Normal ECG

Electrocardiograp
hic view of the
heart

V1-V2 anteroseptal wall II, III, aVF inferior wall

V3-V4 anterior wall I, aVL lateral wall

posterior wall
V5-V6 anterolateral wall V1-V2
(reciprocal)
A normal adult 12-lead ECG. Sinus rhythm is present with a heart rate of 75 beats
per minute.
Waves
Positiv
e
Negativ
e

Segment
s
Intervals
Voltage
calibration:
2 large
squares (10
mm)
5 mm
= 1 mV = 0.5
mV
5 mm
= 0.2
s

Voltage
Paper speed: 25 mm/sec

1 large square = 0.2 s

300 large squares = 300 x 0.2 s = 60s
(1 min).
 vertical
horizontal

Each large(5mm)square : 0.5mV

0.2s
Each small(1mm)square : 0.1mV
0.04s
Waves, intervals and
segments
in normal ECG
P wave
(0.08 to 0.1 s; 0.25 mV or less)
- represents the wave of
depolarization that spreads
from SA node throughout
the atria.
- upright in all leads; but
inverted in aVR.

(atrial repolarization is
submerged in QRS complex)
QRS complex (0.06 to
0.1 s)
(1- 3 small squares)
-represents ventricular
depolarization.
- In most people, QRS
complex is tallest in lead
II, but in leads I and III, it
is also predominantly
upright (i.e. R wave is
greater than S).

-Prolonged QRS complex

(> 0.1s) in Bundle
branch block
Q wave
Small septal Q wave in
any of leads II, aVL, or V5
V6, usually less than 3 mm
deep and less than 1 mm
across.
-represents the normal
depolarization of
interventricular septum
from left to right.

-A small Q wave is also

common in lead III in
normal people in which
T wave
-represents ventricular
repolarization
- In a normal ECG, T
wave is always
inverted in aVR, and
often in V1, but
usually upright in all
the other leads.
U wave
Sometimes a small
U wave may be
seen following T
wave (last
remnants of
ventricular
repolarization and
slow repolarization
of papillary
muscles)
P-R interval
Normal range is 0.12 to 0.2 s
(3 5 small squares)
- the period of time
from the onset of the
P wave to the beginning
of the QRS complex.
-represents the time
taken for depolarization
of atria, and conduction
through AV node and
His-Purkinje system.
A long PR interval reflects slow conduction
(heart block, bradyarrhythmia)
Q-T interval (0.2 to 0.4 s)
- represents the time for
both ventricular
depolarization and
repolarization.

- At high heart rates,

Q-T interval decreases.

- Long QT syndrome
(K+ channel mutation,
myocardial ischemia
electrolyte abnormalities)
ST segment
- the part between S wave and
T wave.
- is the time at which the
entire ventricle is depolarized.

-should be horizontal and

isoelectric.

-roughly corresponds to
the plateau phase of
ventricular depolarization
-Important for diagnosis of ventricular
ischemia (depressed or elevated)
ST segment
- An elevation of the ST segment
is the hallmark of an acute
myocardial infarction.
- Horizontal ST segment depression
of more than 2mm indicates
ischaemia.
 Cardiac axis
Depolarization wave of the
heart normally spreads through
the ventricles from 11 oclock
to 5 oclock,
i.e. towards leads I, II and III.
So the deflections in lead VR
are normally mainly downward
(negative) and lead II mainly
upward (positive).
Direction of the axis can be
derived most easily from the
QRS complex in leads
I, II and III.
 The cardiac axis
By near-consensus, the normal QRS
axis is defined as ranging from -30
to +90.
-30 to -90 is referred to as a left axis
deviation (LAD)
+90 to +180 is referred to as a right
axis deviation (RAD)

Abnormalities of axis can hint at:

Ventricular enlargement and/or
conduction defects (i.e. hemiblocks)
 Right axis deviation

If right ventricle becomes hypertrophied, the axis will swing

towards the right : the deflection in lead I becomes negative
and
the deflection in lead III is more positive.
 Left axis deviation

When left ventricle becomes hypertrophied, the axis may

swing
to the left, so that the QRS complex becomes predominantly
negative in lead III.
 Uses of ECG
Recording of rate and rhythm
diagnosis of cardiac arrhythmias
detection of conduction
abnormalities (e.g. heart block,
accelerated conduction)
screening tool for ischaemic heart
disease (during a cardiac stress
test)
 Uses of ECG
It guides therapy and risk
stratification for patients with
suspected acute myocardial
infarction
It helps detect electrolyte
disturbances (e.g.
hyperkalaemia and
hypokalaemia)
RR interval = one ventricular cycle Ventricula
rate heart rate

PP interval = one atrial cycle

atrial rate
 Heart Rate Determination
Method 1
Most rates can be calculated this way. Find an R wave on a
heavy line (large box) count off
"300, 150, 100, 75, 60, 50"
for each large box you land on until you reach the next R
wave. Estimate
the rate if the second R wave doesn't fall on a heavy
black line.
 Heart Rate Determination
Method 2
Use this method if there is a regular bradycardia,
i.e. - rate < 50.
If the distance between the two R waves is too
long to use the common method
300/[# large boxes between two R waves].

The number of large boxes between first and second R

waves = 7.5. Thus 300/7.5 large boxes = rate 40.
 Heart Rate = ?

Heart Rate = 300/5 = 60/min

 rate <60 =sinus bradycardia
rate >100 =sinus tachycardia
 Diagnosis of cardiac arrhythmias
A normal 12-lead ECG and rhythm strip (Long
lead
HeartII).
Rate = 300/4 = 75 bpm
Rhythm : Sinus rhythm
regular,
Cardinal features of Sinus rhythm
The P wave is upright in lead II,
inverted in aVR
Each P wave is usually followed by a
QRS complex
The heart rate is 60 99 beats/min

rate <60 =sinus bradycardia

rate >100 =sinus tachycardia
Abnormalities of cardiac
rhythm
Look at the P waves and the width
of the QRS complex
Supraventricular rhythms have
narrow QRS complexes
Ventricular rhythms have wide
QRS complexes (due to slower
pathway through the Purkinje
fibers)
 Atrial
Arrhythmias

Abnormally shaped P wave

Rate: 150 -
250 /m
(Abnormal P waves,
one P wave/QRS)

Rate: 250 -
350 /m

(saw-tooth waves)

Rate:
Atrial 350+
fibrillation with a/m
totally
irregular ventricular rate.
Atrial rate 300-500/min.
 Supraventricular rhythms
Atrial tachycardia:
QRS complex rate greater than
150/min;
Abnormal P waves, usually with short
PR intervals, usually one P wave per
QRS complex, but sometimes P wave
rate 200-240/min with 2:1 block

Rate: 150 -
250 /m
(Abnormal P waves,
one P wave/QRS)
 Supraventricular rhythms
Atrial flutter: P wave rate 300/min,
saw-toothed pattern, 2:1, 3:1 or 4:1
block

Rate: 250 -
350 /m
 Supraventricular rhythms
Atrial fibrillation:
the most irregular rhythm of all,
QRS complex rate characteristically
over 160/min without treatment, but
can be slower
no P waves identifiable, but there is a
varying completely irregular wavy
baseline
 Ventricular
Arrhythmias

Ventricular
premature beat
(extrasystole)

Ventricular
tachycardia
(fast rate, no P wave,
wide bizarre QRS)

Ventricular Defibrillator
fibrillation
(erratic, wavy
 Ventricular extrasystoles:
Early QRS complex;
No P wave,
QRS complex wide (greater than 120ms);
abnormally shaped; followed by a
compensatory pause
Abnormally shaped T wave,
Next P wave is on time
 Ventricular tachycardia:
No P waves;
QRS complex rate greater than
160/min; accelerated idioventricular
rhythm
Wide bizarrely shaped QRS complex
 Ventricular fibrillation:
The most frequent cause of sudden
death in patients with myocardial
infarction
In the absence of emergency
treatment, lasts a few minutes; fatal
Look at the patient, not the ECG

Ventricular Defibrillator
fibrillation
(erratic, wavy
baseline)
 Cardiac Electrocardiograp Diagnosi
Physiology hy s

Ventricular Fibrillation

Ischemia
Electric Shock
 Detection of conduction
abnormalities (e.g. heart block,
accelerated conduction)
First degree block:
One P wave per QRS complex
PR interval greater than .2 s
Mobitz Type 2:
(2:1 or 3:1 block)
Occasional non-conducted beats
Two or three P waves per QRS complex
Normal P wave rate,
PR intervals are constant
QRS is dropped intermittantly
Progressive PR lengthening then
non-conducted P wave,
And then repetition of the cycle
 Bundle Branch Block

If there is abnormal conduction

through either the left or right bundle
branches (bundle branch block), there
will be a delay in the depolarization of
part of the ventricular muscle
The extra time taken for
depolarization of the whole of the
ventricular muscle causes widening
of the QRS complex
Third degree block (complete block):
No relationship between P waves and QRS comp
P wave and QRS march out separately
Usually, wide QRS complexes
Usual QRS complex rate less than 50/min
Sometimes narrow QRS complexes, rate 50-60/m
 Screening tool for ischaemic heart
disease (during a cardiac stress
test)
Exercise or stress ECG
 Lead
V4:
At rest

After 4 min of
exercise

3 mm (0.3 mV) of horizontal ST-

segment depression, indicating a
positive test for ischemia.
 It guides therapy and risk
stratification for patients with
suspected acute myocardial
infarction
 Anterior Q wave infarction

Deep Q waves, ST segment elevation. Later T inversion

reciprocal ST depressions in leads III, and aVF.
 Inferior Q wave infarction

may be associated with reciprocal ST depressions in leads

V1 to V3.
 Myocardial Infarction
Sequence of ECG changes
Normal ECG
Raised ST segments
Appearance of Q waves
Normalization of ST segments
Inversion of T waves
 Ischemia T inversion
Injury ST segment elevation
Infarct pathologic Q wave
 It helps detect electrolyte
disturbances (e.g. hyperkalaemia
and hypokalaemia)
(Very tall, slender peaked T wave)

(T inversion, prominent U wave)

 Electrolyte abnormalities
Low K+: T wave flattening and the
appearance of a hump on the end of the
T wave called a U wave.
High K+: tall, wide, peaked T waves with
the disappearance of the ST segment.
The QRS complex may be widened.
(Effects of abnormal magnesium levels are
similar.)
Low Ca2+ : prolongation of the QT
interval
High Ca2+ : shortening of the QT interval
 How to report an ECG
Rate
Rhythm
Conduction intervals
Cardiac axis
A description of QRS complexes
A description of the ST segments and
T wave
Description Interpretation
Heart rate 110/min, Normal ECG
Sinus rhythm
Normal PR interval (140 ms)
Normal QRS duration (120 ms)
Normal cardiac axis
Normal QRS complexes
Nor T waves