ECG

Lia Trapaidze
 ECG
• The standard electrocardiography (ECG) provides 12 different
vector views of the heart’s electrical activity as reflected by
electrical potential differences between positive and negative
electrodes placed on the limbs and chest wall.
• Six of these views are vertical (using frontal leads I, II, and III
and limb leads aVR, aVL, and aVF), and 6 are horizontal (using
precordial leads V1, V2, V3, V4, V5, and V6). The 12-lead ECG is
crucial for establishing many cardiac diagnoses, including:
• Arrhythmias
• Myocardial ischemia
• Atrial enlargement
• Ventricular hypertrophy
• Conditions that predispose to syncope or sudden death (eg,
Wolff-Parkinson-White syndrome, long QT syndrome, Brugada
syndrome)
 ORIENTATION OF THE 12-LEAD ECG (think in 3
dimension’s)
• It is important to remember that the 12-lead ECG provides spatial information about the
• heart's electrical activity in 3 approximately orthogonal directions (think: X, Y, Z):
• Right – Left (X)
• Superior – Inferior (Y)
• Anterior – Posterior (Z)
• Each of the 12 leads represents a particular orientation in 3-D space, as indicated below.
• Bipolar limb leads (frontal plane):
• Lead I: RA (- pole) to LA (+ pole) (Right -to- Left direction)
• Lead II: RA (-) to LL (+) (mostly Superior -to- Inferior direction)
• Lead III: LA (-) to LL (+) (mostly Superior -to- Inferior direction)
• Augmented limb leads (frontal plane):
• Lead aVR: RA (+) to [LA & LL] (-) (mostly Rightward direction)
• Lead aVL: LA (+) to [RA & LL] (-) (mostly Leftward direction)
• Lead aVF: LL (+) to [RA & LA] (-) (Inferior direction)
• “Unipolar” (+) chest leads (horizontal plane):
• Leads V1, V2, V3: (mostly Posterior -to- Anterior direction)
• Leads V4, V5, V6: (mostly Right -to- Left direction)
 Interpretation of Abnormal ECGs
Abnormal
Description Possible Causes
Component
P waves Abnormal Left or right atrial hypertrophy, atrial escape (ectopic) beats
P waves Absent Atrial fibrillation, sinus node arrest or exit block, hyperkalemia
 (severe)
P-P interval Varying Sinus arrhythmia
PR interval Long First-degree atrioventricular block
PR interval Varying Mobitz type I atrioventricular block, multifocal atrial tachycardia
QRS complex Wide Right or left bundle branch block, ventricular flutter, 
ventricular fibrillation, hyperkalemia
QT interval Long Myocardial infarction, myocarditis, stress cardiomyopathy, 
hypocalcemia, hypokalemia, hypomagnesemia, hypothyroidism, 
subarachnoid hemorrhage, intracerebral hemorrhage, stroke, 
congenital long QT syndrome, antiarrhythmics
(eg, sotalol, amiodarone, quinidine), tricyclic antidepressants,
phenothiazines, other drugs
QT interval Short Hypercalcemia, hypermagnesemia, Graves disease, digoxin
 Interpretation of Abnormal ECGs
Abnormal
Description Possible Causes
Component
ST segment Depression Myocardial ischemia; acute posterior myocardial
infarction; digoxin; ventricular hypertrophy; pulmonary embolism;
left bundle branch block in leads V5–V6 and possibly in I and aVL;
right bundle branch block in leads V1–V3 and possibly in II, III, and
aVF; hyperventilation; hypokalemia
ST segment Elevation Myocardial ischemia, acute myocardial infarction, left bundle
branch block in leads V1–V3 and possibly in II, III, and aVF, acute 
pericarditis, left ventricular hypertrophy, hyperkalemia,
pulmonary embolism, digoxin, normal variation (eg, 
athlete's heart), hypothermia
T wave Tall Hyperkalemia, acute myocardial infarction, left bundle branch
block, stroke, ventricular hypertrophy
T wave Small, Myocardial ischemia, myocarditis, age, race, hyperventilation,
flattened, or anxiety, drinking hot or cold beverages, left ventricular
inverted hypertrophy, certain drugs (eg, digoxin), pericarditis, pulmonary
embolism, conduction disturbances (eg, right bundle branch
block), electrolyte disturbances (eg, hypokalemia), stress
cardiomyopathy
U wave Prominent Hypokalemia, hypomagnesemia, ischemia
 Standard ECG Components

• By convention, the ECG tracing is divided into the P wave,

PR interval, QRS complex, QT interval, ST segment, T
wave, and U wave.
• P wave = activation (depolarization) of atria.
• PR interval =time interval between onset of atrial
depolarization and onset of ventricular depolarization.
• QRS complex = depolarization of ventricles, consisting of
the Q, R, and S waves.
• QT interval = time interval between onset of ventricular
depolarization and end of ventricular repolarization.
• R-R interval = time interval between 2 QRS complexes.
• T wave = ventricular repolarization.
• ST segment plus T wave (ST-T) = ventricular
repolarization.
• U wave = probably after-depolarization (relaxation) of
ventricles.
P wave = activation (depolarization) of atria. PR interval =time interval between onset of atrial depolarization and
Electrocardiography (ECG) waves

onset of ventricular depolarization. QRS complex = depolarization of ventricles, consisting of the Q, R, and S

waves. QT interval = time interval between onset of ventricular depolarization and end of ventricular
repolarization. R-R interval = time interval between 2 QRS complexes. T wave = ventricular repolarization. ST
segment plus T wave (ST-T) = ventricular repolarization. U wave = probably after-depolarization (relaxation) of
ventricles.
1. MEASUREMENTS (usually made in
the frontal plane leads):
• Heart rate (state both atrial and ventricular
rates, if different)
• PR interval (from beginning of P to beginning
of QRS complex)
• QRS duration (width of most representative
QRS)
• QT interval (from beginning of QRS to end of
T)
• QRS axis in frontal plane (see "How to
Measure QRS Axis" on p 8)
1. MEASUREMENTS (usually made in
the frontal plane leads):
• Heart rate (state both atrial and ventricular
rates, if different)
• PR interval (from beginning of P to beginning
of QRS complex)
• QRS duration (width of most representative
QRS)
• QT interval (from beginning of QRS to end of
T)
• QRS axis in frontal plane.
 2. RHYTHM ANALYSIS:
• State the basic rhythm (e.g., "normal sinus
rhythm", "atrial fibrillation", etc.)
• Identify additional rhythm events if present
(e.g., "PVC's", "PAC's", etc.)
• Remember that arrhythmias may originate in
the atria, AV junction, and ventricles
 3. CONDUCTION ANALYSIS:
• "Normal" conduction implies normal sino-atrial (SA), atrio-
ventricular (AV), and
• intraventricular (IV) conduction.
• The following conduction abnormalities are to be identified
if present:
• 2nd degree SA ‘exit’ block (type I, type II, or uncertain)
• 1st, 2nd (type I or type II), and 3rd degree AV block
• IV blocks: bundle branch, fascicular, and nonspecific blocks
• Exit blocks are blocks just distal to the sinus or ectopic
pacemaker site
 4. WAVEFORM DESCRIPTION:
• Carefully analyze each of the12-leads for abnormalities of the
waveforms in the order in which they appear: P-waves, QRS
complexes, ST segments, T waves, and…. Don't forget the U waves.
• P waves: are they too wide, too tall, look funny (i.e., are they
ectopic), etc.?
• QRS complexes: look for pathologic Q waves, abnormal voltage,
etc.
• ST segments: look for leads with abnormal ST elevation and/or
depression.
• T waves: look for abnormally inverted T waves or unusually tall T
waves.
• U waves: look for prominent or inverted U waves.
 5. FINAL ECG INTERPRETATION:
• This is the conclusion of the above analyses. Interpret the ECG as
"Normal", or "Abnormal". Occasionally the term "borderline" is used
if unsure about the significance of certain findings or for minor
changes. List all abnormalities.
• Examples of "abnormal" statements are:
• Inferior MI, probably acute
• Old anteroseptal MI
• Left anterior fascicular block (LAFB)
• Left ventricular hypertrophy (LVH)
• Right atrial enlargement (RAE)
• Nonspecific ST-T wave abnormalities
• Specific rhythm abnormalities such as atrial fibrillation
6. COMPARISON WITH PREVIOUS ECG:

• If there is a previous ECG in the patient's file,

the current ECG should be compared with it to
see if any significant changes have occurred.
These changes may have important
implications for clinical management
decisions.
 Standard ECG Components

• P wave
• The P wave represents atrial depolarization. It is upright in most
leads except aVR. It may be biphasic in leads II and V1; the initial
component represents right atrial activity, and the 2nd component
represents left atrial activity.
• An increase in amplitude of either or both components occurs
with atrial enlargement. Right atrial enlargement produces a P
wave > 2 mm in leads II, III, and aVF (P pulmonale); left atrial
enlargement produces a P wave that is broad and double-peaked
in lead II (P mitrale). Normally, the P axis is between 0° and 75°.
• PR interval
• The PR interval is the time between onset of atrial depolarization
and onset of ventricular depolarization. Normally, it is 0.10 to 0.20
second; prolongation defines 1st-degree atrioventricular block.
 Standard ECG Components

• QRS complex
• The QRS complex represents ventricular depolarization.
• The Q wave is the initial downward deflection; normal Q waves last < 0.05 second in all leads
except V1 to V3, in which any Q wave is considered abnormal, indicating past or current
infarction.
• The R wave is the first upward deflection; criteria for normal height or size are not absolute,
but taller R waves may be caused by ventricular hypertrophy. A 2nd upward deflection in a
QRS complex is designated R′.
• The S wave is the 2nd downward deflection if there is a Q wave and the first downward
deflection if not.
• The QRS complex may be R alone, QS (no R), QR (no S), RS (no Q), or RSR′, depending on the
ECG lead, vector, and presence of heart disorders.
• Normally, the QRS interval is 0.07 to 0.10 second. An interval of 0.10 to 0.11 second is
considered incomplete bundle branch block or a nonspecific intraventricular conduction
delay, depending on QRS morphology. An interval ≥ 0.12 second is considered complete
bundle branch block or an intraventricular conduction delay.
• Normally, the QRS axis is 90° to −30°. An axis of −30° to −90° is considered left axis deviation
and occurs in left anterior fascicular block (−60°) and inferior myocardial infarction.
• An axis of 90° to 180° is considered right axis deviation; it occurs in any condition that
increases pulmonary pressures and causes right ventricular hypertrophy (cor pulmonale,
acute pulmonary embolism, pulmonary hypertension), and it sometimes occurs in right
bundle branch block or left posterior fascicular block.
 Standard ECG Components

• QT interval
• The QT interval is the time between onset of ventricular
depolarization and end of ventricular repolarization. The QT
interval must be corrected for heart rate using the formula:
QTc=QT/√RR
• where QTc is the corrected QT interval and R-R interval is
the time between 2 QRS complexes. All intervals are
recorded in seconds. QTc prolongation is strongly implicated
in development of torsades de pointe
ventricular tachycardia. QTc is often difficult to calculate
because the end of the T wave is often unclear or followed
by a U wave with which it merges. Numerous drugs are
implicated in prolonging the QT interval (see CredibleMeds).
 Standard ECG Components

• ST segment
• The ST segment represents completed ventricular myocardial depolarization.
Normally, it is horizontal along the baseline of the PR (or TP) intervals or slightly off
baseline.
• ST segment elevation can be caused by
• Early repolarization
• Left ventricular hypertrophy
• Myocardial ischemia and infarction
• Left ventricular aneurysm
• Pericarditis
• Hyperkalemia
• Hypothermia
• Pulmonary embolism
• ST segment depression can be caused by
• Hypokalemia
• Digoxin
• Subendocardial ischemia
• Reciprocal changes in acute myocardial infarction
 Standard ECG Components

• T wave
• The T wave reflects ventricular repolarization. It usually
takes the same direction as the QRS complex
(concordance); opposite polarity (discordance) may
indicate past or current infarction.
• The T wave is usually smooth and rounded but may be of
low amplitude in hypokalemia and hypomagnesemia and
may be tall and peaked in hyperkalemia, hypocalcemia,
and left ventricular hypertrophy.
• U wave
• The U wave appears commonly in patients who have
hypokalemia, hypomagnesemia, or ischemia. It is often
present in healthy people.