hyperkalaemia and hypokalaemia)
• The extent and location of ischemic changes to heart muscle or
myocardial infarction
16
 Some Indications For Performing An ECG
• Palpitations
• Irregular heart rate, tachycardia, or bradycardia on examination
• Chest pain
• Shortness of breath
• Syncope
• Patients with increased risk factors for CVD (e.g. diabetics, CKD)
• Pre-operative assessment of at-risk patients
• Patients with cerebrovascular accidents
• Episodic dizziness of unknown cause
• Electric shock

17
 PART 2

At the end of this part you are expected to be able to:

• Describe the location of placement of electrodes for LI, II,III, aVR, aVL,
aVF, V1 to V6
• Recognise which part of the heart each lead views
• Explain the graphing ECG paper
• Identify normal ECG waveforms and intervals
• Relate the phases of the cardiac cycle to the ECG

18
 What Is a lead?

A lead is a view of the electrical activity of the heart from a particular

angle across the body obtained between electrodes placed in different
positions on the body.

19
 The 12 Lead ECG
The 12 lead ECG is made up of 6 limb leads (three standard limb leads
(I, II and III) and three augmented limb leads (aVR, aVL and aVF) and six
precordial leads (V1, V2, V3, V4, V5 and V6)
• The standard limb leads (LI, LII and LIII) are bipolar which means that
they are composed of one positive and one negative electrode
• The augmented limb leads (aVR, aVL and aVF) and the chest leads
(V1, V2, V3, V4, V5, V6) are unipolar which means that they are
composed of one positive electrode and a neutral point (they measure
the electrical voltages at one location relative to a zero potential)
• The limb leads record potentials transmitted onto the frontal plane
• The chest leads record potentials transmitted onto the horizontal plane
• The 12 leads are obtained from 10 actual contacts on the body (9
recording leads and one ground lead attached to the right leg)

20
 Lead I
Lead I has the negative electrode on the right arm and the positive
electrode on the left arm

Right Arm -ve LI → Left Arm +ve

- ___________________________ +

21
 Lead II
Lead II has the negative electrode on the right arm and the positive
electrode on the left foot

Right arm –ve

Left foot +ve

22
 Lead III
Lead III has the negative electrode on the left arm and the positive
electrode on the left foot

Left arm –ve

Left foot +ve

23
Einthoven’s Triangle

Anne Evans- Murray, 2006. E.C.G’S Simply, Cardiac Arrhythmias Made

Easy. Southwood Press.

24
Bipolar Limb Leads (LI,LII,LIII)

25
 Augmented Limb Leads

What do aVR, aVL and aVF stand for

• The letter “a” refers to “augmented
• The letter “V” refers to “voltage”
• The letter “R” refers to “right arm”
• The letter “L” refers to “left arm”
• The letter “F” refers to “left foot”

26
 Augmented Leads
In Lead aVR the electrode on the right arm is positive
In Lead aVL the electrode on the left arm is positive
In Lead aVF the electrode on the left foot is positive

Depolarisation waves move away from aVR and accordingly the

deflections in aVR are downwards

27
Augmented Limb Leads (aVR, aVL, aVF)

28
The Hexaxial Reference System

29
 Limb Leads: Frontal Plane
Image adapted from Bickley L S. BATES’ Guide to Physical
Examination And History Taking. Tenth Edition(2009)

30
 Chest Leads: Transverse Plane
Image adapted from Bickley L S. BATES’ Guide to Physical
Examination And History Taking. Tenth Edition(2009)

31
 The Location Of Placement Of Electrodes
Four electrodes are placed on the patient’s limbs (limb lead electrodes)
and six are placed on the patient’s chest (chest lead electrodes).
Limb lead electrodes are placed on the right and left wrists and on the
right and left ankles
Chest lead electrodes are placed as follows:
•V1 → 4th right intercostal space adjacent to the sternum
•V2 → 4th left intercostal space adjacent to the sternum
•V3 → Midway between V2 and V4
•V4 → 5th left intercostal space in the mid-clavicular line
•V5 → same horizontal level as V4 anterior axillary line
•V6 → same horizontal level as V4 mid-axillary line
32
 Part Of The Heart Each Lead Views
Leads look at the heart from different angles
• LI and aVL look at the left lateral part of the heart
Why?
Because the +ve electrode in these two leads is the left arm
• LII, LIII and aVF look at the inferior part of the heart
Why?
Because the +ve electrode in these three leads is the left foot
• V1, V2, V3, V4 look at the anterior part of the heart
V1 and V2 are called “the right chest leads”
V5 and V6 are called “the left chest leads”

33
 The Graphing ECG Paper
• The ECG is recorded on paper which is ruled into small squares of 1
mm and large squares of 5mm. The paper generally moves at 25
mm/sec (though other settings are possible and valuable in certain
scenarios). At this speed (25 mm/sec), each small square thus
represents 0.04 second and each large square 0.20 seconds. The
amplification factor is generally adjusted so that a 1 mV signal produces
a vertical deflection of 1.0 cm (10 small squares).
• It is usual to record 2-3 cardiac cycles at each of the 12 leads, except
for Lead II, where at least 6 cycles are recorded (so that an accurate
rate and rhythm can be determined).

34
 The Graphing ECG Paper
The ECG graphing paper is made
up of small squares and larger
heavy-lined squares
• Each small square is 1mm high
and 1mmwide
• There are 5 small squares in
each big heavy lined square
• The horizontal lines measure
time
• The vertical lines measure
amplitude of voltage

Shiley A Jones., 2008. ECG Success. Exercises in ECG Interpretation

F.A.Davis Company

35
 The Graphing ECG Paper (continued)
• The ECG machine usually runs
at 25mm/sec
• At 25mm/s, the width of each
small square = 0.04 seconds
(1mm/25mm/sec= 0.04sec)
• The width of one large square =
0.04 x 5 = 0.20 seconds
• Five large squares = 0.20x5=one
second
• One large square = 5 mm high =
0.5 millivolts

Shiley A Jones., 2008. ECG Success. Exercises in ECG Interpretation

F.A.Davis Company
36
 Components Of The ECG Tracing
An ECG tracing is composed of:
• Waves (P , T and occasionally U )
- Waves are deflections away from the baseline of the ECG tracing
- Deflections can be upward or downward away from the baseline
• Segments (ST)
- A segment is a straight line between waves or complexes
• Complexes (QRS)
- A complex is made up of several waves
• Intervals (PR & QT)
- An interval is made up of a segment and a wave

37
 Remember The Following

• Depolarisation and repolarisation are electrical phenomena caused by

the movements of ions
• The appearance of the waves on the ECG tracing depend on the
position of the electrodes with respect to the electrical activity of the
heart
• An upward wave on the ECG tracing represents a depolarisation wave
moving towards a positive electrode
• A downward wave on the ECG tracing represents a depolarisation
wave moving away from a positive electrode
• A wave of repolarisation moving toward a positive electrode results in a
downward deflection
• A wave of repolarisation moving away from a positive electrode results
in an upward deflection 38
The Standard ECG Trace

The standard ECG trace, showing the important deflections and intervals. (Adapted
from Berne and Levy, 3rd ed)

39
 The P Wave
• Represents atrial depolarization
• Precedes the QRS complex
• Is usually rounded and positive in
all leads apart from aVR.
• Its height should not exceed 2.5
mm
• Its width should not exceed 0.10
seconds (2.5 small squares)
• Its first part represents
depolarisation of the right atrium
• Its second part represents The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)
depolarization of the left atrium
40
 The P Wave

Right atrial hypertrophy Left atrial hypertrophy

• Is manifested by tall • Is manifested by wide
peaked P waves > 2.5 mm notched P waves
height • P mitrale - in mitral
stenosis - (is a P wave
shaped like an M)

Ary L. Goldberger, 2006. Clinical Electrocardiography.

A Simplified Approach. 7th ed. Mosby
Ary L. Goldberger, 2006. Clinical Electrocardiography.
A Simplified Approach. 7th ed. Mosby

41
 The PR interval

• Has a normal duration 0.12 -

0.20s (3 to 5 small squares)
• Represents the time from
onset of atrial activation to
onset of ventricular activation

The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)

42
 The QRS Complex

• Is NOT that complex

• Represents ventricular
depolarisation
• Consists of 3 waveforms (Q, R
and S)
• All ventricular complexes are
known as QRS complexes even
if every wave is not present in all
complexes

The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)

43
 The Normal QRS Complex
• Follows the PR interval
• Represents ventricular depolarization (remember that ventricular wall
depolarisation spreads from endocardium to epicardium)
• Might look different in each lead
• Its duration is 0.06 to 0.10 seconds – a duration of > 0.12 seconds (is
abnormal)
• Its duration is measured from the beginning of the Q wave (or the R
wave if Q is absent) to the end of the S wave
• Proceeding from V1 to V6, the R waves get taller while the S waves get
shorter

44
 The QRS Complex

The Q Wave The Q wave

• Is the first negative/downward
deflection following the P waves
• Represents septal
depolarisation (remember that
the left side of the septum is
depolarised first)
• Its amplitude should be less
than 1/3 of the amplitude of the
R wave in the same lead
• A deep or broad Q is abnormal
The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)

45
 The QRS Complex

The R Wave The R Wave

• Is the first upward
deflection of the QRS
complex
• Represents ventricular
depolarisation

The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)

46
 The QRS Complex

The S wave The S wave

• Is any downward deflection
following the R wave
• Represents depolarisation
of the Purkinje fibres

The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)

47
 The ST Segment

• Corresponds to the plateau

phase of ventricular
depolarisation
• Should be isoelectric (on the
baseline)

The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)

48
 The T Wave

• Represents ventricular
repolarisation
• Should be asymmetric with
gradual incline and steeper
decline
• Normally points in the same
direction as the QRS complex
• Repolarization starts on the
epicardium and spreads to the
endocardium
The standard ECG trace, showing the important deflections and intervals.
(Adapted from Berne and Levy, 3rd ed)

49
 The QT Interval
• Is measured from the beginning
of QRS to the end of the T wave
• Represents the interval from
beginning of depolarization to the
end of repolarization (total
ventricular activity)
• Is usually between 0.33 and 0.42
seconds (Shouldn’t be > half the
distance between two R waves)
• Varies inversely with heart rate
• Is hard to measure if T waves are
flat

50
 The U Wave

• Is occasionally seen
• Is a low voltage deflection
• Is usually positive
• Follows the T wave
• Is usually in the same direction of
the T wave
• Is thought to represent late
repolarisation of the Purkinge
fibers in the ventricles

Anne Evans- Murray, 2006. E.C.G’S Simply, Cardiac

Arrhythmias Made Easy. Southwood Press.

51
 Relating The Phases Of The Cardiac
Cycle To The ECG
• The P wave represents atrial systole
• The QRS complex represents ventricular systole
• The T wave represents the beginning of ventricular relaxation or
diastole

52
 PART 3
At the end of this part of the tutorial you are expected to be able to:
• Apply a systematic approach to interpret any ECG
• Determine the heart rate on an ECG
• Explain the normal sinus rhythm
• Identify ECG features of common heart blocks
• Visually identify different heart rhythms from an ECG strip
• Estimate the mean electrical axis and identify possible common causes
of axis deviation
• Identify ECG hypertrophy patterns
• Explain the specific ECG changes associated with myocardial ischemia,
injury and infarction

53
 ECG Analysis
It is important to follow a systematic approach for the interpretation
of an ECG
Remember that:
• An upward wave on the ECG represents a depolarisation wave which is
moving towards a +ve electrode
• A wave of depolarisation travelling away from a +ve electrode results in
a downward deflection
• The electrodes placed on the chest in all the 6 chest leads are always
+ve
• Depolarisation and repolarisation are electrically opposite processes

54
 Steps For Analysing Any ECG
• Name of patient, date and time the ECG was taken
• Technical errors
• Rate
• Rhythm
• Cardiac axis
• P wave
• P-R interval
• QRS morphology
• ST segment
• T wave
• U wave (if present)
• QT interval
• Interpretation/Diagnosis
55
 Patient Name, Date And Time The ECG
Was Taken
• I think I do not need to explain why do we need the patient’s name
• Date and time the ECG was taken – Why?
Comparing a current ECG tracing with a previous one is essential for
making a correct diagnosis

56
 Technical Errors

Look for interference, shifting baseline and calibration.

What technical errors can you think of?
• Misplacement of electrodes
• Patient not relaxed or shivering
• Poor contact between the patient’s skin and the electrodes

Look at the next slide- Sometimes, technical errors might look like an
arrhythmia

57
 The Effect Of Shivering

Hampton J R. The ECG Made Easy. 7th ed. 2008. Churchill Livingstone Elsevier Limited

58
 The Heart Rate

• The normal heart rate is between 60 and 100 beats/minute(bpm)

• Bradycardia is a heart rate of < 60bpm
• Tachycardia is a heart rate of > 100bpm

59
 Calculation Of The Heart Rate On An ECG
Strip

• The rate of a Normal Sinus Rhythm is 60-100 beats per minute

• Remember that 1 small square is 0.04 seconds (1mm/25mm/sec=
0.04sec)
• Because we calculate the rate as the number of beats/minute and not/
second, every 1500 small squares= 1 minute (60/0.04= 1500)
• Also 1 large square is 0.2 seconds (1 large square has 5 small squares,
0.04x5=0.2sec)
• Because we calculate the rate as the number of beats/minute and not/
second, every 300 large squares= 1 minute (60/0.2= 300)

60
 Calculating The Heart Rate Of A Regular
Rhythm
Method 1
• Count the number of large
squares between two R
waves
• Divide 300/this
number=beats/minute

Anne Evans- Murray, 2006. E.C.G’S Simply, Cardiac Arrhythmias

Made Easy. Southwood Press.

61
 Calculating The Heart Rate Of A Regular
Rhythm
Method 2
1500/21= 71bpm
Is more accurate than
method 1
• Count the number of the
small squares between 2 R
waves
• Divide 1500/this number=
beats/minute
Anne Evans- Murray, 2006. E.C.G’S Simply, Cardiac Arrhythmias
Made Easy. Southwood Press.

62
What Is The Heart Rate On The Following
ECG Strip?

Answer: There are 4 large squares between each 2 R waves

300/4= 75 beats/minute
63
 How Do We Calculate The Heart Rate Of
An Irregular Rhythm?

• Count the number of big squares between 6 R waves (5 cycles)

• Multiply 300x5
• Divide 300x5/the number of big squares between the 6 R waves
• OR
• Count the number of small squares between 6 R waves (5 cycles)
• Multiply 1500x5
• Divide 1500x5/by the number of small squares between the 6 R waves

64
 Regularity Of The ECG

• You need to measure R-R intervals

• R- R intervals are consistent in a regular rhythm
• A regularly irregular rhythm has a repeating pattern
• An irregularly irregular rhythm has NO pattern

65
 The Normal Sinus Rhythm
The normal sinus rhythm has the following characteristics:
• Normal P wave
• Regular
• Rate 60 – 100/minute
• PR interval 0.12 – 0.20s
• QRS duration 0.06 – 0.10s
• Ratio of P waves to R waves is1:1

66
 Assessment Of Rhythm Abnormalities
In order to assess rhythm abnormalities you need to look at the R-R
interval, P waves and the width of the QRS complex.
1- Look at the distance between R waves: is this constant or variable,
does it vary regularly or irregularly? (Regular means that the distances
between R waves is equal)
2- Check if there is a P wave
3- Check if each QRS complex is preceded by a P wave
4- Check if each P wave is followed by a QRS complex
6- Measure the width of the QRS complex (should be <0.12seconds)

67
 Sinus Bradycardia and Sinus Tachycardia

• The SA node is the primary pacemaker in the normal heart and has an
an intrinsic rate of 60 - 100 beats/ minute
• In sinus bradycardia a P wave precedes each QRS complex, PR
interval is normal but the rate is slow < 60bpm
• In sinus tachycardia a P wave precedes each QRS complex, PR
interval is normal but the rate is fast>100bpm

68
 Arrhythmias
Arrhythmias can arise from problems in the:
• Sinus node (e.g. sinus bradycardia, sinus tachycardia)
• Atrial cells (e.g. atrial fibrillation/AF, atrial flutter, atrial
ectopics/extrasystoles/premature beats)
• AV junction (e.g. AV blocks, junctional extrasystoles)
• Ventricular cells (e.g. ventricular fibrillation, ventricular tachycardia,
ventricular ectopics/extrasystoles/premature beats)

We will discuss these later

69
 The Cardiac Axis

• The cardiac electrical axis represents the average direction of the

spread of the depolarisation of the heart
• The normal cardiac axis is between -30 degrees and 90 degrees
• An axis smaller than -30 degrees is referred to as left axis deviation
• An axis greater than 90 degrees is referred to as right axis deviation

70
 What Causes The Axis To Deviate?
• The wave of electrical depolarisation spreads from the atria down
though the IVS to the ventricles. The direction of this electrical
depolarisation is normally from the superior to the inferior part of the
heart towards the left. This is due to the leftward orientation of the heart
in the chest and also because the left ventricle has a greater muscle
than the right ventricle. The electrical axis represents the overall
direction of travel of the electrical depolarisation through the heart.
• The cardiac electrical axis can deviate in some conditions when the
electrical pathway goes a different way (eg. when disrupted by death of
tissue in myocardial infarction), or when the heart is in a different
position (eg. Dextrocardia) or if some parts of the cardiac muscle are
working harder than usual (eg. Lung problems).

71
 What Causes Left or Right Axis Deviation

• Left axis deviation might suggest inferior MI, left ventricular hypertrophy,
or loss of electrical activity in the right ventricle
• Right axis deviation might suggest right heart strain (eg. PE ), chronic
lung disease, or high lateral MI, right ventricular hypertrophy or in loss
of electrical activity in the left ventricle. However can be normal in
children.

72
 Calculating The Electrical Cardiac Axis

In order to calculate the electrical cardiac axis we need to look at QRS in

LI and in aVF and find out whether it is +ve or –ve
What do we mean by +ve and –ve here?
If the height of R minus the height of S is >0 then QRS is positive in this
lead and if the height of R minus the height of S is <0 then QRS is
negative in this lead

73
 Steps For Calculating The Cardiac Axis
Step 1
• Look at QRS in L I
• Is it +ve or –ve?
• Locate in which half is the axis (right or left)
Step 2
• Look at QRS in aVF
• Is it +ve or –ve?
• Locate in which half is the axis (upper or lower)
 Step 3
 Find out in which quadrant both L I and aVF fall

74
 What Next?

If both L I and aVF fall in:

• The lower inner quadrant
Normal axis
• The lower outer quadrant Right
axis deviation
• The upper outer quadrant North
West or no man’s land
• The upper inner quadrant
Normal axis or Left axis deviation

75
 Left Axis Deviation
What if L I and aVF fall in
the upper inner quadrant? ?

The cardiac electrical axis can

then be either normal (if between 0
and 30 degrees or Left axis
deviation (if between 30 and -90
degrees).
• In this situation you then also
need to look at QRS in L2
• Normal axis if QRS is +ve in L2
• Left axis deviation if QRS is -ve
in L2

76
 Is There Any Easy Way To Suggest That
The Electrical Axis Of The Heart Is
Normal?

You can easily say that the electrical axis of the heart is Normal if
QRS is +ve in L I, aVF and L2

77
 Let’s Calculate The Axis

• The hight of R is > the

height of S in L1, LII
and aVF
Accordingly, the electrical
axis here is NORMAL

78
What About The Axis In The Following
ECG?

Hutchinson’s Clinical Methods. 21st ed. 2004

QRS in LI is +ve,
The height of R in equal to the height of S in aVF
The electrical axis is at zero degrees (Normal)

79
 The P Wave
• The P wave reflects atrial depolarisation
• The clearest P wave is usually seen in lead II
• Look for the P wave and check if it is present or absent
• If present - what shape is it? (peaked broad or bifid waves are
abnormal)
• Tall P waves >2.5 mm that are peaked indicate right atrial hypertrophy
• Broad P waves (>0.10seconds) that are bifid suggest left atrial
hypertrophy
• If the P wave is absent check if the baseline is regular or irregular
• Absent P wave and irregularly irregular rhythm- consider AF (atrial
fibrillation)
• Note that a biphasic P wave in lead V1 is normal
80
 The PR Interval
The PR interval is the distance from the beginning of the P wave to the
beginning of the QRS complex and represents the time between the
beginning of atrial depolarisation and ventricular depolarisation
• Measure the PR interval - (it is usually 0.12-0.20 seconds)
• Abnormalities usually result from transmission delays in the conducting
system

81
 1st, 2nd And 3rd Degree AV block
• In 1st degree AV block P-R interval is longer than normal (but every P
wave is followed by a QRS complex)
• In 2nd degree AV block there is an occasional drop of a QRS
complex
Remember that there are two types of 2nd degree AV block: type 1-
Mobitz1(Wenckebach) and type 2 - Mobitz2
• In 2nd degree type 1 AV block, P-R interval gradually lengthens until for
one beat AV conduction does not occur at all
• In 2nd degree type 2, a sudden AV block results in the sudden absence
of a QRS complex (P-R intervals are not lengthened)
• In 3rd degree AV block (Complete AV block) the AV node and the
bundle branches do not let any supraventricular impulse to pass
through them (atrial impulses do not reach the ventricles)
82
 First Degree Heart Block
Image adapted from Hampton J R. The ECG Made Easy. 7th ed. 2008. Churchill Livingstone Elsevier Limited

PR interval is 0.32 seconds (8 small squares x 0.04)

Each P wave is followed by a QRS complex

83
2nd Degree AV Block Type 1

Ary L. Goldberger, 2006. Clinical Electrocardiography.

A Simplified Approach. 7th ed. Mosby

84
2nd Degree AV Block Type 2

Second degree AV block type 2

3: 1

85
 Third Degree/Complete Heart Block
• Complete dissociation of the atria
and the ventricles no relationship
exists between P waves and
QRS complexes Image Adapted from: Hampton J R. The ECG Made Easy. 7th ed. 2008.
Churchill Livingstone Elsevier Limited.

• More P waves than QRS

complexes are seen on the ECG
(the atrial rate is faster than the
ventricular rate)
• The atrial rhythm has a rate
between 60-100 beats/minute
while the ventricular rhythm has a
rate slower than 40 beats/minute

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 What If PR interval Is < 0.12s
Wolff-Parkinson-White Syndrome and Lown-Ganong-Levine Syndrome
are examples of conditions associated with a PR interval < 0.12 s
What is Wolff-Parkinson-White Syndrome ?
Some individuals have an accessory conducting bundle (the bundle of
Kent) between the atria and the ventricles causing the depolarisation
wave to reach the ventricles early as it is not delayed by the AV node -
leading to pre-excitation of the ventricles.
ECG findings in WPW syndrome include; Normal P waves; Shortened
PR interval; Delta waves; Prolonged QRS interval (which is due to the
Delta waves)

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 Q Wave
• A Q wave is any negative deflection at the beginning of a QRS complex
• Q waves represent normal septal depolarisation from left to right (that’s
why it is a downwards deflection)
• Q waves are almost absent in all leads
• Very small Q waves might be present normally in some leads
• A significant Q wave is ≥ one small square wide (> 0.04s) or ≥1/3 of the
height of its partner R wave and might indicate necrosis/ myocardial
infarction

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 QRS Morphology
The QRS complex results from ventricular depolarisation
• Measure QRS duration – it is usually 0.06 - 0.10 seconds (<2.5 small
squares)
What if QRS duration is > 0.12 seconds?

• A delay in intra-ventricular conduction results in a wide QRS

(e.g. Bundle Branch Blocks)
• Ventricular tachycardia
• Pre-excitation of the ventricles
What if QRS deflexion is exaggerated?
• Consider left or right ventricular hypertrophy
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 Ventricular Hypertrophy
In Left Ventricular Hypertrophy, the left ventricle enlarges and
accordingly, more electrical activity will be moving towards the leads
oriented to the left ventricle V5, V6, aVL and away from the leads
oriented away from the left ventricle (V1, V2). Therefore leads V5, V6
and aVL will have tall R waves, while leads V1 and V2 will have deep S
waves.
Rules;
• If you add the amplitude/height of the deepest S wave in V1 or V2 and
the amplitude/height of the tallest R wave in V5 or V6 and the sum is ≥
than 35 mm Left Ventricular Hypertrophy
• In Right Ventricular Hypertrophy, the amplitude of R in V1 + the
amplitude of S in V6 is ≥ 10 mm

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 Bundle Branch Blocks

In bundle branch blocks, electrical signal takes longer to pass throughout

ventricles and accordingly QRS complex widens (> 0.12 sec) and QRS
morphology changes (an M shaped R wave).
In Right Bundle Branch Block (RBBB);
QRS complex is >0.12seconds and the M shaped R appears in V1 and V2
(right leads)
In Left Bundle Branch Block (LBBB);
QRS complex is >0.12seconds and the M shaped R appears in V5 and
V6 (left leads)

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 Right Bundle Branch Block

Hampton J R. The ECG Made Easy. 7th ed. 2008. Churchill Livingstone
Elsevier Limited.

92
 Myocardial Infarction
• Myocardial Infarction is an evolving process and can be;
- transmural (involving the entire wall of the affected area of the heart-
STEMI) or
- subendocardial (affecting only the inner area of the affected area the
heart muscle- NSTMI)
• Changes are usually localized to leads looking at the affected area of
the heart

• Remember that a normal 12 lead does not rule out an acute

myocardial infarction
• History, physical examination, ECG and serum cardiac markers
should all be taken into consideration
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 Myocardial Infarction
• Initially the 12 lead ECG may show tall T waves and this signifies
cardiac ischemia, however because these changes may be present for
a short period of time after ischemia has begun they might not be
present at the time of presentation to the ED
• ST segment elevation is usually seen in the leads directed towards the
area of injury within the first few hours after the onset of symptoms
• Reciprocal changes are seen as ST depression in the opposite leads
from where the ST elevation is seen (e.g. Leads II, III and aVF are
opposite to Leads I, aVL, and all of the V leads)
• ST depression can be seen in ischemia as well as in subendocardial
infarction/ non-ST elevation myocardial infarction NSTMI
• Q waves indicate necrosis and may develop 1 to 2 hours after the onset
of symptoms but can take anywhere from 12 to 24 hours to develop
• Several hours after an infarct, T waves begin to invert
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 Myocardial Infarction
We need to remember the following:
• ST-segment elevation usually signifies acute coronary occlusion/Acute
myocardial infarction
• Wide/deep Q waves signify necrosis
• Wide/deep Q waves only without ST segment elevation signify an
OLD myocardial infarction
• T waves (flat or inverted) signify ischemia
• Peaked tall T waves signifies the initial stage of an acute myocardial
infarction

95
 Question

How can you locate the myocardial infarction from an ECG?

Remember that:
• The anterior part of the heart is best viewed in V1,V2,V3, V4
• The lateral part of the heart is best viewed in LI, aVL,V5,V6
• The inferior part of the heart is best viewed in LII,LIII,aVF

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Acute Inferior Myocardial Infarction

Hampton J R. The ECG Made Easy. 7th ed. 2008. Churchill Livingstone Elsevier Limited.

Why is it inferior?
Because the ST elevation is in LII, LIII and aVF (inferior leads)

97
 Atrial Fibrillation

• Irregularly irregular rhythm

• No P waves

Shiley A Jones., 2008. ECG Success. Exercises in ECG Interpretation

F.A.Davis Company

98
 Atrial Flutter
• Saw tooth appearance
• Is due to re-entry within the atria
• The rhythm is relatively regular
• Often presents with 2:1 or 4:1 AV blocks

Shiley A Jones., 2008. ECG Success. Exercises in ECG Interpretation

F.A.Davis Company

99
 Atrial Ectopic
• P wave present – might have a different shape in the premature beat
• PR interval might vary in the premature beat only
• QRS complex normal

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 Ventricular Ectopic
• The premature ventricular beat is usually followed by a compensatory
pause
• QRS complex, in the premature beat, looks different than the other
normal beats and is wider
• P wave and PR interval not associated with the premature ventricular
beat

Image Adapted from: Hampton J R. The ECG Made Easy. 7th ed. 2008.
Churchill Livingstone Elsevier Limited.

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 Ventricular Fibrillation
• A Medical Emergency
• Irregularly irregular rhythm
• No p waves
• Wide QRS complexes

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 Ventricular Fibrillation

Image Adapted from: Hampton J R. The ECG Made Easy. 7th ed. 2008. Churchill Livingstone Elsevier Limited.

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 Interpretation

All the above are taken into account and an interpretation is made

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4
 The Practical Tutorial
At the end of the practical session and its related activities you are
expected to be able to:
• Analyse ECG tracings and make a diagnosis
• Practice ECG recording

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 References
• Anne Evans- Murray, 2006. E.C.G’S Simply, Cardiac ArrhythmiasMade
Easy. Southwood Press.
• Ary L. Goldberger, 2006. Clinical Electrocardiography. A Simplified
Approach. 7th ed. Mosby.
• Bickley L S. BATES’ Guide to Physical Examination And History
Taking. Tenth Edition(2009).
• Hampton J R. The ECG Made Easy. 7th ed. 2008. Churchill Livingstone
Elsevier Limited.
• Hutchison’s Cinical Methods. M. Swash,2004. 21st Ed.Elsevier Limited.
Saunders.
• Shiley A Jones., 2008. ECG Success. Exercises in ECG Interpretation
F.A.Davis Company.

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