ECG Rhythm Interpretation

ECG Basics
 Course Objectives

• To recognize the normal rhythm of the

heart - “Normal Sinus Rhythm.”
• To recognize the 13 most common
rhythm disturbances.
• To recognize an acute myocardial
infarction on a 12-lead ECG.
 Learning Modules

• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
Normal Impulse Conduction
Sinoatrial node
I
V
AV node
I
Bundle of His

Bundle Branches
I
V
Purkinje fibers
Impulse Conduction & the ECG
Sinoatrial node

AV node

Bundle of His
v
Bundle Branches

Purkinje fibers
The “PQRST”

• P wave - Atrial

depolarization
• QRS - Ventricular
depolarization
• T wave - Ventricular
repolarization
 The PR Interval

Atrial depolarization
+
delay in AV junction
(AV node /Bundle of His)

(delay allows time for

the atria to contract
before the ventricles
contract)
 Pacemakers of the Heart

SA Node - Dominant pacemaker with

an intrinsic rate of 60 - 100
beats/minute.

• AV Node - Back-up pacemaker with an

intrinsic rate of 40 - 60 beats/minute.
• Ventricular cells - Back-up pacemaker
with an intrinsic rate of 20 - 45 bpm.
 The ECG Paper

• Horizontally
E2
- One small box - 0.04 s
- One large box - 0.20 s
• Vertically
- One large box - 0.5 mV

I mi
I i
ji _ JL^
^
* Every 3 seconds (15 large boxes) is
marked by a vertical line.
• This helps when calculating the heart
rate.
NOTE: the following strips are not marked
but all are 6 seconds long.
ECG Rhythm Interpretation

Module II

How to Analyze a Rhythm

 Course Objectives

• To recognize the normal rhythm of the

heart - “Normal Sinus Rhythm.”

• To recognize the 13 most common

rhythm disturbances.

• To recognize an acute myocardial

infarction on a 12-lead ECG.
 Learning Modules

• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
 Rhythm Analysis

• Step 1: Calculate rate.

• Step 2: Determine regularity.
• Step 3: Assess the P waves.
• Step 4: Determine PR interval.
• Step 5: Determine QRS duration.
Step 1: Calculate Rate

• Option 1
- Count the # of R waves in a 6 second
rhythm strip, then multiply by 10.
- Reminder: all rhythm strips in the Modules
are 6 seconds in length.
Interpretation? 9 x 10 = 90 bpm
Step 1: Calculate Rate
/ >/- 75" «r
“
r\
~50"

R wave

• Option 2
- Find a R wave that lands on a bold line.
- Count the # of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300 , 2 boxes - 150, 3
boxes - 100, 4 boxes - 75, etc. (cont)
Step 1: Calculate Rate
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0
J ] J I I

• Option 2 (cont)
- Memorize the sequence :
300 - 150 - 100 - 75 - 60 - 50

Interpretation? Approx. 1 box less than

100 = 95 bpm
Step 2: Determine regularity

• Look at the R-R distances (using a caliper or

markings on a pen or paper).
• Regular (are they equidistant apart) ?
Occasionally irregular? Regularly irregular?
Irregularly irregular?
Interpretation? Regular
Step 3: Assess the P waves

ILJL 1
1

• Are there P waves?

• Do the P waves all look alike?
• Do the P waves occur at a regular rate?
• Is there one P wave before each QRS?
Interpretation? Normal P waves with 1 P
wave for every QRS
Step 4: Determine PR interval

• Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)

Interpretation? 0.12 seconds

Step 5: QRS duration

• Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)

Interpretation? 0.08 seconds

 Rhythm Summary

• Rate 90-95 bpm

• Regularity regular
• P waves normal
• PR interval 0.12 s
• QRS duration 0.08 s
Interpretation? Normal Sinus Rhythm
ECG Rhythm Interpretation

Module III

Normal Sinus Rhythm

 Course Objectives
• To recognize the normal rhythm of the
heart - “Normal Sinus Rhythm,”
• To recognize the 13 most common
rhythm disturbances.
• To recognize an acute myocardial
infarction on a 12-lead ECG.
 Learning Modules

• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
 Normal Sinus Rhythm (NSR)

• Etiology : the electrical impulse is

formed in the SA node and conducted
normally.
• This is the normal rhythm of the heart;
other rhythms that do not conduct via
the typical pathway are called
arrhythmias.
 NSR Parameters

• Rate 60 - 100 bpm

• Regularity regular
• P waves normal
• PR interval 0.12 - 0.20 s
• QRS duration 0.04 - 0.12 s
Any deviation from above is sinus
tachycardia, sinus bradycardia or an
 Arrhythmia Formation

Arrhythmias can arise from problems in

the:
• Sinus node
• Atrial cells
• AV junction
• Ventricular cells
 SA Node Problems

The SA Node can:

• fire too slow Sinus Bradycardia
• fire too fast Sinus Tachycardia

Sinus Tachycardia may be an appropriate

response to stress.
 Atrial Cell Problems

Atrial cells can:

• fire occasionally Premature Atrial
from a focus Contractions (PACs)

• fire continuously Atrial Flutter

due to a looping
re-entrant circuit
 Teaching Moment
• A re-entrant
pathway occurs
when an impulse
loops and results
in self-
perpetuating
impulse
formation.
 Atrial Cell Problems
Atrial cells can also:
• fire continuously Atrial Fibrillation
from multiple foci
or
fire continuously Atrial Fibrillation
due to multiple
micro re-entrant
“wavelets”
 Teaching Moment
Atrial tissue
Multiple micro re-
entrant “wavelets”
refers to wandering
small areas of
activation which
generate fine chaotic
impulses. Colliding
wavelets can, in turn,
generate new foci of
activation.
 AV Junctional Problems

The AV junction can:

• fire continuously Paroxysmal
due to a looping Supraventricular
re-entrant circuit Tachycardia
* block impulses AV Junctional Blocks
coming from the
SA Node
 Ventricular Cell Problems
Ventricular cells can:
• fire occasionally Premature Ventricular
from 1 or more foci Contractions (PVCs)
• fire continuously Ventricular Fibrillation
from multiple foci
• fire continuously Ventricular Tachycardia
due to a looping
re-entrant circuit
ECG Rhythm Interpretation

Sinus Rhythms and

Premature Beats
 Course Objectives

• To recognize the normal rhythm of the

heart - “Normal Sinus Rhythm.”
• To recognize the 13 most common
rhythm disturbances.
• To recognize an acute myocardial
infarction on a 12-lead ECG.
 Learning Modules

• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
 Arrhythmias

• Sinus Rhythms
• Premature Beats
• Supraventricular Arrhythmias
• Ventricular Arrhythmias
• AV Junctional Blocks
 Sinus Rhythms

• Sinus Bradycardia
• Sinus Tachycardia
 Rhythm #1

• Rate? 30 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.12 s
• QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
 Sinus Bradycardia

• Deviation from NSR

- Rate < 60 bpm
 Sinus Bradycardia

• Etiology : SA node is depolarizing slower

than normal, impulse is conducted
normally ( i.e. normal PR and QRS
interval).
 Rhythm #2

• Rate? 130 bpm

• Regularity? regular
• P waves? normal
• PR interval? 0.16 s
• QRS duration? 0.08 s
Interpretation? Sinus Tachycardia
 Sinus Tachycardia
B . .. > . .

• Deviation from NSR

- Rate > 100 bpm
 Sinus Tachycardia
ft .. U1
• Etiology : SA node is depolarizing faster
than normal, impulse is conducted
normally.
* Remember: sinus tachycardia is a
response to physical or psychological
stress, not a primary arrhythmia.
 Premature Beats

• Premature Atrial Contractions

(PACs)
• Premature Ventricular Contractions
(PVCs)
 Rhythm #3

• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2/7 different contour
• PR interval? 0.14 s ( except 2/7)
• QRS duration? 0.08 s
Interpretation? NSR with Premature Atrial
Contractions
 Premature Atrial Contractions
I—
• Deviation from NSR
- These
—— - L-^

ectopic beats originate in the

I
-

atria (but not in the SA node),

therefore the contour of the P wave,
the PR interval , and the tinning are
different than a normally generated
pulse from the SA node.
Premature Atrial Contractions

• Etiology : Excitation of an atrial cell

forms an impulse that is then conducted
normally through the AV node and
ventricles.
 Teaching Moment
• When an impulse originates anywhere in
the atria (SA node, atrial cells, AV node,
Bundle of His) and then is conducted
normally through the ventricles, the QRS
will be narrow (0.04 - 0.12 s).

HHttHM
 Rhythm #4

• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s (7th wide )
Interpretation? Sinus Rhythm with 1 PVC
• Deviation from NSR
- Ectopic beats originate in the ventricles
resulting in wide and bizarre QRS
complexes.
- When there are more than 1 premature
beats and look alike, they are called
“uniform". When they look different, they are
called "multiform”.
 PVCs

• Etiology : One or more ventricular cells

are depolarizing and the impulses are
abnormally conducting through the
ventricles.
 Teaching Moment
• When an impulse originates in a
ventricle, conduction through the
ventricles will be inefficient and the
QRS will be wide and bizarre.
 Ventricular Conduction

Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
ECG Rhythm Interpretation

Module IV b

Supraventricular and
Ventricular Arrhythmias
 Course Objectives

• To recognize the normal rhythm of the

heart - “Normal Sinus Rhythm.”

• To recognize the 13 most common

rhythm disturbances.

• To recognize an acute myocardial

infarction on a 12-lead ECG.
 Learning Modules

• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
 Arrhythmias

• Sinus Rhythms
• Premature Beats
• Supraventricular Arrhythmias
• Ventricular Arrhythmias
• AV Junctional Blocks
 Supraventricular Arrhythmias
• Atrial Fibrillation
• Atrial Flutter

Paroxysmal Supraventricular
Tachycardia
 Rhythm #5

• Rate? 100 bpm

• Regularity? irregularly irregular
• P waves? none
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Fibrillation
 Atrial Fibrillation
ji i
j: k
• Deviation from NSR
- No organized atrial depolarization, so
no normal P waves (impulses are not
originating from the sinus node ).
- Atrial activity is chaotic (resulting in an
irregularly irregular rate).
- Common, affects 2-4%, up to 5-10% if
> 80 years old
 Atrial Fibrillation

• Etiology : Recent theories suggest that it

is due to multiple re-entrant wavelets
conducted between the R & L atria.
Either way, impulses are formed in a
totally unpredictable fashion. The AV
node allows some of the impulses to
pass through at variable intervals (so
rhythm is irregularly irregular).
 Rhythm #6

• Rate? 70 bpm
• Regularity? regular
• P waves? flutter waves
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Flutter
 Atrial Flutter

* Deviation from NSR

- No P waves. Instead flutter waves (note
“sawtooth” pattern) are formed at a rate
of 250 - 350 bpm.
- Only some impulses conduct through
the AV node (usually every other
impulse).
 Atrial Flutter

• Etiology : Reentrant pathway in the right

atrium with every 2nd, 3rd or 4th
impulse generating a QRS (others are
blocked in the AV node as the node
repolarizes).
 Rhythm #7

• Rate? 74 ->148 bpm

• Regularity? Regular -> regular
• P waves? Normal -> none
• PR interval? 0.16 s -> none
• QRS duration? 0.08 s
Interpretation? Paroxysmal Supraventricular
Tachycardia (PSVT)
 PSVT

• Deviation from NSR

- The heart rate suddenly speeds up,
often triggered by a PAC (not seen
here) and the P waves are lost.
 PSVT

• Etiology : There are several types of

PSVT but all originate above the
ventricles (therefore the QRS is narrow).

• Most common: abnormal conduction in

the AV node (reentrant circuit looping in
the AV node).
 Ventricular Arrhythmias
• Ventricular Tachycardia

• Ventricular Fibrillation
 Rhythm #8

• Rate? 160 bpm

• Regularity? regular
• P waves? none
• PR interval? none
• QRS duration? wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
 Ventricular Tachycardia

• Deviation from NSR

- Impulse is originating in the ventricles
(no P waves, wide QRS).
 Ventricular Tachycardia

• Etiology : There is a re-entrant pathway

i
looping in a ventricle (most common
cause).

• Ventricular tachycardia can sometimes

generate enough cardiac output to
produce a pulse; at other times no pulse
can be felt.
 Rhythm #9
mMEm./VyvVVv^^AA h^
^
• Rate? none
• Regularity? irregularly irreg.
• P waves? none
• PR interval? none
• QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
 Ventricular Fibrillation
A mvmi

• Deviation from NSR

- Completely abnormal.
 Ventricular Fibrillation
BAAA^AAA^V\ A /^^
^
P
W\ A /W\ AA,^AAA

• Etiology : The ventricular cells are

excitable and depolarizing randomly.

• Rapid drop in cardiac output and death

occurs if not quickly reversed
ECG Rhythm Interpretation

AV Junctional Blocks
 Course Objectives

• To recognize the normal rhythm of the

heart - “Normal Sinus Rhythm.”
• To recognize the 13 most common
rhythm disturbances.
• To recognize an acute myocardial
infarction on a 12-lead ECG.
 Learning Modules

• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
 Arrhythmias

• Sinus Rhythms
• Premature Beats
• Supraventricular Arrhythmias
• Ventricular Arrhythmias
• AV Junctional Blocks
 AV Nodal Blocks
• 1st Degree AV Block
• 2nd Degree AV Block, Type I
’ 2nd Degree AV Block, Type II
• 3rd Degree AV Block
 Rhythm #10

• Rate? 60 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.36 s
• QRS duration? 0.08 s
Interpretation? 1st Degree AV Block
 1st Degree AV Block

* Deviation from NSR

- PR Interval > 0.20 s
 1st Degree AV Block

• Etiology : Prolonged conduction delay in

the AV node or Bundle of His.
 Rhythm #11

• Rate? 50 bpm
• Regularity? regularly irregular
• P waves? nl, but 4th no QRS
• PR interval? lengthens
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block , Type I
2nd Degree AV Block, Type I

• Deviation from NSR

- PR interval progressively lengthens,
then the impulse is completely blocked
(P wave not followed by QRS).
 2nd Degree AV Block, Type I

• Etiology : Each successive atrial impulse

encounters a longer and longer delay in
the AV node until one impulse (usually
the 3rd or 4th) fails to make it through
the AV node.
 Rhythm #12

• Rate? 40 bpm
• Regularity? regular
• P waves? nl, 2 of 3 no QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block , Type II
2nd Degree AV Block, Type II

• Deviation from NSR

- Occasional P waves are completely
blocked (P wave not followed by QRS).
2nd Degree AV Block, Type II

Etiology : Conduction is all or nothing

(no prolongation of PR interval);
typically block occurs in the Bundle of
His.
 Rhythm #13

W ti
- V- f i t 1 I t t
• Rate? 40 bpm
• Regularity? regular
• P waves? no relation to QRS
• PR interval? none
• QRS duration? wide (> 0.12 s)
Interpretation? 3rd Degree AV Block
 3rd Degree AV Block

• Deviation from NSR

- The P waves are completely blocked in
the AV junction; QRS complexes
originate independently from below the
junction.
 3rd Degree AV Block

BA \r 1' '
• Etiology : There is complete block of
I
conduction in the AV junction, so the
atria and ventricles form impulses
independently of each other. Without
impulses from the atria, the ventricles
own intrinsic pacemaker kicks in at
around 30 - 45 beats/minute.
 Remember
* When an impulse originates in a ventricle
conduction through the ventricles will be
inefficient and the QRS will be wide and
bizarre.

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