Step one Heart rate: ECG Box Time Values:

 1 small box = 0.04 seconds = 40 milliseconds (ms)

 1 large box = 5 small boxes
→ 5 × 0.04 s = 0.20 seconds = 200 milliseconds

 So, when you count large boxes between two R waves, you’re measuring time in 0.2-
second increments.

Big Box Method Formula Calculation for heart rate formula is:

👉 Heart Rate = 300 ÷ number of big boxes between R waves

(Since: 300 = 60 seconds ÷ 0.2 seconds per big box)

Small Box Method Formula Calculation for heart rate: Heart Rate (bpm) =
1500 ÷ number of small boxes between two R waves

You count 18 small boxes between the two R waves.

Now apply the formula: Heart Rate = 1500 ÷ 18 = 83.3 bpm So, the heart rate is approximately
83 beats per minute.

Example Big Box Method Formula:

Heart Rate (bpm) = 300 ÷ number of big boxes between two R waves

Example: If you count 4 big boxes between two R wave peaks:

Heart Rate = 300 ÷ 4 = 75 bpm

Step two sinus rhythm:

P wave before any QRS complex

Step three Determine Axis Deviation Look at Leads I and aVF

Lead I Lead aVF Axis Interpretation

Positive Positive Normal Axis (–30° to +90°)
Positive Negative Left Axis Deviation (–30° to –90°)
Negative Positive Right Axis Deviation (+90° to +180°)
Negative Negative Extreme Axis Deviation (–90° to ±180°, also called
“northwest axis”)

🩺 1. Left Axis Deviation (LAD)

QRS axis between -30° and -90°
🔍 Common Causes:
Left anterior fascicular block (most common), Left ventricular hypertrophy
(LVH), Inferior myocardial infarction, Wolff-Parkinson-White (WPW)
syndrome (with right-sided accessory pathway), Congenital heart disease
(e.g., ostium primum ASD)

🧠 Example:
A patient with chronic hypertension develops LVH. ECG shows tall R waves
in V5-V6, and QRS axis of –45°. Diagnosis: Left Axis Deviation due to LVH.

🩺 2. Right Axis Deviation (RAD)

QRS axis between +90° and +180°

🔍 Common Causes:
Right ventricular hypertrophy (RVH), Pulmonary hypertension or pulmonary
embolism
,Chronic lung disease (COPD — “cor pulmonale”), Left posterior fascicular
block ,Lateral myocardial infarction ,Congenital heart disease (e.g.,
Tetralogy of Fallot)
🧠 Example:
A patient with COPD has an ECG showing a QRS axis of +110° and right
atrial enlargement. Diagnosis: Right Axis Deviation due to chronic cor
pulmonale.

🩺 3. Extreme Axis Deviation (“Northwest Axis”)

QRS axis between –90° and ±180°

🔍 Common Causes:
Ventricular rhythms (e.g., ventricular tachycardia)

Severe biventricular hypertrophy ,Hyperkalemia ,Lead misplacement

🧠 Example:
A patient in the emergency department shows a wide QRS, bizarre
morphology, and axis of –150°. Diagnosis: Ventricular tachycardia.

Waves and intervals

P wave: It represents atrial depolarization , the electrical activity that

causes the atria to contract and push blood into the ventricles. It starts
when the sinoatrial (SA) node fires. It counts about (2–3 small boxes).
Normal P Wave Direction: In most leads (especially lead II), the P wave
should be upright. That’s because the SA node fires from the top right
atrium downward toward the AV node. Normal direction always upright in
leads I, II, aVF
In Which Lead Should You Look for P wave Inversion?
Lead II is best to assess P wave axis. Also check aVR and V1 for
morphology.

Abnormal P Waves: May indicate atrial enlargement or atrial arrhythmias.

P Wave Abnormality Possible Cause: (Inverted P wave Ectopic atrial
rhythm or junctional rhythm), (Peaked P wave Right atrial enlargement (P
pulmonale)), (Notched/Broad P wave Left atrial enlargement (P mitrale)),
(Absent P wave Atrial fibrillation or sinoatrial (SA) block).

Shortened/Absent P Waves: Seen in: Junctional rhythms (originating

near or in the AV node), Hyperkalemia (early stages—flattened or absent P
waves)
Sinus tachycardia (shortens ECG intervals due to fast rate), Atrial
fibrosis/scarring

Inverted P Waves: When They Are Abnormal

Inverted P waves typically indicate that the atrial impulse is not originating from the sinoatrial
node but from an abnormal location. The following conditions are associated with inverted or
retrograde P waves:

Condition Description ECG Features

The AV node or nearby tissue acts as
Inverted P waves in
Junctional Rhythm the pacemaker. Impulse travels
leads II, III, and aVF
retrogradely into the atria.
A non-SA atrial site initiates the
Inverted P wave in lead
Ectopic Atrial Rhythm impulse, causing abnormal
II; upright in lead aVR
depolarization.
Atria depolarized after ventricles in P waves appear after the
Retrograde P Waves
junctional rhythms. QRS complex
Atrial Reentrant P waves may be inverted
Retrograde atrial activation via an
Tachycardia / AVRT (e.g., or absent, often
accessory pathway.
WPW Syndrome) following the QRS

Example: Junctional Rhythm: P Wave: Inverted in lead II

PR Interval: Shortened or absent; P wave may appear before, during, or
after the QRS complex. Heart Rate: Typically, 40–60 bpm (reflecting intrinsic
AV nodal rate)

PR interval : It reflects the time it takes for the electrical impulse to travel
from the atria (P wave) through the AV node to the ventricles (start of QRS).
atrial depolarization to ventricular depolarization.

Normal PR Interval: Normal Duration: 0.12 to 0.20 seconds. That’s 120 to

200 milliseconds
Normal PR = 3 to 5 small boxes

Abnormal PR Intervals:
Short PR < 3 boxes May suggest pre-excitation (e.g. WPW syndrome) or AV
junctional rhythm
Prolonged PR > 5 boxes Indicates 1st-degree AV block or delayed
conduction
P-R Interval: Prolonged P-R Interval: Suggests first-degree AV block or other
atrioventricular conduction delays

QRS Complex: Represents ventricular depolarization.

Wide or Irregular QRS: May indicate a bundle branch block or ventricular ectopy or
ventricular rhythm
ST interval: S-T Segment: Elevation or depression in the S-T segment can indicate
myocardial ischemia or infarction.

QT interval It reflects ventricular depolarization and repolarization, and

abnormalities can signal a risk for dangerous arrhythmias like Torsades de
Pointes.
Normal QT Interval Duration:
Normal QT Duration (in seconds):
Men: ≤ 0.44 seconds (440 ms)

Women: ≤ 0.46 seconds (460 ms)

Number of Boxes:
Since each small box = 0.04 seconds (40 ms):

Normal QT = ≤ 11 small boxes (0.44 s) in men

Normal QT = ≤ 11.5–12 small boxes (0.46 s) in women
Always count from beginning of Q wave to end of T wave.
Abnormal QT Interval:
QT Interval Duration (seconds) Small Boxes Interpretation
Short QT < 0.36 sec < 9 boxes Risk of atrial/ventricular arrhythmias
Normal QT 0.36–0.44 sec 9–11 boxes Normal
Borderline prolonged 0.45–0.47 sec 11–12 boxes Needs correlation with
symptoms,
Prolonged QT > 0.47 sec (♂), > 0.48 sec (♀) > 12 boxes
Causes:

o Electrolyte imbalances: Hypokalemia, hypocalcemia, hypomagnesemia

o Medications: Antiarrhythmics, antibiotics, antidepressants, antipsychotics
o Congenital Long QT Syndrome, , Ischemia or myocarditis
 Risks:
o Increased risk of Torsades de Pointes (a form of polymorphic ventricular
tachycardia)

Shortened QT Interval

 Causes:
o Hypercalcemia (most common)
o Short QT Syndrome (genetic channelopathy)
o Digitalis toxicity
o Sympathetic stimulation (e.g., fever, stress)
Because QT changes with heart rate, we use QTc (corrected QT) — most
commonly with Bazett’s formula: QTc=QT/square root of RR
Where: QT = in seconds, RR = time between R waves (in seconds)
Normal QTc values: Men: < 440 ms, Women: < 460 ms
Clinical Insight:
QT interval < 350 ms (QTc) is considered abnormally short.
Torsades de Pointes: A specific and dangerous type of polymorphic ventricular
tachycardia characterized by QRS complexes that appear to "twist" around the isoelectric line.
Causes: Prolonged QT Interval due to:
o Electrolyte imbalances (low K⁺, Mg²⁺, Ca²⁺)
o Medications (that prolong QT)
o Bradycardia
o Congenital Long QT Syndrome
o Drug overdose
Symptoms
 Dizziness
 Palpitations
 Syncope
 Seizure-like activity
 Sudden cardiac arrest
Treatment
 IV Magnesium Sulfate (even if Mg²⁺ is normal)
 Electrolyte correction
 Discontinuation of QT-prolonging drugs
 Emergency Defibrillation (if unstable)
 Implantable Cardioverter-Defibrillator (ICD) or pacing in recurrent cases
S-T Segment: Should be isoelectric, indicating the period between ventricular
depolarization and repolarization.

 Elevation or Depression:
o May signify myocardial ischemia, infarction, or pericarditis.
T wave : Reflects ventricular repolarization.
 Inverted or Flattened T Waves:
o Suggest ischemia or hypokalemia
 Peaked T Waves:
o Often indicate hyperkalemia
 General T Wave Abnormalities: Caused by electrolyte imbalances, ischemia, or
medications
Clinical Insight:T wave changes → Think electrolytes, especially potassium levels.
Summary Table
ECG Feature Abnormality Possible Causes
P Wave Shortened/Absent Junctional rhythm, hyperkalemia, tachycardia
P-R Interval Prolonged AV block
QRS Complex Wide/Irregular Bundle branch block, ventricular origin
S-T Segment Elevation/Depression Ischemia, infarction, pericarditis
T Wave Peaked/Flattened/Inverted Electrolyte imbalances (K⁺), ischemia
Q-T Interval Prolonged Electrolyte imbalance, drugs, Long QT syndrome
ECG Feature Abnormality Possible Causes
Shortened Hypercalcemia, Short QT syndrome, digitalis