ODON M. MALLARI, M.D.

ECG Reading
Is a skill which can be learned with repeated practice.
Cannot be learned by reading a book but rather by
reading ECG tracings.
Easy as pie, Piece of cake
ECG Tracing
Usual speed of tracing = 25 mm/sec
Each mm horizontally is equal to 0.04 secs (1/25 =0.04
secs)
5 small squares = 1 big square
Each big square is equal to 0.2 secs
1 millivolt is equal 10 millimeters vertically
ECG basics
Deflections
Positive
Negative

Equiphasic

Isoelectric
Clinical Value of the ECG

Myocardial ischemia and infarction

Rhythm abnormalities
Chamber hypertrophy
Pericarditis
Electrolyte imbalance
Evaluation of cardiac pacemakers
Determination of the effect of cardiac drugs
12 LEAD ECG
Electrode placement
Limb Leads
RA Red Right arm
RL Black Right leg
LA Yellow Left arm
LL Green Left leg
Chest Leads
V1 Red 4th ICS RPSB
V2 Yellow 4th ICS LPSB
V3 Green Midway between V2 and
V4
V4 Brown 5th ICS LMCL
V5 Black 5th ICS LAAL
V6 Violet 5th ICS LMAL
12 LEAD ECG
 Chest Leads
V1 Red 4th ICS RPSB
V2 Yellow 4th ICS LPSB
V3 Green between V2
and V4
V4 Brown 5th ICS LMCL
V5 Black 5th ICS LAAL
Anatomy
 LAYERS OF THE HEART WALL
 Epicardium
Coronary arteries are found in
this layer
 Myocardium
Responsible for contraction of
the heart
 Endocardium
Lines the inside of the
myocardium
Covers the heart valves
 60 to 100 beats per
minute
 triggered by
electrical impulses
 heart's natural
pacemaker, called
the sinoatrial node
(SA node)

THE NORMAL ELECTROCARDIOGRAM
P wave
 Generated by activation of the atria

PR segment
 Represents the duration of
atrioventricular (AV) conduction
QRS complex
 Produced by activation of both
ventricles
ST-T wave
 Reflects ventricular recovery
 TERMINOLOGY
 Waveform
Movement away from the
baseline in either a positive or
negative direction
 Segment
A line between wave forms
 Interval
A waveform and a segment
 Complex
Consists of several waveforms
STANDARD 12 LEAD ECG
 The P wave
Atrial activation
Height < 0.2 mV (2 mm)
Duration < 0.12 sec
STANDARD 12 LEAD ECG
 P-R Interval
Intraatrial, internodal,
His purkinje conduction
Duration 0.12 to 0.20 or
0.22 sec
STANDARD 12 LEAD ECG
 The QRS Complex
Ventricular activation
Duration of 0.10 sec
STANDARD 12 LEAD ECG
 The ST-segment
Phase 2 of
transmembrane potential
Isoelectric in normal
subjects
STANDARD 12 LEAD ECG

 The T wave
Upright after the age of 16
Juvenile T wave
STANDARD 12 LEAD ECG
 The U wave
Surface reflection of
negative after potential
Repolarization of Purkinje
fibers
Ventricular relaxation
ECG READING PATTERN
I. RATE
II. RHYTHM
III. AXIS
IV. HYPERTROPHY
V. ISCHEMIA/INFARCTION
VI. MISCELLANEOUS
Rate
Normal: 60 – 100 beats per minute
ECG speed= 25mm/sec
Normal rate: 3 to 5 big squares
< 3 squares between R waves = tachycardia
> 5 squares between R waves = bradycardia
Rate
By formula
300 divided by # of big squares
1500 divided by # of small squares
By six second strip(can be used for regular and irregular
rhythms)
multiply number of R waves by 10
By memorizing(eyeballing) 300, 150, 100, 75, 60, 50
Diagnosis: Sinus Bradycardia
P – P interval regular and > 5 big squares
Each P is followed by a QRS complex
PR interval is fixed and constant
Rate interpretation has 3 possibilities
Bradycardia(<60 beats per minute)
Normal rate(60-100 per minute)
Tachycadia(>100 beats per minute)
Sinus Tachycardia

P – P interval is regular and < 3 big squares

Each P wave is followed by a QRS complex
I. Disturbance in Impulse Formation

II. Disturbance in Conduction

III. Pacemaker rhythm

I. Disturbance of Impulse Formation
A. Disturbance of Sinus Impulse formation(Sinus Node
Dysfunction)
1) Sinus tachycardia

2) Sinus bradycardia

3) Sinus arrhythmia

4) Sinus Arrest(pause or standstill)

B. Disturbance of Ectopic Impulse formation
1) Atrial in origin
a. Premature atrial contractions(extrasystoles)
b. Reentrant atrial tachycardia
c. Atrial tachycardia with AV block
d. Atrial flutter
e. Atial fibrillation
f. Ectopic atrial mechanism
g. Wandering atrial pacemaker
h. Multifocal atrial tachycardia
2) A-V junctional in origin
a. Premature junctional complexes
b. A-V junctional rhythm
c. Paroxysmal supraventricular tachycardia
3) Ventricular in origin
a. Premature ventricular contractions(extrasystoles)
b. Idioventricular rhythm
c. Ventricular tachycardia
d. Ventricular fibrillation
II. Disturbance of Conduction
A. Sinoatrial Block(Sinus Exit Block)
B. AV Nodal Block
1. First degree(PR interval >0.20 sec)
2. Second degree
a) Mobitz type
i. Mobitz type I(Wenckebach)
ii. Mobitz type II
b) Fixed high grade type
3. Third degree or complete heart block
 C. Intraventricular Block
1. Right bundle branch block
2. Left bundle branch block

3. Trifascicular block

4. Nonspecific intraventricular block

D. Ventricular Pre-excitation
III. Pacemaker rhythm
Rhythm analysis
Identify the P wave- determine from the
configuration if this is a sinus P
Check the relation of P wave to QRS
P wave is before QRS(normal)
P wave is buried or after QRS
Check PR interval(normal PR interval: 0.12-0.20 sec)
Short PR(WPW) syndrome
Normal PR
Prolonged PR(1st or 2nd degree AV block)
Check QRS duration(normal QRS duration < 0.10 sec)
Normal QRS
Wide QRS(bundle branch blocks)
Check the relation of R-R interval and P-P interval
Equal R-R and P-P interval(normal)
P-P interval shorter than R-R interval(complete heart
block)
P-P interval longer than R-R interval(AV dissociation)
Sinus Arrhythmia
P – P interval gradually increase and decrease.
Difference of longest and shortest P – P interval is
0.16 sec.
PR interval is constant
Each P wave is followed by a QRS complex
Premature Atrial Contractions
Premature depolarization
P’ morphology different from regular P waves
The interval between the sinus P waves preceding
and following a PAC is less than twice the normal P-P
interval (non fully compensatory pause)
Atrial Flutter

Saw toothed “Flutter waves” - regular negative

deflections in leads II, III and aVF
R-R interval may be constant or variable
Supraventricular tachycardia
Synonymous with AVNRT
Regular tachycardia
Narrow QRS complex
ST segment depression may be seen
P waves may be buried or after QRS complex
Multifocal Atrial Tachycardia ( MAT)
Irregular atrial rhythm  irregular ventricular
rhythm
Atrial rate 100 – 180 / min.
Varying P-P interval
Varying P-R interval
Varying R-R interval
3 consecutive P waves of different morphology at
a rate >100/min. in a single lead.
Atrial Fibrillation

No P waves
“f” waves – undulating deflections of varying sizes
and shapes
Irregularly irregular ventricular contractions
(varying R-R interval)
PR Interval
0.12 – 0.20 secs in duration
Normal = “3-5 small squares”
Represents AV node transit
Shortened: Pre-excitation Syndromes
Prolonged: First degree AV block
Wolff – Parkinson – White Syndrome

Short PR interval (< 0.12 sec).

Normal P wave vector
Presence of delta wave
QRS duration > 0.10 sec.
First Degree AV Block (1 AVB)

PR interval prolonged (>0.20 sec)

PR interval constant
P-P and R-R interval constant
Each P wave is followed a QRS complex
2 AVB, Mobitz Type I
(Wenckebach)

Progressively prolonging PR interval then

followed by a dropped beat
“Grouped beating”
Decreasing R-R interval
P-P interval is constant
2 AVB, Mobitz Type II

PR interval is normal or sl. Prolonged

PR interval is usually fixed and constant
Dropped beat in a regular intervals.
Third Degree AV block (3AVB)

R-R interval constant

P-P interval constant
P-R interval variable
Dissociation of Atrial and Ventricular
depolarizations
Premature Ventricular Contraction

Premature depolarization with no P wave

Widened QRS with displaced T waves and ST
segments
Idioventricular Rhythm

Rate: 30 – 40 /min.
No P waves
Widened QRS complexes
Abnormal ST segments and secondary T wave
changes
Ventricular Tachycardia (VT)
3 successive ventricular ectopic beats in a rate
>100 /min.
Widened QRS complexes
Distinct ST segments and T waves may not be
evident
Independent P waves but usually obscured
Torsades de Pointes
Ventricular Fibrillation

Chaotic ventricular rhythm

No P waves noted
Rapid irregular rhythm with no distinct
complexes
QRS Complex
Represents ventricular depolarization
0.05 – 0.10 secs in duration
Widening = intraventricular conduction defect :
RBBB, LBBB
Increased size: Hypertrophy
Complete Right Bundle Branch Block
QRS > 0.12 sec
Slurred S waves in Lead I, V5-6
RSR’ pattern in V1-2
Wide, Slurred R waves in V1-2
ST depression, T wave depression in V1-2
Complete Left Bundle Branch Block
QRS > 0.12 secs.
No q wave in Lead I, V5-6
QRS complex wide, notched, or slurred
QRS upright in leads I, V5-6
ST depression and T wave inversion in leads I, V5-6
Axis
Plotting Lead I – avF Method
By quadrant Lead I – avF method
By Lead I, II, III method
By equiphasic method
 Right Left
atrium atrium

Composed of two waves (of depolarization)

P wave
Not to exceed 0.10 secs in duration
Not to exceed 2.5 mm in height
Normal = “2. 5 X 2.5 small squares”
Prolonged duration = LAE
Increased height = RAE
“Height is for right”
Right Atrial Enlargement

P wave > 2.5 mm in lead II

Frontal plane P wave shifted rightward (>+75)
Left Atrial Enlargement
P wave duration  0.11 sec
Notched P wave
Frontal plane P wave vector shifted leftward (0 to
-30)
Biphasic P wave in Lead V1 ( 0.04 sec. and 1 mm
in depth)
Left Ventricular Hypertrophy
Sum of S wave in V1 or V2 and R wave in V5 or V6
>35 mm or
Sum of highest R and deepest S wave in
precordial leads > 45 mm or
R wave in V6  18 mm or
R wave in aVL  12 mm or
Sum of R wave in I and S wave in III  16 mm or
R wave in lead I  14 mm
Right Ventricular Hypertrophy
RAD > +110 w/o RBBB, LPIB or anterolateral or
inferior MI
Dominant R wave >7 mm in Lead V1
R/S ratio in lead V1  1.0
R/S ratio in V5 or V6 ,  1.0
RSR pattern in lead V1 with a QRS duration of <0.12
sec.
Combined LVH and RVH
Voltage changes in the precordial leads
“diagnostic” of both LVH and RVH
Voltage criteria of LVH +
RAD > +110 or
R/S ratio in V1  1.0
 to 7 mm R wave in V1 or
Deep S wave in V6 or
RAE + vertical mean QRS axis
Combined LVH and RVH
Voltage criteria for RVH +
R/S ratio in V2-V4 and/or in 2 or more
limb leads of nearly 1.0 (Katz-
Wachtel Sign)
Large R waves in V5 or V6 with strain
pattern and LAE
V. ISCHEMIA/INFARCTION
Acute Myocardial Infarction
Myocardial infarction
Abnormal Q waves or ST-T wave changes in:
II, III, aVF : inferior wall MI
V1 – V3 : anteroseptal wall MI
I, aVL, V4-V6 : lateral wall MI
V1 or V2 to V6 : anterolateral wall MI
Hyperkalemia
Serum K: 5.5 – 6.6 mEq/L
-Tall, peaked, narrow T waves in
precordial leads
-Deep S wave in Lead 1 and V6
-QRS complex usually normal
Hyperkalemia
Serum K: 7.0 – 8.0 mEq/L
-QRS widening
-Slurring of both initial and terminal
portions of the QRS
-ST segment elevation
-Low, wide P waves
-1st and 2nd degree AVB
-Atrial arrest
-Bradycardia
Hyperkalemia

Serum K: >8.0 mEq/L

-Marked widening of QRS complex
-Distinct ST-T wave may not be noted
-High risk of VF or asystole
Hypokalemia

Serum K: 3.0-3.5 mEq/L

-ECG may be normal
-T wave flattening and presence of U
waves
-QT interval and QRS duration normal
Hypokalemia
Serum K: 2.7 – 3.0 mEq/L
-U waves become taller and T waves
become smaller
-The ratio of the amplitude of the U
wave to the amplitude of T wave
exceeds 1.0 in V2 or V3
Hypokalemia

Serum K: < 2.6 mEq/L

-Almost always accompanied by ECG
changes
-ST segment depression associated with
tall U waves and low amplitude T
waves
Hypercalcemia
Slight increase in QRS duration
ST segment short or absent
QT interval shortened
PR interval may be prolonged
T wave amplitude and duration usually normal
U wave amplitude may be normal or sl. increased
Hypocalcemia
Slight decrease in QRS duration
ST segment lengthened and QT interval
prolonged
PR interval may be shortened
T waves may become flat or inverted in severe
hypocalcemia