ECG Cookbook
Question Answer Diagnosis
1. Rhythm Criteria for sinus rhythm Sinus rhythm or
no sinus rhythm?
1. Are the P waves positive in leads I and II?
2. Is there a QRS complex after each P wave?
3. Are the PR intervals constant?
4. Are the RR intervals constant?
2. Heart rate Estimate heart rate: Heart rate in beats per minute
300 / number of large boxes between two QRS complexes
3. P waves a) Large P-wave amplitude (> 2.5 mm in II, III, or aVF) Right atrial enlargement
b) Prolonged negative part of P wave in lead V1 (1 mm), Left atrial enlargement
P wave with 2 peaks in lead II, P wave duration > 0.12 seconds
4. PR interval a) > 0.2 seconds (if PR interval is constant for all beats and First-degree atrioventricular
each P wave is followed by a QRS complex) (AV) block
b) < 0.12 seconds and normal QRS complex Lown-Ganong-Levine
(LGL) syndrome
c) < 0.12 seconds and visible delta wave Wolff-Parkinson-White
(WPW) syndrome
5. QRS axis Determine the axis according to leads I, II, and aVF. Normal axis
Left axis deviation
Right axis deviation
Northwest axis
6. QRS duration a) ≥ 0.12 seconds (always think of WPW syndrome as Complete bundle
a differential) branch block
b) > 0.1 seconds and < 0.12 seconds with typical bundle Incomplete bundle
branch block appearance (notching) branch block
7. Rotation Rotation is defined according to the heart’s transition zone. Transition zone at V5–V6:
Normally the transition zone is located at V4, which means clockwise rotation
that right ventricular myocardium is located at V1–V3 and left
ventricular myocardium is at V5–V6. Transition zone at V1–V3:
counterclockwise rotation
NOTE: do not evaluate rotation
in the setting of myocardial
infarction, WPW syndrome, or
bundle branch block
8. QRS amplitude a) QRS amplitude < 0.5 mV in all standard leads Low voltage
b) Positive criteria for left ventricular hypertrophy Left ventricular hypertrophy
c) Positive criteria for right ventricular hypertrophy Right ventricular hypertrophy
9. QRS infarction signs Abnormal Q waves, QS waves, missing R-wave progression Myocardial infarction;
localization according to
affected leads
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10. ST-T segment
Tall T wave ST depression ST depression ST elevation Negative T
Hyperkalemia,
QRS normal vagotonia
Probably ischemia
(differential
QRS normal
diagnosis: digitalis)
Nonspecific
repolarization
QRS normal
abnormality
Acute ischemia,
QRS normal perimyocarditis,
variant angina
ST-elevation
myocardial
QRS normal infarction (STEMI) /
perimyocarditis in
resolution
Subacute STEMI,
non-STEMI (NSTEMI),
QRS normal
perimyocarditis
Acute STEMI,
STEMI in resolution,
QRS with Q wave
subacute STEMI
Left ventricular
hypertrophy
QRS: left ventricular
hypertrophy with abnormal
repolarization
In these situations,
an ST-segment
QRS: right ventricular deviation is almost
hypertrophy, bundle branch always present and
block, or WPW syndrome cannot be interpreted
in and of itself. It has
to be left out of the
ECG report.
11. QT duration, a) QT shortening Hypercalcemia
T-U waves
b) QT prolongation Hypocalcemia
c) Tall and peaked T wave Hyperkalemia
d) U wave, ST depression, T-wave flattening, or a combination of these Hypokalemia
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