Introduction to ECG reading
Dr. Sadiq Ameen
Emergency physician
Content
• Definition of Electrocardiography. • ECG leads system.
• Anatomy of the heart. • ECG paper and Ink.
• Electrophysiology of the heart and • The Basic beats.
vectors • How to read an ECG systematically.
• Normal sinus rhythm
Basic Rules
• The only way to learn electrocardiography is to look at thousands of ECGs and answer
the question, “sick or not sick.
• The ECG MUST be interpreted within the context of the clinical presentation,
including information such as the patient’s age, chief and secondary complaints,
physical examination, and other diagnostic test results.
• ECG interpretation is personnel dependent.
Basic Rules
• Clinical judgment has a very important role in the interpretation of the ECG within
the individual clinical event.
• The ECG can provide information to confirm a diagnosis, rule out a diagnosis, risk
stratify certain conditions, provide an indication for therapy, and predict
complications.
• The ECG has numerous limitations in the various clinical scenarios in which it is used.
An awareness of these limitations is vital to the correct application of the ECG in
clinical care.
Definition of Electrocardiography
• Electrocardiography (ECG) is the simple diagnostic test which records the electrical
activity of the heart over a set time period via the process of attaching a series of
electrodes at particular points on a patient’s body.
History of ECG
Why ECG ?
Clinical applications of the ECG
Assessing the end-organ impact of a syndrome
Assessing the impact of therapy
Continuous or intermittent cardiac monitoring
Determining inpatient disposition location
Establishing a diagnosis
Guiding additional diagnostic studies
Guiding management
Predicting risk of cardiovascular complication
Providing an indication for certain therapies
Ruling out a syndrome
Clinical reasons for obtaining a 12-lead ECG
Toxicology
Diaphoresis
3%
9%
AMS
5% Chest pain
29%
Dizziness
7%
Syncope
6%
Arrythmia
7%
Dyspnea
Palpiatations 22%
4%
Nausea / Vomiting
9%
Impacts of the 12-lead ECG on diagnostic, therapeutic,
and disposition issues in ED
Change to discharge CXR Rule-out MI protocol
2% 5% 3%
Change to admission
11%
Change to observation Other test
1% 21%
Serum marker…
Aspirin
8%
Heparin
5%
Serial ECG
18%
Antianginal
5%
Reperfusion
1%
Other therapy…
What is the Diagnosis ?
What is the Diagnosis ?
Limitation of ECG
• Normal ECG does not rule out
• Prior MI
• Acute MI
• Severe coronary artery disease
• Significant LVH
• Significant right ventricular hypertrophy (RVH)
• Intermittent arrhythmias such as paroxysmal atrial fibrillation (AF), paroxysmal
supraventricular tachycardia (PSVT), ventricular tachycardia (VT), and bradycardias
• Acute pulmonary embolism
• Pericarditis, acute or chronic
• Pacemaker
Anatomy of the Heart
• Gross Anatomy.
• Anterior view.
• Cross section.
Anatomy of the heart (Cont’)
• The heart as a pump
Anatomy of the heart (Cont’)
The Electrical Conduction System:
Component of the conduction system and their vascular supply
Anatomy of the heart (Cont’)
Blood Supply:
Schematic Overview of the coronary arteries and their relation to ECG
Electrophysiology of the Heart
• Action Potential of the cardiac muscle:
• A.P include depolarization (activation), and repolarization (recovery).
• Occurs in all cardiac muscles BUT its appearance depends on the cell type.
• Propagation of the A.P is equal to spread of an electrical current.
• All the tissues surrounding the heart contain abundance of ions, so act as a
conductors to the skin detected by electorodes.
Electrophysiology of the Heart
Electrophysiology of the Heart
• Automaticity of the pacemaker cells:
• Leakage of Na into the cells during resting phase (pacemaker potential)
• Cell depolarizes when threshold is reached at _40 mv ( calcium channels open
and flow into the cells).
• Outward flow of potassium causes the repolarization.
Electrophysiology of the Heart
Absolute and relative refractory periods during action potential:
Electrophysiology of the Heart
Electrical Vector:
Electrical vector is a physical quantity which has both magnitude and direction in
space and equal to the average direction of the impulse
Electrical Vectors of the Heart
How to Record Good Quality ECG ?
• Supine position
• Head at a 30-45º tilt
• On a couch, wide enough to
accommodate both arms comfortably
• Relaxed and still
Types of Surface ECG electrodes
How to Record Good Quality ECG ?
How to Record Good Quality ECG ?
Causes of Poor Quality ECG ?
Type of ECG systems
• 3-leads ECG
• 5-leads ECG
• 12-leads ECG (standard ECG and Rt-sided ECG)
• 15-leads ECG (used in PWMI).
ECG leads Classification
3-Leads ECG
5-Leads ECG
12-Leads ECG
12-Leads ECG
15-Leads ECG (Posterior ECG)
15-Leads ECG (Posterior ECG)
Indications:
Changes in V1-V3
• Horizontal STD
• Tall, broad R wave > 30 ms
• Upright T waves
• Dominant R wave (R/S ratio >1) in V2
Right-sided ECG
Indications:
IWMI +
• STE in V1
• STE in V1 & STD in V2 (highly specific)
• Isoelectric V1 & marked STD in V2
• STE in III > II
ECG Paper & Ink
ECG Paper & Ink
ECG Paper & Ink
ECG Paper & Ink
SYSTEMATIC INTERPRETATION
OF ECG
Systemic Interpretation
Rule of Fours:
• Four Initial features to look for on an ECG
• Four waves or complexes on ECG
• Four intervals or segments on ECG
Systemic Interpretation
Four Initial features to look for on an ECG:
• History and clinical picture, patient identifiers, standardization and technical errors.
• Rate
• Rhythm
• Axis
Systemic Interpretation
Four waves or complexes on ECG:
• P wave: Positive in lead II, P pulmonale or P mitrale
• QRS complexes: Q wave and RR progression.
• T wave.
• U wave
Systemic Interpretation
Four intervals or segments on ECG:
• PR interval
• QRS width (interval)
• ST segment (interval)
• QT interval
Basic Beats
• Wave: is a deflection from the baseline that represents some cardiac event.
• Segment: is a specific portion of the complex as it is represented on the ECG.
• Interval: is the distance, measured as time, occurring between two cardiac events.
Basic Beats
Technical Errors
1) Limb lead reversal.
2) Dextrocardia.
3) High placement of V1 – V2.
4) Artifacts.
Limb lead reversal (Rt-Lt arm)
• Lead I becomes completely inverted (P, QRS, T)
• Lead II and III switches places.
• Leads aVL and aVR switches places.
• Leads aVF remains unchanged.
• Lead aVR often becomes positive
Limb lead reversal (Rt-Lt arm)
Dextrocardia
• Positive QRS complexes with upright P wave in aVR.
• Right axis deviation.
• Lead I: Global negativity.
• Absent R wave progression in the chest leads.
What is the diagnosis?
What is the diagnosis?
High placement of V1 – V2
Produce the following:
• IRBBB (rSr’ pattern).
• Old septal MI.
• False STEMI.
• Brugada – Type 2.
• T wave inversion
High placement of V1 – V2 - IRBBB
High placement of V1 – V2 – Old Septal MI
High placement of V1 – V2 – False STEMI
High placement of V1 – V2 – Brugada- 2 pattern
High placement of V1 – V2 – T wave inversion
Artifacts
Rate
Rhythm
Axis
Axis Interpretation
• Quadrant Method
• Three lead analysis
• Isoelectric lead analysis
• Super SAM the axis Man
Axis Interpretation
Quadrant Method:
Possible LAD > look for
lead II
Axis Interpretation
Axis Interpretation
P wave
P wave
Lead V1 Lead II
Normal
Left Atrial Enlargement
Right Atrial Enlargement
QRS Complexes
• Q wave abnormalities.
• Dominant R wave in V1
• Dominant R wave in aVR
• Poor R wave progression
QRS Complexes
QRS Complexes
Causes of Dominant R in aVR:
• Left/right arm lead reversal
• Dextrocardia
• Ventricular tachycardia
• Na channel toxicity (TCA)
QRS Complexes
T wave
Characteristic of normal T wave: T wave abnormalities:
• Upright in all leads except aVR and V1 • Peaked T wave
• Hyperacute T wave
• Amplitude <5 mm in limb leads, <
• Inverted T wave
10mm in precordial leads.
• Biphasic T wave
• Camel hump T wave
• Flattened T wave
PR interval
Characteristic of normal PR interval: PR interval abnormalities:
• Duration: 120 – 200 ms • Prolonged PR : FHB, Mobitz I
• Short PR: junctional, Pre-excitation
QRS interval
Characteristic of normal QRS interval: QRS interval abnormalities:
• Duration: < 100 ms normally • Wide QRS: > 120 msec
• High voltage QRS.
• Low voltage QRS.
• Electrical alternans.
ST Segment
Normal Sinus Rhythm
• Regular rhythm at rate of 60 – 100 bpm (age appropriate)
• Each QRS complex is preceded by a normal P wave
• Normal P wave axis: upright P in I and II, inverted in aVR
• The PR interval remains constant
• QRS complex is less than 100 msec unless IVCD is present.
We do not rise to the level of our expectations. We fall to
the level of our training
