BASIC ECG INTERPRETATION and

ARRHYTHMIA RECOGNITION

By: MA. VICTORIA E. MARTINEZ

ER - RN
 What is an electrocardiogram (ECG)?

• An electrocardiogram (ECG or EKG) is

one of the simplest and fastest
procedures used to evaluate the heart.
Electrodes (small, plastic patches) are
placed at certain locations on your chest,
arms, and legs. When the electrodes are
connected to the ECG machine by lead
wires, the electrical activity of your heart
is measured, interpreted, and printed
out for the physician's information and
further interpretation.
 Why is an ECG performed?
• The electrical activity of the heart is
measured by an electrocardiogram. By
placing electrodes at specific locations
on the body (chest, arms, and legs), a
graphic representation, or tracing, of
the electrical activity can be obtained.
Changes in an ECG from the normal
tracing can indicate one, or more, of
several heart-related conditions.
 Some medical conditions which may cause changes in
the ECG pattern include, but are not limited to, the

following:
• conditions in which the heart is enlarged - these conditions
can be caused by various factors, such as congenital (present at
birth) heart defects, valve disorders, high blood pressure,
congestive heart failure, or conduction disturbances.
• ischemia - decreased blood flow to the heart muscle due to
clogged or partially-clogged arteries.
• conduction disorders - a dysfunction in the heart's electrical
conduction system, which can make the heart beat too fast, too
slow, or at an uneven rate.
• electrolyte disturbances - an imbalance in the level of
electrolytes, or chemicals, in the blood, such as potassium,
magnesium, or calcium.
• pericarditis - an inflammation or infection of the sac which
surrounds the heart.
• valve disease - malfunction of one or more of the heart valves
may cause an obstruction of the blood flow within the heart.
• chest trauma - blunt trauma to the chest, such as a motorist
hitting the steering wheel in an automobile accident.
 An ECG may also be performed for other reasons,
including, but not limited to, the following:

• during a physical examination to obtain a baseline

tracing of the heart's function (This baseline tracing
may be used later as a comparison with future ECGs,
to see if any changes have occurred.)
• as part of a work-up prior to a procedure such as
surgery to make sure no heart condition exists that
might cause complications during or after the
procedure
• to check the function of an implanted pacemaker
• to check the effectiveness of certain heart
medications
• to check the heart's status after a heart-related
procedure such as a cardiac catheterization, heart
surgery, or electrophysiological studies
 CONDUCTION SYSTEM

• The heart's conducting system consists of the sinoatrial node (SA node), atrioventicular
node (AV node), the bundle of His, the bundle branches and the Purkinje fibers.
• The electrical impulse that causes rhythmic contraction of heart muscles arises in the SA node
which is the intrinsic pacemaker of the heart. From the SA node, the impulse spreads over the atrial
muscles causing atrial contraction. The impulse is also conducted to the atrioventicular (AV) node.
• From the AV node the electrical impulse is conducted to ventricular muscles via the bundle of His,
the bundle branches and the Purkinje fibers. The bundle branches and the Purkinje fibers are
collectively called the ventricular conduction system.
 EKG Leads
• EKG Standard Leads
• There are three of these leads
which are usually designated as I, II
and III.

• They are all bipolar (i.e., they

detect a change in electric potential
between two points) and detect an
electrical potential change in the
frontal plane.
• Lead I is between the right arm and
left arm electrodes, the left arm
being positive.
• Lead II is between the right arm
and left leg electrodes, the left leg
being positive.
• Lead III is between the left arm and
left leg electrodes, the left leg again
being positive
• EKG Augmented Limb Leads
• The same three leads that form
the standard leads also form the
three unipolar leads known as
the augmented leads. These
three leads are referred to as
aVR (right arm), aVL (left arm)
and aVF (left leg) and also
record a change in electric
potential in the frontal plane.
• These leads are unipolar in that
they measure the electric potential
at one point with respect to a null
point (one which doesn't register
any significant variation in electric
potential during contraction of the
heart).
• This null point is obtained for each
lead by adding the potential from
the other two leads. For example,
in lead aVR, the electric potential
of the right arm is compared to a
null point which is obtained by
adding together the potential of
lead aVL and lead aVF
• EKG Precordial Leads
• These six unipolar leads, each in a different position on the
chest, record the electric potential changes in the heart in a
cross sectional plane. Each lead records the electrical variations
that occur directly under the electrode.
 Sinus Rhythm on ECG

• Sinus rhythm is characterized by a usual rate of anywhere between 60-100

bpm. Every QRS complex is preceded by a P wave and every P wave must be
followed by a QRS (the opposite occurs if there is second or third degree AV
block). The P wave morphology and axis must be normal and the PR interval
will usually be 120 ms to 200 ms. In normal sinus rhythm, electrical impulses
from the SA node travel to the AV node with successful contraction of the
two atria. The electrical impulses from the AV node successfully contract the
ventricles. On the ECG, there are normal PQRST elements with no evidence
of arrhythmia, tachycardia, or bradycardia. Normal sinus rhythm on an ECG
does not rule out a diagnosis of AMI. Documentation of the condition of ST
segment and QT values must be evaluated. Simply documenting "ECG NSR"
only indicates the underlying rhythm.
– The first little upward notch of the ECG tracing is called the "P wave."
The P wave indicates that the atria (the two upper chambers of the
heart) are electrically stimulated to pump blood to the ventricles.
• The next part of the tracing is a short downward section
connected to a tall upward section. This next part is called the
"QRS complex." This part indicates that the ventricles (the two
lower chambers of the heart) are electrically stimulated to pump
out blood.
• The next short flat segment is called the "ST segment." The ST
segment indicates the amount of time from the end of the
contraction of the ventricles to the beginning of the "T wave".
• The next upward curve is the T wave. The T wave indicates the
recovery period of the ventricles.
 ECG WAVEFORM

• P Wave
• P waves are caused by atrial depolarization. In normal sinus rhythm, the
SA node acts as the pacemaker. The electrical impulse from the SA node
spreads over the right and left atria to cause atrial depolarization. The P
wave contour is usually smooth, entirely positive and of uniform size.
The P wave duration is normally less than 0.12 sec and the amplitude is
normally less than 0.25 mV. A negative P-wave can indicate
depolarization arising from the AV node.
• Note that the P wave corresponds to electrical impulses not mechanical
atria contraction. Atrial contraction begins at about the middle of the P
wave and continues during the PR segment.
– The PR Segment
– PR segment is the portion on the EKG wave from the end of the P
wave to the beginning of the QRS complex, lasting about 0.1
seconds. The PR segment corresponds to the time between the end
of atrial depolarization to the onset of ventricular depolarization.
The PR segment is an isoelectric segment, that is, no wave or
deflection is recorded. During the PR segment, the impulse travels
from the AV node through the conducting tissue (bundle branches,
and Purkinje fibers) towards the ventricles. (Note a wave will be
recorded only after the impulses exit the conducting systems and
activates the ventricular muscle to give the QRS complex). Most of
the delay in the PR segment occurs in the AV node. 
– PR interval 0.12 ~ 0.20 sec
• The QRS Complex
– In normal sinus rhythm, each P wave is followed by a QRS complex. The QRS
complex represents the time it takes for depolarization of the ventricles.
Activation of the anterioseptal region of the ventricular myocardium
corresponds to the negative Q wave. The Q wave is not always present.
Activation of the rest of the ventricular muscle from the endocardial surface
corresponds to the rest of the QRS wave. The R wave is the point when half of
the ventricular myocardium has been depolarized. Activation of the
posteriobasal portion of the ventricles give the RS line. The normal QRS
duration range is from 0.04 sec to 0.12 sec measured from the initial deflection of
the QRS from the isoelectric line to the end of the QRS complex.
– Normal ventricular depolarization requires normal function of the right and left
bundle branches. A block in either the right or left bundle branch delays
depolarization of the ventricles, resulting in a prolonged QRS duration.

• QRS Interval (QRS) 0.08 < QRS < 0.12 sec

– The ST Segment
– The ST segment represents the period from the end of ventricular
depolarization to the beginning of ventricular repolarization. The
ST segment lies between the end of the QRS complex and the initial
deflection of the T-wave and is normally isoelectric. It is clinically
important if elevated or depressed as it can be a sign of ischemia and
hyperkalemia.
– The QT Interval
– The QT interval begins at the onset of the QRS complex and to the end of
the T wave. It represents the time between the start of ventricular
depolarization and the end of ventricular repolarization. It is useful as a
measure of the duration of repolarization. The QT interval will vary
depending on the heart rate, age and gender. It increases with bradycardia
and decreases with tachycardia. Men have shorter QT intervals (0.39 sec)
than women (0.41 sec). The QT interval is influenced by electrolyte balance,
drugs, and ischemia.
– The T Wave
– The T wave corresponds to the rapid ventricular
repolarization. The wave is normally rounded and positive.
The T wave can become inverted, peaked or flattened due to
electrolyte imbalance, hyperventilation, CNS disease, ischemia or
myocardial infarction.
 Determining Heart Rate and Rhythm

• The EKG paper is made of a grid of big boxes

and small boxes. Each big box is 10 mm in
length has five small boxes and is 0.20 sec.
Each small box is 1 mm and represents 0.04
sec. The EKG paper moves at a standard
speed of 25 mm/sec. At standard speed, the
heart rate can be determined by either of the
following methods.
• A single cardiac cycle measures 0.8 sec
 
• Method I
• Examine the distance between QRS complexes and determine if the
peaks (RR intervals) are regularly spaced. 
• The EKG below shows regular RR intervals. If the RR distances are
regular, count the number of "small boxes" from the beginning of one
QRS complex to the beginning of the next QRS complex. Then divide
1500 by the number of "small boxes" to obtain the heart rate in beats
per minute.
•                     
– Heart Rate =  1500No / small boxes

–  

• The EKG on the bottom right shows irregularly spaced RR intervals. If the
distances are irregular, count the number of QRS complexes within 30 large
boxes (which each represent 0.2 seconds) and multiply this number by 10 to
obtain the heart rate in beats/minute.
•
• Method II
• If the peaks are regular, the heart rate can be estimated using the  EKG
grid. To do this locate a QRS complex on a bold line. If the next QRS
complex is separated by:
• i.   One large box, the heart rate is 300 BPM (300/1)
• ii.  Two large boxes, the heart rate is 150 BPM (300/2)
• iii. Three large boxes, the heart rate is 100 BPM (300/3)
• iv. Four large boxes, the heart rate is 75 BPM (300/4)
 Arrhythmias
• The term "arrhythmia" refers to any change from
the normal sequence of electrical impulses. The
electrical impulses may happen too fast, too
slowly, or erratically – causing the heart to beat
too fast, too slowly, or erratically.
• When the heart doesn’t beat properly, it can’t
pump blood effectively. When the heart doesn’t
pump blood effectively, the lungs, brain and all
other organs can’t work properly and may shut
down or be damaged.
 Types of Arrhythmias

Bradycardia = too slow

Tachycardia = too fast
Fibrillation = quivering
Premature contraction = early beat
 Bradycardia

• Bradycardia = too slow

• A heart rate of less than 60 beats per minute (BPM) in adults is called
bradycardia.  What’s too slow for you may depend on your age and
physical condition.
• Physically active adults often have a resting heart rate slower than 60
BPM but it doesn’t cause problems.
• Your heart rate may fall below 60 BPM during deep sleep.
• Elderly people are more prone to problems with a slow heart rate.
 Tachycardia
• Tachycardia =Too fast
A heart rate of more than 100 beats per
minute (BPM) in adults is called
tachycardia. What’s too fast for you may
depend on your age and physical
condition.
 Types of tachycardias

Atrial or Supraventricular tachycardias  start either in the upper chambers

(atria) or the middle region (AV node or the very beginning portion of the His-
Purkinje system.
• Supraventricular means "above the ventricles," in other words,
originating from the atria, the upper chambers of the heart.

• Supraventricular tachycardia, then, is a rapid heartbeat originating in

the atria.
 Sinus tachycardia 

• is a heart rate that’s faster than normal but the

heart functions properly.
 Ventricular tachycardias 
•  

• An abnormally rapid heart rhythm that originates from

a ventricle, one of the lower chambers of the heart.
Although the beat is regular, ventricular tachycardia is
life-threatening because it can lead to a dreaded
condition, ventricular fibrillation.
 Fibrillation
• Fibrillation = quivering

The fibrillating heart is like shaking a bowl

of gelatin – it just quivers but doesn’t
produce the coordinated pumping action
needed to force blood through the heart
and out into the body.
 Atrial Fibrillation

• Atrial Fibrillation = Upper chambers of the heart quiver

The heart's two small upper chambers (the atria) quiver (like shaking a bowl of gelatin),
instead of beating rhythmically and effectively.
• How it happens
Many parts of the atria (the heart's two upper chambers) start emitting uncoordinated
electrical signals. The atria pump too fast , unevenly (irregularly) and won't fully contract
(squeeze blood out of the heart completely). Some electrical signals go to the ventricles,
which still pump out blood. But blood isn't pumped completely out of them, so it may
pool and clot. If a piece of a blood clot in the atria leaves the heart and becomes lodged in
an artery in the brain, a stroke results.
 Ventricular Fibrillation

• Ventricular fibrillation (v-fib for short) is the most serious cardiac rhythm disturbance.
The lower chambers quiver and the heart can't pump any blood, causing cardiac arrest. 
• How it works
The heart's electrical activity becomes disordered. When this happens, the heart's lower
(pumping) chambers contract in a rapid, unsynchronized way. (The ventricles "flutter"
rather than beat.)  The heart pumps little or no blood.   Collapse and sudden cardiac
arrest follows -- this is a medical emergency !
 Premature Ventricular Contraction
are extra, abnormal heartbeats that begin in one of your heart's
two lower pumping chambers (ventricles). These extra beats
disrupt your regular heart rhythm, sometimes causing you to feel
a flip-flop or skipped beat in your chest. Premature ventricular
contractions are very common — they occur in most people at
some point.
• Premature ventricular contractions are also called:
• Premature ventricular complexes
• PVCs
• Ventricular premature beats
• Ectopic heartbeats
• Extrasystoles
• If you have occasional extra beats, but you are an otherwise
healthy person, there's generally no reason for concern, and no
treatment is needed. If you have frequent symptoms or you have
underlying heart disease, you may need treatment to help you
feel better and treat underlying heart problems.
• Rate = variableP waveusually obscured by the QRS,
PST or T wave of the PVC
QRS = wide > 0.12 seconds; morphology
is bizarre with the ST segment and the T wave
opposite in polarity. May be multifocal and exhibit
different morphologies.
Conduction = the impulse originates below the
branching portion of the Bundle of His; full
compensatory pause is characteristic.
Rhythm = irregular. PVC's may occur in singles,
couplets or triplets; or in bigeminy, trigeminy or
quadrigeminy
 PVCs can occur in healthy hearts. For example, an increase in
circulating catecholamines can cause PVCs. They also occur in
diseased hearts and from drug (such as digitalis) toxicities.

Treatment is required if they are:

associated with an acute MI,
occur as couplets, bigeminy or trigeminy,
are multifocal, or
are frequent (>6/min).

Interventions include:
lidocaine,
pronestyl, or
quinidine.
THANK YOU