ECG Examination and
Interpretation
Citra Ayu Aprilia, MD
Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Impulse Conduction & the ECG
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Pacemakers of the Heart
SA Node - Dominant pacemaker with an
intrinsic rate of 60 - 100 beats/minute.
AV Node - Back-up pacemaker with an
intrinsic rate of 40 - 60 beats/minute.
Ventricular cells - Back-up pacemaker
with an intrinsic rate of 20 - 45 bpm.
The PQRST
P wave - Atrial
depolarization
QRS Ventr. depolarization
T wave - Ventricular
repolarization
Atrial repolarization
hidden by QRS
The ECG Paper
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
How to Analyze An ECG
ECG
ECG Analysis
Step 1: Determine rythm
Step 2: Calculate rate.
Step 3: Asess QRS axis
Step 4: Assess the P waves.
Step 5: Determine PR interval.
Step 6: Determine QRS
Step 7: Determine ST segment
Step 8: Asess the T waves.
Normal Sinus Rhythm (NSR)
Etiology: the electrical impulse is formed
in the SA node and conducted normally.
This is the normal rhythm of the heart;
other rhythms that do not conduct via the
typical pathway are called arrhythmias.
NSR Parameters
Rate
60 - 100 bpm
Regularity regular
P waves
normal
PR interval 0.12 - 0.20 s
QRS duration
0.04 - 0.12 s
Any deviation from above is sinus tachycardia,
sinus bradycardia or an arrhythmia
Determine regularity
R
Look at the R-R distances (using a caliper or
markings on a pen or paper).
Regular (are they equidistant apart)?
Occasionally irregular? Regularly irregular?
Irregularly irregular?
Interpretation?
Regular
Arrhythmia Formation
Arrhythmias can arise from problems in
the:
Sinus node
Atrial cells
AV junction
Ventricular cells
SA Node Problems
The SA Node can:
fire too slow
fire too fast
Sinus Bradycardia
Sinus Tachycardia
Sinus Tachycardia may be an appropriate
response to stress.
Rhythm #1
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
30 bpm
regular
normal
0.12 s
0.10 s
Interpretation? Sinus Bradycardia
Sinus Bradycardia
Deviation from NSR
- Rate
< 60 bpm
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
130 bpm
regular
normal
0.16 s
0.08 s
Interpretation? Sinus Tachycardia
Sinus Tachycardia
Deviation from NSR
- Rate
> 100 bpm
Sinus Tachycardia
Etiology: SA node is depolarizing faster
than normal, impulse is conducted
normally.
Remember: sinus tachycardia is a
response to physical or psychological
stress, not a primary arrhythmia.
Calculate Rate
Option 1
1500 / small boxes (R R interval)
300 / large boxes (R R interval)
Calculate Rate
R wave
Option 2
Find a R wave that lands on a bold line.
Count the # of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes 100, 4 boxes - 75, etc. (cont)
Calculate Rate
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0
Option 2 (cont)
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50
Interpretation? Approx. 1 box less than
100 = 95 bpm
Calculate Rate
3 sec
3 sec
Option 3
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.
Reminder: all rhythm strips in the Modules
are 6 seconds in length.
Interpretation? 9 x 10 = 90 bpm
ECG Lead
Assess the P waves
Are there P waves?
Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation? Normal P waves with 1 P
wave for every QRS
Atrial Depolarization
GELOMBANG P
a. Lebar kurang dari 0,12 detik
b. Tinggi kurang dari 0,25 mv
c. Selalu Positif di lead II
d. Selalu negative di lead AVR
Abnormality of P wave
PR Interval
P R Interval :
Diukur dari permulaan gelombang P
sampai permulaan gelombang QRS
Normal : 0,12 0,20 detik
Ventricle Depolarization
Gelombang QRS :
Normal : lebar tidak melebihi 0,12
Tinggi tergantung lead
Gelombang QRS terdiri dari gel Q,
Gel R dan gelombang S
QRS
Q wave
1st negative deflection
< 0,25 mv and/or < 0.04 s
R wave
1st positive deflection
S wave
2nd negative deflection
LVH
LVH in response to pressure overload
2ndary to cond, AS, and HT
Result R wave amplitude in the left
leads (I, aVL, and V4-6) and dept in
right leads (III, aVR, V1-3)
Thickened LV wall prolonged depol
R wave peak time and delayed depol
(ST-T wave abnormalities) in the lat leads
Segmen ST
Diukur dari akhir QRS s/d awal gel T
Normal :
Isoelektris
Kepentingan : Elevasi pd injuri/infark akut
Depresi pd iskemia
NON STEMI
STEMI
Non-ST Elevation Infarction
Heres an ECG of an inferior MI later in time:
Now what do
you see in the
inferior leads?
ST elevation,
Q-waves and
T-wave
inversion
Non-ST Elevation Infarction
The ECG changes seen with a non-ST elevation infarction are:
Before injury Normal ECG
Ischemia
ST depression & T-wave inversion
Infarction
ST depression & T-wave inversion
Fibrosis
ST returns to baseline, but T-wave
inversion persists
Non-ST Elevation Infarction
Heres an ECG of an evolving non-ST elevation MI:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.
Question:
What area of
the heart is
infarcting?
Anterolateral
UAP/Acute NSTEMI
61
Views of the Heart
Some leads get a
good view of the:
Anterior portion
of the heart
Inferior portion
of the heart
Lateral portion
of the heart
Injury
Prolonged ischemia > few minutes
injury
Do not depol completely electrically
more positive than in uninjured areas
elevation of ST segment
ST Elevation
One way to
diagnose an
acute MI is to
look for
elevation of
the ST
segment.
ST Elevation (cont)
Elevation of the
ST segment
(greater than 1
small box) and >
0.04 s in 2 leads
is consistent with
a myocardial
infarction.
Anterior View of the Heart
The anterior portion of the heart is best
viewed using leads V1- V4.
Anterior Myocardial Infarction
If you see changes in leads V1 - V4
that are consistent with a myocardial
infarction, you can conclude that it is
an anterior wall myocardial infarction.
Putting it all Together
Do you think this person is having a
myocardial infarction. If so, where?
Interpretation
Yes, this person is having an acute anterior
wall myocardial infarction.
Other MI Locations
Now that you know where to look for an
anterior wall myocardial infarction lets
look at how you would determine if the MI
involves the lateral wall or the inferior wall
of the heart.
Other MI Locations
First, take a look
again at this
picture of the heart.
Anterior portion
of the heart
Inferior portion
of the heart
Lateral portion
of the heart
Other MI Locations
Second, remember that the 12-leads of the ECG look at different
portions of the heart. The limb and augmented leads see
electrical activity moving inferiorly (II, III and aVF), to the left (I,
aVL) and to the right (aVR). Whereas, the precordial leads see
electrical activity in the posterior to anterior direction.
Limb Leads
Augmented Leads
Precordial Leads
Other MI Locations
Now, using these 3 diagrams lets figure where
to look for a lateral wall and inferior wall MI.
Limb Leads
Augmented Leads
Precordial Leads
Anterior MI
Remember the anterior portion of the heart is
best viewed using leads V1- V4.
Limb Leads
Augmented Leads
Precordial Leads
Lateral MI
So what leads do you think
the lateral portion of the
heart is best viewed?
Limb Leads
Leads I, aVL, and V5- V6
Augmented Leads
Precordial Leads
Inferior MI
Now how about the inferior
portion of the heart?
Limb Leads
Leads II, III and aVF
Augmented Leads
Precordial Leads
Putting it all Together
Now, where do you think this person is
having a myocardial infarction?
Inferior Wall MI
This is an inferior MI. Note the ST elevation
in leads II, III and aVF.
Putting it all Together
How about now?
Right MCI
Right sided chest leads
The most useful lead: V4R
The V4R should be recorded with
inferior infarction
Anterolateral MI
This persons MI involves both the anterior wall
(V2-V4) and the lateral wall (V5-V6, I, and aVL)!
Right MCI
Posterior MCI
ST segment depression and tall R
waves in the ant leads in V1 post
infarts are the mirror images of ant
infarct on ECG
ST segment elevation in V7 V9
T wave
Ventr repol
More time
than depol
+ U waves
additional
repol wave
Hyperkalemia
Tall, thin, pointed
(peak) T waves
Prolonged PR interval
Duration of QRS
complex
QT interval
Seluruh waktu depol dan repol ventrikel.
Waktu lamanya potensial aksi ventrikel
Dapat merupakan tanda dr bbrp jenis
aritmia ventrikel
Berubah dg HR interval <
QTc = QT / RR (0.44 s)
Prolonged in hypocalcemia
Rate Rhythm Axis
Intervals Hypertrophy Infarct
QT = 0.40 s
RR = 0.68 s
Square root of
RR = 0.82
QTc = 0.40/0.82
= 0.49 s
QTc
PR
QRS
0.16
0.08
0.49
interval?
interval?
width?
seconds
seconds
Interpretation
of seconds
Normal PR and
QRS, long
intervals?
QT
Atrial Cell Problems
Atrial cells can:
fire occasionally
from a focus
fire continuously
due to a looping
re-entrant circuit
Premature Atrial
Contractions (PACs)
Atrial Flutter
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
70 bpm
occasionally irreg.
2/7 different contour
0.14 s (except 2/7)
0.08 s
Interpretation? NSR with Premature Atrial
Contractions
Premature Atrial Contractions
Deviation from NSR
These ectopic beats originate in the
atria (but not in the SA node), therefore
the contour of the P wave, the PR
interval, and the timing are different
than a normally generated pulse from
the SA node.
Premature Atrial Contractions
Etiology: Excitation of an atrial cell
forms an impulse that is then conducted
normally through the AV node and
ventricles.
When an impulse originates anywhere in
the atria (SA node, atrial cells, AV node,
Bundle of His) and then is conducted
normally through the ventricles, the QRS
will be narrow (0.04 - 0.12 s).
A re-entrant
pathway occurs
when an impulse
loops and results
in selfperpetuating
impulse
formation.
Atrial Flutter
Deviation from NSR
No P waves. Instead flutter waves
(note sawtooth pattern) are formed at
a rate of 250 - 350 bpm.
Only some impulses conduct through
the AV node (usually every other
impulse).
Atrial Flutter
Etiology: Reentrant pathway in the right
atrium with every 2nd, 3rd or 4th
impulse generating a QRS (others are
blocked in the AV node as the node
repolarizes).
Atrial Cell Problems
Atrial cells can also:
fire continuously
Atrial Fibrillation
from multiple foci
or
Atrial Fibrillation
fire continuously
due to multiple
micro re-entrant
wavelets
Multiple micro reentrant wavelets
refers to wandering
small areas of
activation which
generate fine chaotic
impulses. Colliding
wavelets can, in turn,
generate new foci of
activation.
Atrial tissue
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
100 bpm
irregularly irregular
none
none
0.06 s
Interpretation? Atrial Fibrillation
Atrial Fibrillation
Deviation from NSR
No organized atrial depolarization, so no
normal P waves (impulses are not
originating from the sinus node).
Atrial activity is chaotic (resulting in an
irregularly irregular rate).
Common, affects 2-4%, up to 5-10% if >
80 years old
Atrial Fibrillation
Etiology: multiple re-entrant wavelets
conducted between the R & L atria.
Either way, impulses are formed in a
totally unpredictable fashion.
The AV node allows some of the
impulses to pass through at variable
intervals (so rhythm is irregularly
irregular).
AV Junctional Problems
The AV junction can:
fire continuously
due to a looping
re-entrant circuit
block impulses
coming from the
SA Node
Paroxysmal
Supraventricular
Tachycardia
AV Junctional Blocks
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
74 148 bpm
Regular
regular
Normal none
0.16 s none
0.08 s
Interpretation? Paroxysmal Supraventricular
Tachycardia (PSVT)
Ventricular Cell Problems
Ventricular cells can:
fire occasionally
from 1 or more foci
fire continuously
from multiple foci
fire continuously
due to a looping reentrant circuit
Premature Ventricular
Contractions (PVCs)
Ventricular Fibrillation
Ventricular Tachycardia
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
60 bpm
occasionally irreg.
none for 7th QRS
0.14 s
0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
PVCs
Deviation from NSR
Ectopic beats originate in the ventricles
resulting in wide and bizarre QRS
complexes.
When there are more than 1 premature
beats and look alike, they are called
uniform. When they look different, they are
called multiform.
PVCs
Etiology: One or more ventricular cells
are depolarizing and the impulses are
abnormally conducting through the
ventricles.
When an impulse originates in a
ventricle, conduction through the
ventricles will be inefficient and the
QRS will be wide and bizarre.
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
160 bpm
regular
none
none
wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
Ventricular Tachycardia
Deviation from NSR
Impulse is originating in the ventricles
(no P waves, wide QRS).
Ventricular Tachycardia
Etiology: There is a re-entrant pathway
looping in a ventricle (most common
cause).
Ventricular tachycardia can sometimes
generate enough cardiac output to
produce a pulse; at other times no pulse
can be felt.
Rhythm #9
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
none
irregularly irreg.
none
none
wide, if recognizable
Interpretation? Ventricular Fibrillation
Ventricular Fibrillation
Deviation from NSR
Completely abnormal.
Ventricular Fibrillation
Etiology: The ventricular cells are
excitable and depolarizing randomly.
Rapid drop in cardiac output and death
occurs if not quickly reversed
