BASIC ECG

Position of Chest Leads

V1

= 4th ICS at the right sternal border

V2

= 4th ICS at the left sternal border

V3

= Halfway between V2 and V4

V4

= 5th ICS at the left midclavicular line

V5

= 5th ICS at the left anterior axillary

V6

= 5th ICS at the left mid-axillary line

V3R = Halfway between V1 & V4R

V4R = 5th ICS at the right midclavicular line

Electrode placement

ECG LEADS
+210

-90
AVL

AVR

-30

I
0

+180
III

AVF

+120

+90

II
+60

ECG LEADS

Inferior wall leads: II, III, AVF

High lateral wall leads: I, aVL
Septal wall leads: V1, V2
Anterior wall leads: V3-V4
Lateral wall leads: V5, V6

ECG Graph paper

ECG TRACING
R
P

J
Q S
PR
interval

QRS
interval

QT
interval

ST
segment

2
6

4
5

Normal Range of intervals (seconds)

P-R

QRS

Rate

Q-T

ST

Adult

0.12-0.20 0.07-0.11

60

0.33-0.43 0.14-0.16

Children

0.15-0.18

70

0.31-0.41 0.13-0.15

80

0.29-0.38 0.12-0.14

90

0.28-0.36

0.11-0.13

100

0.27-0.35

0.10-0.11

120

0.25-0.32 0.06-0.07

Determination of QT interval

Corrected QT interval = _QTactual

R-R

GUIDE IN READING ECG

Standardization and technique

Rate
Rhythm
Axis
Hypertrophy
Ischemia and infarction
T wave, U wave, PR /ST/QT segments
P and QRS morphology and duration

25 mm/s = 0.04 s

NORMAL VALUES

50 mm/s = 0.02 s
10 mm/s = 0.10 s

1 small square = 0.04 seconds

0.1 mv

PR = 0.12 0.22 seconds

QRS < 0.12 seconds

QT = 0.33 0.43

RATE INTERPRETATION

Rule of 300

RR interval 1
Heart rate 300

2
150

3
100

4
75

5
60

6
50

Formula
(1500 / # small boxes) or (300 / # big boxes)

RHYTHM

Is there a sinus P?
Does the P wave come before the QRS
Check PR interval
Check QRS interval

-90

AXIS
+210

AVL

AVR

-30

I
0

+180
III

AVF

+120

+90

II
+60

Determination of Axis:

Hexaxial System

AXIS

Normal or left axis deviation

90
------------- x AVF
I + AVF

Right axis deviation

(AVF / I) tan + 90

DIFFERENTIALS FOR LAD

Normal variant in short fat individuals

Left ventricular hypertrophy
Inferior wall infarction
Left bundle branch block
Left anterior fascicular block
WPW syndrome
ASD primum

DIFFERENTIALS FOR RAD

Normal variant in tall thin individuals

Right ventricular hypertrophy
Lateral wall infarction
Pulmonary embolism
Left posterior fascicular block
WPW syndrome
ASD secundum

Normal 12 leads ECG

LVH
SOKOLOW-LYON CRITERIA

S in V1 + R in V5 or V6 > 35 mm
R in AVL > 11 mm (12 mm)
R in AVF > 20 mm
R in I + S in III > 25 mm
S in V1 > 24 mm

Cannot be assessed in the presence of LBBB

DIFFERENTIALS FOR LVH

Hypertension
Aortic stenosis
Aortic insufficiency
Cardiomyopathy
Initial compensating mechanism
in obesity, smoking, dyslipidemia,
obstructive sleep apnea, DM

RVH

RAD > 110 with any of the following

1) R > S wave in V1
2) Deep S in V5 V6 (R:S ratio < 1)
3) ST depression and T inversion V1-V3

RVH
SOKOLOW-LYON CRITERIA

R in V1 + S in V5 or V6 > 11 mm
R in V1 > 7 mm
R:S ratio in V1 > 1
RAD > 90

DIFFERENTIALS FOR RVH

Tall R in V1
Normal in young adults and
children
COPD
RBBB
True posterior infarction
WPW syndrome

LAE (p mitrale)

LEAD V1 terminal component of P > 1

mm wide and deep
II
V1

ANY LEAD p > 0.12 s with > 1mm notch

in the middle

RAE (p pulmonale)

LEAD V1 initial component of P > 2

mm in amplitude
V1

ANY LEAD P > 0.25 mm tall

II

Arrythmia

Atrial / Supraventricular
Ventricular

Block

1-3 degree
ICVD, LBBB,RBBB

SINUS ARRHYTHMIA
Variation in the P-P interval (and R-R
interval) > 0.12 sec
P waves normal and unchanging
2 Types:
A. Phasic- respiratory variation
(heart rate faster on inspiration,
slower during expiration).
B. Non phasic- not influenced by
respiration.

Premature Atrial Complexes (PAC) with

normal conduction
1. A premature P wave with an abnormal P axis
and/or morphology.
2. Normal QRS morphology
3. A compensatory pause may follow PACs:
a. If full, the SA node is not reset.
b. If not full, the SA node is reset.

Premature Atrial Complex

Where is the PACs here ??

Analysis of SVT
1. Regular
2. P retrograde
3. Frequency 150-250
4. Normal QRS

Atrial Flutter

1. Regular with saw-tooth pattern

2. Atrium rate is approximately 300/min (220350/min).
3. Ventricular rate is usually 150/min with a 2:1,
3 : 1 or 4:1 AV nodal conduction.
4. Usually normal QRS complex.
5. F wave best seen in leads II, III, AVF and V1.

Atrial Flutter

Atrial Flutter

Criteria for Diagnosis of Atrial Fibrillation

1. Absent normal P wave.
2. Irregulary irregular
3. Fibrillatory wave
4. Atrium 350-500 bpm
5. normal QRS morphology .

Whats this ?

Atrial Fibrillation

Whats this ?

Junctional Rhythm

Premature Ventricular
Contractions

General Features of PVCs

QRS duration is usually > 0.1. sec. (wide

QRS)
QRS complex appears bizarre and
notched
ST segment and T wave are usually
displaced in the direction opposite the
main deflection of the QRS complex

Premature Ventricular
Contractions

Variations of PVC Patterns

Interpolated PVCs - no
compensatory pause when the
sinus rhythm is slow

Variations of PVC Patterns

Bigeminy

Variations of PVC Patterns

Trigeminy

Variations of PVC Patterns

Quadrigeminy

Variations in PVC Patterns

Multifocal PVCs
caused by several ventricular ectopic foci

variable morphology in a single lead

Variations in PVC Patterns

couplets : 2 consecutive PVCs

Variations in PVC Patterns

Triplets : 3 consecutive PVCs

Ventricular Tachycardia

run of more than 3 PVCs in rapid

succession
rate : 140 - 220 beats / min
slightly irregular rhythm
indicative of serious organic heart disease
or drug (digitalis or quinidine) intoxication

Ventricular Tachycardia

Ventricular Arrythmias

Ventricular Fibrillation

originates from numerous ventricular foci

firing at the same time
results in irregular twitching of the
ventricles
totally irregular appearance on the
tracings
cardiac contractions are ineffective
virtually no cardiac output

Ventricular Fibrillation

Whats dis?

Whats dis? Treatment?

Whatz dis?

Right Bundle Branch Block

ECG Findings:
A broad QRS complex 0.12 s or more
measured in the lead where it is widest

An rR pattern or a wide slurred R wave in

leads V1 and/or V2

A late, broad s or S in leads V5, V6 and/or I

ST displacement and T waves opposite in

direction to the terminal deflection of the QRS

Right bundle branch block

Right Bundle Branch Block

Left Bundle Branch Block

ECG Findings:
Broad QRS complex of 0.12 s or more measured
in lead where it is widest

Wide slurred R wave in V5, V6 and/or lead I

Late broad S wave in V1 and/or V2

ST displacement and T waves opposite in direction

to the terminal deflection of the QRS complex

Left bundle branch block

Left Bundle Branch Block

AV Blocks
1o

2o

3o

First Degree AV Block

First degree AV block

Second Degree AV Block Type I

(Wenckebach)

Second Degree AV Block Type II

Third degree AV Block

Lown ganong Levine (James)

BIVENTRICULAR
HYPERTROPHY

Meets 1 or more of the criteria for LVH

and RVH

Chest leads show signs of LVH but axis is

> 90

BIATRIAL
ENLARGEMENT

LEAD V1 large biphasic P with initial

component > 2 mm and terminal negative
component > 1 mm deep and wide

ANY LEAD amplitude > 2.5 mm with

duration > 0.12 s

ST DEPRESSION

Significant if > 1 mm deep from J point

Differentials
digitalis effect
hypokalemia
in V5-V6 in LVH with strain
in V1-V2 in RVH with strain
LBBB or RBBB
NSTEMI

ST ELEVATION

Significant if > 2 mm in chest leads, > 1

mm in limb leads
Differentials
AMI
acute pericarditis
ventricular aneurysm
severe LV wall hypokinesia
early repolarization changes
prinzmetal angina

Q WAVES

Not significant if
in AVR
in lead III or V1 alone
in V1-V3 if associated with LBBB

Pathologic if
> 0.04 seconds duration
> 25% of the R wave amplitude

Ischemia (T-wave inversion),

lateral wall

Acute MI (ST elevation)anterolateral

and inferior MI (Q wave), age (?)

Acute MI (ST elevation), inferior

wall

<6 hours
hyper
acute

>24
hours
recent

>72
hours
healing

6-24
hours
acute

> 1-2
months
Healed/
scarred

U WAVES

Best seen at leads V2 V3

Significant if as tall as or taller

than the T wave

nonspecific

HYPOKALEMIA

ECG may be normal

Prominent U waves
Flattened or inverted T waves
ST depression
Fusion of T and U waves
Prolonged QRS

HYPERKALEMIA

Peaked T waves
> 5 mm in most limb leads
> 10 mm in most chest leads

Slurring and widening of QRS

ST elevation
Low, wide P waves

HYPERKALEMIA

Bradycardia
1st and 2nd degree AVB
Atrial arrest
Ventricular fibrillation

HYPERCALCEMIA
HYPOCALCEMIA
Prolonged QT

Shortened QT

BASSETS FORMULA FOR QTc

QTc =

Qta
RR interval

Correct if bradycardic or tachycardic

POOR R WAVE
PROGRESSION
Height of R in V3 < 3 mm
DIFFERENTIALS
Old anteroseptal wall MI
LVH
Heart rotated clockwise
LBBB

EARLY REPOLARIZATION
CHANGES
ST elevation 2-3 mm in V2 V4
Usually in males < 40
DIFFERENTIALS
Acute anteroseptal wall MI
Acute pericarditis