ECG

Assoc. Prof. Dr. Abdus Salam

Department of medicine
Shaheed Ziaur Rahman Medical College Hospital,
Bogra
• ECG stands for Electrocardiogram or
electrocardiograph

• ECG records electric activity of heart at its

different stage of cardiac cycle
Lead doesn’t means “Wires or
Electrodes” attached to body surface
Rather
It means “The virtual planes” that look
heart from different angles

A standard ECG has 12 leads-

Limb lead: I, II, III
Chest lead: V1, V2, V3, V4, V5, V6
Augmented leads: aVL, aVR, aVF
 Electrodes
Usually consist of a conducting gel, embedded in
the middle of a self-adhesive pad onto which
cables clip. Ten electrodes are used for a 12-lead
ECG.

cement of electrodes The limb electrodes

RA - On the right arm, avoiding thick muscle
LA – On the left arm this time.
RL - On the right leg, lateral calf muscle
LL- On the left leg this time.

The 6 chest electrodes

V1 - Fourth intercostal space, right sternal border.
V2 - Fourth intercostal space, left sternal border.
V3 - Midway between V2 and V4.
V4 - Fifth intercostal space, left midclavicular line.
V5 - Level with V4, left anterior axillary line.
V6 - Level with V4, left mid axillary line.
 STANDARD
CALLIBRATION
Speed = 25mm/s
Amplitude = 0.1mV/mm
1mV 10mm high
1 large square 
0.2s(200ms)
1 small square 0.04s
(40ms) or 1 mV
amplitude
NORMAL ECG <3 small square

< 2 small square

<3-5 small square

< 2 large square

12 lead complete ECG
(Normal ECG)
The best way to interpret an ECG is to do it
step-by-step
• Rate
• Rhythm
• Cardiac Axis
• P – wave
• PR - interval
• QRS Complex
• ST Segment
• QT interval (Include T and U wave)
• Other ECG signs
Rate
 Calculating Rate
Look at lead II. This lead is the rhythm strip which shows the
rhythm for the whole time the ECG is recorded. To calculate
rate, use any of the following formulas:

300
Rate =
The number of LARGE SQUARE between
R-R interval
OR

Rate = 1500
The number of SMALL SQUARE between R-
R interval
 If rhythm is not regular, count the number of electrical
beats in a 6-second strip (30 large square) and multiply that
number by 10 Example below
1 2 3 4 5 6 7 8

Rate = (Number of waves in 6-second strips) x 10

= 8 x 10
= 80 bpm
 Rate

Sinus Bradycardia

Rate < 60bpm, otherwise normal

 Rate

Sinus Tachycardia

Rate >100bpm, otherwise, normal

 Rythm
• Look at P waves & its relationship to QRS complexes.
• Lead II is commonly used
Regular or irregular?
If in doubt, use a paper strip to map out consecutive beats and see whether
the rate is the same further along the ECG.
Measure ventricular rhythm by measuring the R-R interval and atrial rhythm
by measuring P-P interval
 Rythm

Atrial Fibrilation
Irregularly irregular rhythm, no visible P waves,
QRS occur irregularly with its length usually < 0.12s
Rythm
 Rythm

Atrial Flutter

Similar to Atrial fibrilation, but have flutter waves,

ECG baseline adapts ‘saw-toothed’ appearance’.
Occurs with atrioventricular block (fixed degree), eg:
3 flutters to 1 QRS complex:
 Rythm

Ventricular Fibrillation

QRS is chaotic, wide, bizarre, irregular. No P wave

 Rythm
Ventricular tachycardia

Fast heart rhythm, that originates in one of

the ventricles- Rate=100-250bpm. P wave
absent, QRS wide
 Rythm

Supraventricular Tachycardia

Atrial and ventricular rate= 150-250bpm

Regular rhythm, P absent, QRS narrow
 Rythm
Atrial premature beat (APB)

Arises from an irritable focus in one of the atria. APB

produces different looking P wave, because
depolarization vector is abnormal. QRS complex has
normal duration and same morphology .
 Rythm

Premature Ventricular Complexes (PVCs)

The heartbeat is initiated by the heart ventricles(arrow)

rather than by the sinoatrial node, Rate depends on
underlying rhythm and number of PVCs. Occasionally
irregular rhythm, no p-wave associated with PVCs. May
produce bizarre looking T wave.
Cardiac axis
 Cardiac axis
The cardiac axis refers to the general direction of the heart's
depolarization wavefront (or mean electrical vector) in the frontal
plane. With a healthy conducting system the cardiac axis is related to
where the major muscle bulk of the heart lies.

Electrical impulse that travels towards the electrode produces an

upright (positive) deflection (of the QRS complex) relative to the
isoelectric baseline. One that travels away produces negative
deflection. And one that travels at a right angle to the lead, produces a
biphasic wave.
 Cardiac axis
To determine cardiac axis look at QRS complexes of lead I, II, III
Axis Lead I Lead II Lead III

Normal Positive Positive Positive/Negative

Right axis Negative Positive Positive

deviation

Left axis Positive Negative Negative

deviation
Cardiac axis

Normal Axis
Cardiac axis

Left Axis Deviation

Cardiac axis

Right Axis Deviation

P wave
P wave

Normal P- wave
3 small square wide, and 2.5 small square high.
Always positive in lead I and II in NSR
Always negative in lead aVR
Commonly biphasic in lead V1
P wave
P pulmonale
Tall peaked P wave. Generally due to enlarged right
atrium- commonly associated with congenital heart’
disease, tricuspid valve disease, pulmonary
hypertension and diffuse lung disease.

Biphasic P wave
Its terminal negative deflection more than 40 ms wide
and more than 1 mm deep is an ECG sign of left atrial
enlargement.

P mitrale
Wide P wave, often bifid, may be due to mitral
stenosis or left atrial enlargement.
PR interval
PR interval

Long PR interval may

indicate heart block

Short PR interval may

disease like Wolf-
Parkinson-White
PR-Interval 3-5 small
square (120-200ms)
PR interval

First degree heart block

P wave precedes QRS complex but P-R intervals

prolong (>5 small squares) and remain constant
from beat to beat
 PR interval
Second degree heart block

1. Mobitz Type I or Wenckenbach

First P-R interval is often normal. With successive beat,

P-R interval lengthens until there will be a P wave with no
following QRS complex
 PR interval
Second degree heart block

2. Mobitz Type 2

P-R interval is constant, duration is normal/prolonged. Periodically,

no conduction between atria and ventricles- producing a p wave
with no associated QRS complex. (blocked p wave)
 PR interval

Third degree heart block (Complete heart block)

No relationship between P waves and QRS complexes

Atrial rate= 60-100bpm.Ventricular rate based on site of
escape pacemaker. Atrial and ventricular rhythm both
are regular.
QRS Complex
 QRS complex
Left Bundle Branch Block (LBBB) Right bundle branch block (RBBB)
indirect activation causes left ventricle contracts later indirect activation causes right ventricle contracts
than the right ventricle. later than the left ventricle

QS or rS complex in V1 - W-shaped Terminal R wave (rSR’) in V1 - M-shaped

RsR' wave in V6- M-shaped Slurred S wave in V6 - W-shaped
ST segment
ST segment
NORMAL ST SEGMENT

ST segment < 2-3 small square (80 to 120 ms)

 ST segment

Abnormality

ST elevation ST depression
•Acute MI •Acute MI
•Acute pericarditis •Ventricular hypertrophy with strain
•Prinzmetal angina •Digoxin toxicity
•Ventricular aneurysm
Q wave
 Q wave

Pathological Q wave

Characteristics • Cause
•Deep >2 mm • MI
•Wide >.04 sec (1 small square) • Ventricular hypertrophy
•Q wave > 25% of the following • Cardiomyopathy
R wave of same lead
• LBBB
• Emphysema
• Q only in LIII in
Pulmonary embolism
Myocardial
Infarction
 Myocardial infarction
Any 2 criteria out of 3 to be fulfilled for diagnosing MI
1. Typical symptom
2. ECG change
3. Troponin I

In this section we will discuss briefly about ECG

changes in MI
Myocardial infarction
Criteria:
•ST elevation in > 2 chest leads > 2mm
elevation
•ST elevation in > 2 limb leads > 1mm
elevation
•Q wave > 0.04s (1 small square).
 Myocardial infarction
• Only pathological Q wave: Old MI

• Only ST elevation/Depression: Acute MI

• Pathological Q wave + ST elevation/Depression: Acute MI

 Myocardial infarction
Site of MI Lead with ECG Affected
changes coronary artery

Anterior V1, V2, LAD

Septum V3, V4 LAD

Antero septal V1, V2, V3, V4 LAD

Lateral I, aVL, V5 and or V6 Left circumflex

Inferior II, III, aVF RCA

Right atrium aVR, V1 RCA
 Acute MI (Inferior)
Pathological Q and ST elevation in II, III, aVF
 Old MI (Inferior)
Pathological Q in II, III, aVF. No ST elevation
 Acute anteroseptal MI
Pathological Q and ST elevation in V1-V4
 Old MI (Anteroseptal)
Pathological Q and in V1-V4, No ST elevation
LVH and RVH
 Left ventricular hypertrophy
• To determine LVH, use one of the following Criteria
Sokolow & Lyon Criteria: S (V1) + R(V5 or V6) > 35mm
Cornell Criteria: S (V3) + R (aVL) > 28 mm (men) or > 20 mm
(Female)
Others: R (aVL) > 13mm

S (V1) + R(V5) = 15 + 25 = 40mm

S(V3) + R (aVL)= 15 + 14 =29mm
R(aVL) =14 mm
 Right ventricular hypertrophy
Right axis deviation (QRS axis >100o)
V1(R>S), V6 (S>R)
R in V1 >7 small square
Right ventricular strain T wave inversion
Hypokalaemia
&
Hyperkalaemi
a
HYPERKALAEMIA

Narrow and tall peaked T wave (A) is an early sign

PR interval becomes longer
P wave loses its amplitude and may disappear
QRS complex widens (B)
When hyperkalemia is very severe, the widened QRS complexes merge with their
corresponding T waves and the resultant ECG looks like a series of sine waves (C).
If untreated, the heart arrests in asystole

HYPOKALAEMIA
T wave becomes flattened together with appearance of a prominent U
wave.
The ST segment may become depressed and the T wave inverted.
these additional changes are not related to the degree of hypokalemia.