The

Normal
ADULT
ECG
 QRS

ST
P T
U

J
PR

QT
 0.1 mv
1.0 sec

0.04 sec

0.20 sec
 ECG Electrodes and Color Coding
TIP COLOR SYMBOL Electrode Position
Red RA Right Arm
Yellow LA Left Arm
Green LF Left Foot
Black RF Right Foot
RED/white C1 4th ICS R sternal border
YELLOW/whiteC2 4th ICS L sternal border
GREEN/white C3 Midway b/w C2 & C4
BROWN/white C4 5th ICS L MCL
BLACK/white C5 L AAL same level as C4
VIOLET/white C6 L MAL same level as C4
 Guide in ECG Reading
1 Rhythm
2 Rate: Atrial and Ventricular
3 Axis
4 P wave: morphology and duration
5 P – R interval
6 QRS complex: morphology and duration
7 ST segment
8 T wave
9 U wave
10 Q – T interval
1

Normal Rhythm

Arrythmia
 Determination of Heart Rate
“Rule of 300” FORMULA:
1 BSq = 300/min #1: 300 .
2 BSq = 150/min # of BS b/w R-R
3 BSq = 100/min
#2: 1500 .
4 BSq = 75/min # of SmS b/w R-R
5 BSq = 60/min
6 BSq = 50/min Normal = 60 – 100
7 BSq = 43/min Bradycardia = < 60
Tachycardia = > 100
10 BSq = 30/min
2
 Determination of Axis
I – neg -90o I – pos
AVF - neg AVF – neg
II -neg
Indeterminate Left Axis
Axis Deviation
-30o I – pos
AVF – neg
II -pos
180o
0o

Right Axis Normal Axis

I – neg Deviation Deviation
AVF - pos I – pos
AVF - pos

90o
3
 P wave morphology
I AVR

Upright P

Inverted P

V1

Biphasic P

4
 P – R Interval
Normal = 0.12 – 0.22

Short = < 0.12

Prolonged = > 0.22

5
 QRS complex morphology & duration
I AVR

Positive QRS

Negative QRS
V3

Biphasic QRS

6
 S – T Segment
I V1

Normal Elevated

V3

Depressed

7
 T wave Morphology
AVR
I

Upright T Inverted T

8
 Chamber
Enlargement
 Atria
Right Atrial Enlargement (RAE)
Tall P waves in II, III, AVF > 2.5mm

Left Atrial Enlargement (LAE)

P wave in I > 0.11 secs
Terminal Negativity of P wave in VI = > 1mm squared

Bi-atrial Enlargement
RAE + LAE
 Atria
Right Atrial Left Atrial
Enlargement (RAE) Enlargement (LAE)
- due to chronic - commonly seen in
lung diseases or mitral valve
pumonary embolus diseases
 RAE
I
 LAE
I
 LAE
I
 Bi-Atrial Enlargement
II

V1
 Ventricles
Right Ventricular Hypertrophy (RVH)
Sokolow-Lyon Criteria:
R in V1 + S in V5-V6 = > 11mm
R in V1 = > 7mm
R : S in V1 > 1
RAD > +90o
 Ventricles
Right Ventricular Hypertrophy (RVH)
- common causes:
COPD, MS, PS, L – R shunts
- Differentials:
Infero-posterior MI
RBBB
Hemiblocks
WPW
I AVR V1 V4

II AVL V2 V5

III AVF V3 V6
 Ventricles
Left Ventricular Hypertrophy (LVH)
Sokolow-Lyon Criteria:
S in V1 + R in V6 = > 35mm
R in AVL = > 12mm
R in AVF = > 20mm
R in I + S in III = > 25mm
S in V1 > 24mm
 Ventricles
Left Ventricular Hypertrophy (LVH)
- common causes:
HPN, AS (concentric hypertrophy)
AI, CAD (eccentric hypertrophy)
- initial compensatory mechanisms in:
Obesit, smoking, dyslipidemia, DM
- Differentials:
Anterior MI
LBBB
WPW
I AVR V1 V4

II AVL V2 V5

III AVF V3 V6
Ischemia, Injury
& Infarction
 Stages of Ischemic States
 Ischemia
- Deficient O2 delivery for given O2
demand
- Symmetrical T wave inversion and ST
depression

 Injury
- Lack of critical blood supply
- ST elevation in leads corresponding to
involved area

 Infarction
- Irreversible cell necrosis and death
- Pathologic Q waves (but may occur
w/o Q waves)
Criteria for Myocardial Ischemia
 Symmetrical T wave inversions on leads
overlying involved areas
 ST depression on either resting or
exercise ECG:
- At least 1.0mm depression at the J
point lasting ≥ 80 msecs
- Horizontal or downward slope toward
the end of the ST segment at its junction
with the T wave
 Criteria for Myocardial Injury
 Elevation of the origin of the ST segment at its J
point with the QRS of:
- ≥ 1.0mm in ≥ 2 limb leads lasting ≥ 0.80
msecs
- ≥ 2.0mm in precordial leads
 Depression of the origin of the ST segment at
the J point ≥ 1.0mm in at least 2 leads
* ST segment deviation typically either horizontal or slope toward the
direction of the T waves
Criteria for Myocardial Infarction
 Development of new Q waves on areas
overlying the infarct:
- ≥ 0.04 secs duration
- > 25% of the height of assoc R wave
 Rules regarding Q waves:
1. Q waves in AVR are not significant
2. Q waves in V1 are ignored unless with
abnormalities in other precordial leads
3. Q waves in III are ignored unless with
abnormalities in II & AVF
4. Q waves assoc w/ ST changes are more
reliable than those without
5. Q waves in the presence of LBBB are not
significant if located in V1 – V3.
6. Q waves located in V1 – V2 are always
significant in the presence of RBBB
7. Pathologic Q waves should be ≥ 0.04 secs
duration and > 25% of the R wave amplitude
Evolution of changes in MI

Normal Acute

Recent Old
 Time of Onset of MI
 Acute
- Changes appear w/n minutes to hours
- ST segment elevation over involved area
- ST segment depression in the opposing leads (reciprocal changes)
- T waves symmetrically peaked or deeply inverted
- Arrythmias or conduction abnormalities may occur
 Recent
- Changes remain days to weeks after the event
- ST segment may or may not have returned to baseline
- Localized Q waves or QS complexes have appeared
- T waves symmetrically inverted in areas involved
 Old
- Abnormal Q waves, QS complexes or regression or R waves
persist indefinitely
- ST segments are isolectric (otherwise consider aneurysm)
- T wave inversion may persist indefinitely
- Abnormalities may remain unchanged for 6 months
 Anatomy of MI
Infarction Area ECG Leads Cor Artery Branch
Extensive Anterior I, AVL, Left, LM LAD, LCX
V1 – V6
Anteroseptal V1 – V3 Left LAD
Anterolateral I – AVL, Left LCX
V4 – V6
Inferior II, III, AVF Right 80% PDA
True Posterior V1 – V2 Variable LCX, PL
Left/Right

LAD = left anterior descending artery; LCX = left circumflex artery;

LM = left main artery; PDA = posterior descending artery;
PL = posterolateral branch
 ECG Criteria for Infarct Location
Anteroseptal wall MI
- Q waves or QS complexes in leads V1 – V3
- may lose the septal q wave in leads I, AVL, V6
- S waves in leads V1 – V3 may be deeper than before infarct

Anterolateral wall MI
- Qr, QR or QS complexes in leads V4 – V6 or V5 – V6
- If acute or recent:
- convex ST segment elevation in leads V4 – V6 &/or I & AVL
- T wave inversion may occur in leads V4 – V6 &/or I & AVL
- If this is a part of a longer anterior infarction there is loss of the R
wave in leads V2 – V6 and often in leads I & AVL
 ECG Criteria for Infarct Location
High Lateral wall MI
- abnormal Q in I & AVL

Inferior wall MI
- Q waves in leads II, III, AVF; if present only in leads III & AVF, the
diagnosis is weaker
- If acute or recent:
ST segment elevation in II, III, AVF
Varying T wave inversion in leads II, III, AVF
- extension to the lateral wall is indicated by changes in leads V5 –
V6

True Posterior Wall MI

- dominant R in leads V1 – V2
- there is progression of the R waves in leads V1 – V3
- St segment depression in leads V1 & V2 with upright T waves
 ECG Criteria for Infarct Location
Right Ventricle Infarct
- 1.0mm ST segment elevation V4R
sensitivity 100%, specificity 68%
- ST elevation in V1 and ST depression in V2
- depth of ST depression in lead V2 ≤ 50% ST elevation in AVF
- ST elevation in lead III exceeds that in lead II

Differential Dx of ST elevation in V1 – V3 or V3 & V4R include:

Pulmonary embolism LBBB
LVH prior Anterior wall infarction
Pericarditis with aneurysm formation
 Non-Q MI
I AVR V1 V4

II AVL V2 V5

III AVF V3 V6
 Complications of MI
Rhythm disorders
- bradycardia: sinus bradycardia, SA node arrest, AV blocks
- tachycardia: extrasystoles, SVT, V tach, V flutter, V fib

Cardiac wall rupture

Heart failure

Aneurysm of heart wall

Bundle Branch Blocks
QRS<0.12s

P<0.12s
 Intraventricular Conduction Delays
 Incomplete Bundle Branch Blocks
 Left Bundle Branch Blocks
 Right Bundle Branch Blocks
 Fascicular Blocks
- Left Anterior Fascicular Block (Hemiblock)
- Left Posterior Fascicular Block (Hemiblock)
- Bifascicular Block
- Trifascicular Block
Intraventricular Conduction Delays

 Incomplete Bundle Branch Blocks

- Loss of septal q
- slurred and notched upstroke of R
- modest prolongation of QRS (100–120 msecs)
Intraventricular Conduction Delays
 Complete Left Bundle Branch Blocks
- QRS ≥ 120 msecs
- Broad, notched R
- Prolonged intrinsicoid deflection in V5, V6
(and I, AVL)
- Small or absent r in V1, V2 followed by deep S
waves
- Absent septal q waves in left sided leads
 Complete LBBB
I AVR V1 V4

II AVL V2 V5

III AVF V3 V6
Intraventricular Conduction Delays

Conditions Assoc with CLBBB

- Ischemic heart disease
- LVH
a. Hypertension
b. Aortic valve disease
- Cardiomyopathy
- Hyperkalemia
- Previous conditions assoc with RBBB
Intraventricular Conduction Delays
 Complete Right Bundle Branch Blocks
- QRS ≥ 120 msecs
- Broad, notched R (RSR pattern) in V1, V2
- Wide and deep S in V5, V6
- ST displacement and T waves opposite in
direction of the terminal deflection of the QRS
complex
 Complete RBBB
I AVR V1 V4

II AVL V2 V5

III AVF V3 V6
Intraventricular Conduction Delays

Conditions Assoc with CRBBB

- Ischemic heart disease
- Aortic stenosis
- Infective endocarditis with abscess of the
conduction system
- Hyperkalemia
- Ventriculat hypertrophy
Intraventricular Conduction Delays

 Fascicular Blocks
Delayed conduction in a fascicle results in
activation of these sites sequentially
rather than simultaneously
Abnormal sequence of early left ventricular
activation
 Intraventricular Conduction Delays
 Left Anterior Fascicular Blocks
- QRS duration < 120 msecs
- QRS axis of – 45o to – 90o
- rS patterns in II, III, AVF and a qR in AVL

*Common assoc conditions include occlusion of the left

anterior descending artery, LVH, hypertrophic and dilated
cardiomyopathy, degenerative diseases
I AVR V1 V4

II AVL V2 V5

III AVF V3 V6
Intraventricular Conduction Delays
 Left Posterior Fascicular Blocks
- QRS duration < 120 msecs
- QRS axis of +120o
- RS pattern in I, AVL
- qR pattern in II, III, AVF
- exclusion of other factors causing RAD:
RV overload, lateral infarction
Intraventricular Conduction Delays
Bifascicular Blocks
RBBB LAFB
- QRS complex ≥ 0.12s - QRS axis of – 45o or more
- rR pattern or a wide
slurred R wave in
leads V1,V2
- late, broad s or S in
leads V5, V6 (and/or I)
+ OR
- ST displacement and T
waves opposite in
LPFB
direction to the
- QRS axis of 110o or more
terminal deflection of
the QRS complex
Intraventricular Conduction Delays
Trifascicular Blocks
LAFB LPFB
- QRS axis - QRS axis
RBBB
- QRS complex ≥ 0.12s
+ of – 45o + of 110o
- rR pattern or a wide or more or more
slurred R wave in
OR
leads V1,V2
- late, broad s or S in CLBBB
leads V5, V6 (and/or I) - QRS duration ≥ msecs measured
- ST displacement and in lead where it is widest
T waves opposite in + - Broad, notched R wave in V5,
direction to the V6 and usually in I, AVL
terminal deflection of - Small or absent initial r waves in
the QRS complex V1, V2 followed by deep S waves
- prolonged intrinsicoid deflection
(>60 msec) in V5, V6
Bradyarrythmias
QRS<0.12s

P<0.12s

0.12-0.22s
 Types of Bradyarrythmias
 Sinus Bradycardia
 Junctional rhythm
 Idioventricular rhythm
 Sino-atrial blocks
 Atrio-ventricular blocks
 Types of Bradyarrythmias
 Sinus Bradycardia
- Pacemaker: SA node
- Firing Rate: < 60 beats per minute
- P waves: normal/uniform contour; occur before
each QRS complex
- Rhythm: regular
- QRS: < 0.12 secs
- PR interval: < 0.20 secs
 Types of Bradyarrythmias
 AV junctional Rhythm
- Pacemaker: AV Junction
- Firing Rate: 40 - 60 beats per minute
- Any independent atrial arrythmia may exist
- P waves: may be captured retrogadely
(negative in lead II)
- Rhythm: regular
- QRS: < 0.12 secs
- PR interval: < 0.12 secs
V3

Sinus Bradycardia

II

AV Junctional Rhythm
 Types of Bradyarrythmias
 Idioventricular Rhythm
- Pacemaker: HIS – Purkinge system
- Firing Rate: 20 - 40 beats per minute
- Rhythm: regular
- QRS: > 0.12 secs
- PR interval:
- P waves generally absent
- AV dissociation may be present
 Types of Bradyarrythmias
 Sino-atrial Block
- Failure of impulse transmission from
sinus node to adjacent atrial myocardium
- Complete failure of a P wave to appear,
and a cycle appears which is twice the
anticipated P – P interval
- Transient doubling of P – P interval
 Types of Bradyarrythmias
 SA Exit Block
- No visible P–QRS–T complex for ≥ 1 cycle
- Normal P wave morphology before and after
the pause
- Pause is preceded and followed by a normal
P – P cycle
- P – P interval of the pause is a multiple of the
normal P – P interval
V3

Idioventricular Rhythm

V3

SA Exit Block
 Types of Bradyarrythmias
 Atrio-ventricular Block (1st degree)
- There must b P waves
- P – R interval is prolonged ( > 20 secs)
- one P wave to each QRS complex
- P waves and QRS have morphology and
axis usual for the subject
- P – R interval is constant
V3

1st Degree AV Block

 Types of Bradyarrythmias
 Atrio-ventricular Block (2nd degree)
WENKEBACH / MOBITZ TYPE I
- There must be P waves & QRS complexes
- P waves & QRS must have morphology and axis usual for
the subject
- Progressive prolongation of P – R interval with each beat
until there is a dropped beat
- Longest P – R interval is the one immediately before the
dropped beat
- shortest P – R interval is the one assoc with
the first conducted beat after the dropped beat
- The P – R interval before the blocked beat increases, and
do so by progressively decreasing amounts so that
consecutive R – R intervals before dropped beat
progressively shortens
 Types of Bradyarrythmias
 Atrio-ventricular Block (2nd degree)
MOBITZ TYPE II
- There must be P waves & QRS complexes
- P waves & QRS must have morphology and axis usual for
the subject
- P – R interval of conducted beats may be normal or long but
fixed, then there is a dropped beat
- P – R interval must be constant for all conducted beats
- failure of conduction is not seen in relation to two or more
consecutive P waves
- QRS complexes after the transient AV conduction failure
have the same morphology as those preceding it
 2nd Degree AV Block
V3

Mobitz Type I

V3

Mobitz Type II
 Types of Bradyarrythmias
 Atrio-ventricular Block (3rd degree)
COMPLETE AV BLOCK
- No consistent or meaningful relationship
between atrial and ventricular activity. Variable
PR and RP intervals
- QRS rate is usually constant and lies within the
range of 15 – 70 beats/min
- QRS may be normal in shape, duration and
axis but more often are abnormal and are of
constant morphology
V3

3rd Degree AV Block

Miscellaneous ECG
Abnormalities
 ST – T Wave Changes
 Usually isoelectric
 May normally deviate between + 0.5 & 1.0
mm from the baseline in standard and
unipolar extremity leads
 Upward displacement of 2 – 3 mm may be
normal provided ST segment is concave
and T wave is full, broad-based & upright
 Average duration is 0.05 – 0.155
 Criteria for NSSTTW Changes
 ST segment and T wave abnormalities that
lack specifically defined characteristics
 Flattened or slightly inverted T waves
 ST segment slightly above or below the
isoelectric line
 Changes may be diffuse or localized
 ST - T Wave Changes in other Conditions
 ST elevation
- Juvenile ST changes
- Early ventricular repolarization
- Acute pericarditis
- Acute epicardial/myocardial injury
 ST depression
- Anxiety
- Fasting
- Positioning of patient
- Repiratory variation
 ST - T Wave Changes in other Conditions
 Hypokalemia ( < 2.5 meq/L)
- ST depression
- Decrease in T wave amplitude
- Increase in U wave amplitude
V3
 ST - T Wave Changes in other Conditions
Sequential ECG Changes w/ Hypokalemia

K meq/L
5 normal

3.5 low T wave

3.0 Low T wave

High U wave

2.5 Low T wave

High U wave
Low ST segment

T U
 ST - T Wave Changes in other Conditions

 Hyperkalemia ( 8.8 meq/L)

- Broad QRS
- Slow heart rate
- Usually LAD
- Loss of P wave
- Loss of ST segment (continuous with S wave)
- Tall tented T wave
- QTc interval abnormal or shortened
I AVR V1 V4

II AVL V2 V5

III AVF V3 V6
 ST - T Wave Changes in other Conditions
Sequential ECG Changes w/ Hyperkalemia
K meq/L
5 Normal

7 High T wave

8 High T wave
Depressed ST segment

9 Auricular standstill
Intraventricular block

10 Ventricular fibrillation

T U
 K+ level 8.8 meq/L
V4

V5

V6
Thank You