Peter Kühn, MD • Clemens Lang • Franz Wiesbauer, MD MPH

ECG MASTERY
The Simplest Way to
Learn the ECG
 5

Acknowledgements
We would like to thank our entire team at Medmastery for their great work. First and
foremost, we would like to thank Bonnie Bills for coordinating the production process
and for all her thoughtful comments. Secondly, we would like to thank Philipp Gärtner
and Brigitte Mair, our designers, for doing a tremendous job creating the visuals and
layout for the book, and Mary L. Tod for her sharp and sensitive editing. Lastly, we
would like to thank you, our readers, for your feedback, comments, and encourage-
ment.

We’d also like to give a special shout-out to the enthusiastic beta testers and readers
who gave us feedback on our ECG Mastery program (including this text) as we develo-
ped it:

A. B. Atuchukwu, Abdisalam Abdi, Adedeji Adebayo, MD, Ahmad Shoaib, MD, Amina
Durodola, Amr Abdelghany, MD, Besim H Guda, MD, Bulungu Tshinanu, MD, César
Ferreira, Daniel Alves, MD, MSc, Farzane Barzkar, Gaurav Kapoor, MD, Georgi Min-
chev, Godsent Isiguzo, Hassan Almaateeq, Ibrahim Aliyu, Ibrahim Ghazi, MD, Ivana
Begic, MD, José Carlos Moreno Samos, MD, Juliaty Eds, Ka Wah-Li, Katya Mollova,
Katya Mollova, MD, Keramida Kalliopi MD, MSc, PhD, Kero Wasss, Lola Rakhimdja-
nova, Maria del Mar, Mehmet K. Çelenk, Michele Escande Orthlieb, Michelle Gagnon,
BS, RDCS, RVT, Nato Chubinidze, Nchafatso Obonyo, MD, Osman Ahmed, Peter-
Louis Ndifor, Petrica Ciobanca, Rana A Kundu, Rosie Beles, Tarek Mazzawi, Theo
Rosales, Tsogzol Dorji, Virgilio de Asa Jr., Yura Mareev, and Zulfiqar Ahmed, MD.

This book is dedicated to all the doctors out there who are striving to become better
and better every day. It’s your relentless quest for knowledge and mastery that ulti-
mately drives progress in medicine.

Introduction
Level 1

Deconstructing the ECG curve–

the components of the tracing
In this first chapter, you will learn about the different
waves on the ECG and how to recognize them.

Key concepts
Your first step is to learn how to identify QRS complexes, T waves, and P waves on a tracing.

QRS

The isoelectric line is the baseline of the ECG.

A wave that is above the
By definition, it‘s the line on the ECG during isoelectric line is called “positive”
which electrical activity is absent—look for
the flat line that connects a T wave to the
following P wave. Anything above is positive, isoelectric line
anything below is negative. A wave that is below the
isoelectric line is called “negative”
T

QRS

Electrical depolarization of the ventricles leads to sharp

deflections in the ECG called QRS complexes. Every depolarizati-
on is followed by a phase of repolarization. Repolarization of the
ventricles is represented by the so-called T waves. The T wave can
be positive or negative.

QRS

Atrial depolarization is depicted by the P wave, which is steeper P

than the T wave but flatter than the QRS complex. We said that
every depolarization is followed by a phase of repolarization. But
since atrial repolarization happens at the same time as the QRS
P
complex, it cannot be recognized on the ECG.

Level 1 Deconstructing the ECG curve—the components of the tracing

 9

Identifying the components of the QRS complex

There are five concepts that will help you to identify the different components of the QRS complex.

isoelectric line

Q Q

Concept #1 Concept #2 Concept #3

The first downward deflec- Any upward deflection is Any downward deflection
tion is called a Q wave. called an R wave.
S that comes after an R wave
and crosses the isoelectric
line is called an S wave.
R R wave
R′ R′ = R prime

isoelectric line

S
RSR′
Concept #4 Concept #5
A second upward deflection is called R prime (R′) If the entire QRS complex
consists of one large down-
QS ward deflection, then this is
called a QS complex.

Example: identifying P waves, QRS complexes, and T waves

Based on the concepts outlined above, we can now identify the P waves, QRS complexes, and T
waves in an example exercise. Notice that the second wave is steep and edgy; it has sharper
deflections than the other curves and therefore has to be the QRS complex.

P
QRS
T

Dotted vertical lines originate from the different waves of the ECG. They intersect with horizontal lines identifying P, QRS, and T.
In this example we have already identified the different waves for you.

Level 1 Deconstructing the ECG curve—the components of the tracing

10

Level 1

QUIZ SECTION
Now it is your turn. If in doubt, start looking for the QRS complex (focus on
sharp deflections!). Also keep in mind that every QRS complex is followed by
the T wave after 200 – 400 ms (equivalent to 5 – 10 mm on this ECG paper).
In the next step you should already be able to identify the P wave, as the
steepness of its deflection is in between that of the QRS and the T waves.

P
QRS
T

ECG 1

P
QRS
T

ECG 2

P
QRS
T

ECG 3

P
QRS
T

ECG 4

Level 1 Quiz section

Level 2

Interval (time) and amplitude

(voltage) measurements
In this chapter, you will learn about the duration and
amplitudes of the various waves and how to measure
them.

The ECG grid

You can measure in two dimensions mV mV
25mm/s

on the ECG paper. The Y-axis shows

amplitudes (i.e., voltage), while the
X-axis shows time. 10mm = 1mV 25mm = 1s
t t

Measuring is not always necessary in order to come up with the right diagnosis.
Some diseases just require pattern recognition (e.g., acute myocardial infarction),
while others require measurements (e.g., ventricular hypertrophy, bundle branch
blocks, etc.).

The Y-axis—amplitude measurement

Amplitude or voltage is measured on the Y-axis; 10 mm represents 1 millivolt (mV) with standard cali-
bration. Occasionally, calibration is set at double standard (20 mm = 1 mV) or half standard (5 mm = 1
mV). However, this is only rarely done. So just remember that 10 mm = 1 mV and you’ll be fine in 99.9% of
cases.

Here’s how you can tell if the ECG is adjusted to

standard calibration. Almost every ECG printout
also has a rectangular calibration signal on it.
10 mm
If the machine is set to standard calibration
(10 mm = 1 mV), this calibration signal will be
exactly 10 mm high as shown in the example.

Level 2 Interval (time) and amplitude (voltage) measurements

 15

The X-axis—time measurement

Most ECG machines print at a speed of 25 mm per second. Therefore, a 25-mm distance on the X-axis
corresponds to a duration of 1 second. So remember:

• 25 mm on the X-axis = 1 second

• 5 mm (large box) on X-axis = 1/5 of a second or 0.2 seconds
• 1 mm (small box) on X-axis = 1/5 of 0.2 seconds or 0.04 seconds

Occasionally, paper speed is set at 50 mm/s in which case all ECG

intervals are twice as long as normal (large box = 0.1 s instead of
0.2 s, small box = 0.02 s instead of 0.04 s). So whenever all intervals
look too long, check for an increase of paper speed to 50 mm/s.

Measuring intervals
Now it’s time to carry out some measurements. The duration of a wave is measured from its initial devia-
tion from the isoelectric line until the point where it returns to the isoelectric line again. The amplitude of
the wave is the distance between the isoelectric line and the peak or nadir of that wave.

You should try to evaluate and measure each ECG in a systematic

way, one step after the other. In later chapters we will introduce
such an approach, which we call the “ECG Cookbook.”

Here is how to measure the different intervals:

P-wave
duration
Measurement of P-wave duration starts at the point
where the P wave leaves the isoelectric line until it x x isoelectric line
returns to the isoelectric line again.

QRS
duration

isoelectric line x x

Measurement of QRS duration starts at the point

where the QRS complex leaves the isoelectric line
until it returns to the isoelectric line again.

Level 2 Interval (time) and amplitude (voltage) measurements

16

Measurement of the QT interval starts at the

beginning of the QRS complex until the end of
the T wave.
x x isoelectric line

The QT
interval

isoelectric line

Measurement of amplitudes: start measuring

S-wave amplitude at the isoelectric line until the nadir or peak of
the wave.

Level 2 Interval (time) and amplitude (voltage) measurements

 17

Level 2

QUIZ SECTION
Now it is again your turn; perform the measurements mentioned above.

Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

ECG 1

I
ECG 2

ECG 3

V5

ECG 4

Level 2 Quiz section

18

Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

II
ECG 5

ECG 6
V1

ECG 7
I

ECG 8
II

Level 2 Quiz section

Level 3

When the timing is off–the

foundations of interval interpretation
In this chapter, you will learn about the normal values of the
different time intervals and what it means if they are longer or
shorter than normal.

Duration of the P wave

Depolarization of the atria (i.e., P-wave duration) usually takes less than
0.10 seconds. If the left atrium is dilated (enlarged), depolarization takes
longer and P-wave duration will increase to ≥0.12 s.

Normal duration <0.1 s

x x isoelectric line

P–wave duration

The prolonged P wave seen in atrial enlargement has a “double peak” in lead
I and lead II and is called P mitrale (see image). You will learn more about
this in Level 11.

lead II

P mitrale

Level 3 When the timing is off—the foundations of interval interpretation

 23

Duration of the PR interval

The PR interval represents the duration the impulse
takes to travel from the atria to the ventricles. It’s
measured from the beginning of the P wave until the
beginning of the QRS complex. Normal values are
between 0.12 and 0.2 seconds. Any duration below
or above this range is regarded as abnormal.
x x

The PR interval

Paradoxically, it‘s always called a “PR interval,” no matter whether the QRS
complex starts with a Q or an R wave.

When the PR interval is >0.2 seconds

When the PR interval is longer than 0.2 seconds AND there is a QRS complex after each P wave, we have
what is called a first degree atrioventricular block (or AV block I), as seen on the image.

x x

8 mm = 0.32 s

Example of a first degree AV block (AV block I). In this case, the PR interval is 0.32 s and there is a QRS complex after each P wave.

When the PR interval is <0.12 seconds

When the PR interval is shorter than 0.12 seconds, depolarization of the ventricles occurs earlier than nor-
mal. This situation is called preexcitation (or preexcitation syndrome). In these syndromes, an additional
bundle conducts the impulse down from the atria to the ventricles. The conduction speed in the additional
bundle is faster than in the AV node—so the impulse reaches the ventricles earlier than normal and the PR
interval is shortened.

Level 3 When the timing is off—the foundations of interval interpretation

24

There are two important preexcitation syndromes that you should remember. The Lown-Ganong-Levine
syndrome (LGL syndrome) is characterized by a QRS complex that immediately follows the P wave. The
appearance and duration of the QRS complexes are normal.

The other form of preexcitation is called Wolff-Parkinson-White syndrome (WPW syndrome). A slurred
upstroke of the QRS complex immediately follows the P wave; it is also known as a “delta wave,” as it
resembles the Greek letter delta. The duration of the QRS is usually lengthened to >0.12 s.

delta wave

Lown-Ganong-Levine syndrome Wolff-Parkinson-White syndrome

= LGL syndrome = WPW syndrome
• QRS immediately follows the P wave • QRS immediately follows the P wave
• QRS looks normal • QRS looks abnormal (delta wave)
• QRS duration is normal • QRS duration >0.12 s

QRS duration
Under normal circumstances, depolarization of the ventri-
cles takes up to 0.10 seconds. Dilatation of the ventricles
may cause a slight lengthening of the QRS (>0.1 to <0.12
s). A significantly prolonged QRS duration of ≥0.12s, how- x x
ever, indicates that either the right or left bundle branch is
blocked. This situation is called a complete bundle branch QRS duration ≥0.12 s

block. You will learn more about it in Level 5.

Complete bundle branch block

There are also other reasons for broad QRS complexes. As we have just learned, one such example is the
WPW syndrome, in which a delta wave is added at the beginning of the QRS complex. Other reasons will be
introduced in later chapters.

Level 3 When the timing is off—the foundations of interval interpretation

 25

Level 3

QUIZ SECTION
The following examples may seem familiar to you, but at this time not only the
measurements but also the correct diagnoses are required. Note that there may
be more than only one abnormality in a single example!

answers provided
Complete bundle
WPW syndrome
LGL syndrome

branch block

None of the
I° AV block
P mitrale
I

ECG 1

I
ECG 2

ECG 3

Level 3 Quiz section

 26

ECG 7
ECG 6
ECG 5
ECG 4

Level 3 Quiz section

I
V5

II
II
V5

P mitrale

I° AV block

LGL syndrome

WPW syndrome

Complete bundle
branch block

None of the
answers provided
Level 4

The precordial leads—what nobody

ever tells you
In this chapter you will learn where to put the precordial leads
and what they tell you about the heart.

How to place the precordial leads

The precordial leads show the electrical activity of the heart in the horizontal plane. Most com-
monly, six precordial leads are recorded. The precordial leads are registered in combination with
the limb leads. You will learn more about the limb leads in Level 9 of this training.

Proper placement of the precordial leads V1 through V6.

The precordial leads are placed at predefined positions on the chest. Here’s how to go about it:

1. First, find the second rib and the second intercostal space. Then count down to the fourth intercostal
space. Attach V1 in the fourth intercostal space on the right side of the sternum, and attach V2 in the
fourth intercostal space on the left side of the sternum.
2. After you’ve attached V1 and V2, attach V4 at the intersection of the midclavicular line and the fifth
intercostal space.
3. Attach V3 exactly halfway in between V2 and V4. From V4 on, we don’t need to worry about the inter-
costal spaces anymore; the subsequent leads are attached at the same horizontal level as V4.
4. V5 is placed in the anterior axillary line (same level as V4).
5. V6 is placed in the midaxillary line (same level as V4).

Occasionally, two additional leads (V7 and V8) are also attached. V7 is located at the posterior axillary line
(same level as V4), and V8 is attached at the scapular line (same level as V4).

Level 4 The precordial leads—what nobody ever tells you

 31

How to find and count the intercostal spaces correctly

The easiest way to find the fourth intercostal space is to look for the sternal
angle. The sternal angle is a little edge in the upper third of the sternum (see
image), which can be found in almost any patient. The second rib inserts Sternal
right next to the sternal angle. Below the second rib is the second intercostal angle

space. Then you just count down to the fourth and fifth intercostal spaces,
respectively.

Try to find the second rib on yourself using this approach, and
you’ll see that it’s easy. Then count the intercostal spaces.

What anatomical regions are depicted by what leads?

Each precordial lead depicts a certain region of the heart. Some leads even depict more than one region.
Let’s say you see ST elevations on the ECG—a sign of myocardial infarction. Just by looking at the affected
leads, you’ll be able to tell where the infarction is located.

V8

V7

V6 V8

V7

V5

V4 V6
V1 V2 V3

The changes in the right ventricular myocardium

can be seen in leads V1, V2, and V3.
V5

V4
V1 V2 V3

But changes in the basal septum also can be detected

in these leads, although usually only in V2 and V3.

Level 4 The precordial leads—what nobody ever tells you

32
V8

V7

V6

V5
V8

V4 V7
V1 V2 V3

V2, V3, V4: anterior wall of the LV

If changes can be seen in V2, V3, and V4,
then the anterior wall of the left ventricle V6
(and the septum) are affected.

V5
V8

V4
V7 V3
V1 V2

V5, V6: lateral wall of the LV

V5 and V6 show the lateral wall of
the left ventricle.
V6

V5

V4
V1 V2 V3

V7, V8: posterior wall

V7 and V8 depict the posterior
wall of the left ventricle.

Changes that are seen in the anterior AND the lateral walls are called
anterolateral. Changes that are seen in the lateral and posterior walls
are called posterolateral. Changes that are seen in the anterior wall
and the septum are called anteroseptal.

Level 4 The precordial leads—what nobody ever tells you

 33

The normal pattern

Each precordial lead has a typical ECG pattern. Try to remember this picture of normal chest leads:

V1 V2 V3 V4

V5 V6

The R/S ratio (“R to S ratio”)

As the name implies, the R/S ratio compares the size of the R wave to the size of the S wave in each lead.
Let’s look at four examples. Please complete the calculations for examples 3 and 4 (answers are at the
end of the chapter).

Example 1 Example 2 Example 3 Example 4

R (mV) 0.4 1.4

S (mV) 2.0 1.4

R/S 0.4/2.0 = 1/5 = 0.2 1.4/1.4 = 1

[Solution at end of chapter]

A lot of doctors neglect the R to S ratio. But you shouldn’t!

Level 4 The precordial leads—what nobody ever tells you

34

So why is the R/S ratio important?

There are two very important laws that apply under normal circumstances (i.e., when the muscle mass of
the left ventricle exceeds that of the right ventricle). Law number 1 says:

Leads with an R/S ratio <1 correspond to the right ventricle

V8

V7 V1 V2 V3 V4

V6

V5
V5 V6
V4
V1 V2 V3

R/S ratio <1 <1 <1 =1 >1 >1

Leads with an R/S ratio >1 correspond to the left ventricle

V8

V7 V1 V2 V3 V4

V6

V5
V5 V6
V4
V1 V2 V3

R/S ratio <1 <1 <1 =1 >1 >1

Leads with an R/S ratio of =1 correspond to the transitional zone between right and left ventricle
The transitional zone usually occurs at leads V3 or V4.
V8

V7 V1 V2 V3 V4

V6

V5
V5 V6
V4
V1 V2 V3

R/S ratio <1 <1 <1 =1 >1 >1

Level 4 The precordial leads—what nobody ever tells you

 35

And law number 2 says:

Under normal circumstances, the R/S ratio increases as you go from right to left

V8
V1 V2 V3 V4
V7

V6

V5 V6
V5

V4
V1 V2 V3

R/S ratio 0.21 0.31 0.57 1.0 3.8 ∞

It’s also important to note that the amplitude of the initial R wave increases
as we go from V1 over to the left ventricle.

When the transitional zone is off

As you learned above, the transitional zone (the dotted line separating right from left ventricle) usually
occurs at V3 or V4, as depicted in this image:
V1 V2
V3

V4 V5 V6
1
2 V1 V2 V3 V4

5 V5 V6

transitional zone

But not every heart is the same. Sometimes, the heart is “rotated” in a clockwise or counterclockwise
fashion along its longitudinal axis (going from the apex to the base of the heart).

Level 4 The precordial leads—what nobody ever tells you

36

When the heart is rotated in a clockwise fashion, the transitional zone shifts toward V5 or V6:
V1 V2
V3

V6 transitional zone
V4 V5
1
2
V1 V2 V3 V4 V5 V6
3

clockwise rotation

And when the heart is rotated in a counterclockwise fashion, the transitional zone occurs at V1 or V2:
V1 V2
V3 transitional zone

V4 V5 V6
1
2
V1 V2 V3 V4 V5 V6
3

counter-clockwise rotation

You’ll need to be able to tell whether a precordial lead depicts the right or the
left ventricle. Knowledge about rotation is therefore critical.

Answers to R/S ratio calculations:

Example 1 Example 2 Example 3 Example 4

R (mV) 0.4 1.4 2.4 2.3

S (mV) 2.0 1.4 0.3 0

R/S 0.4/2.0 = 1/5 = 0.2 1.4/1.4 = 1 8.0 ∞

Level 4 The precordial leads—what nobody ever tells you

 37

Level 4

QUIZ SECTION
Now it’s time for some exercises. They will help you to repeat and remember
the most important information covered in this level.

Which leads provide information on the...

V1 V2 V3 V4 V5 V6 V7 V8

Right ventricle

Upper part of the septum

Left ventricle

Anterior wall of the LV

Lateral wall of the LV

Posterior wall of the LV

Which ventricle is represented by these leads under normal circumstances?

Right ventricle

Left ventricle

Level 4 Quiz Section

Level 5

The chest leads—100% confidence

In this chapter you’ll learn how to recognize abnormal patterns
in the chest leads.

A normal ECG
It’s very important that you remember the normal appearance of the precordial (chest) leads.
So take a look at this example of a normal ECG again:

V1 V2 V3

V4 V5 V6

In the right ventricle (V1 and V2), we can usually see small R waves and large S waves in normal individuals. In the left
ventricle (V5 and V6), small Q waves and narrow and tall R waves are usually seen in normal individuals.

Patterns in abnormal ECGs

In abnormal QRS complexes, you’ll see a pattern that may be referred to as notching, slurring, an
M shape, or an RSR pattern:

abnormal patterns seen in V1 or V2 abnormal patterns seen in V5 or V6

Level 5 The chest leads—100% confidence

 41

Let’s take a closer look:

notching
M-form

The M pattern is usually quite easy to see. When the delay in depolarization of the
ventricles is less obvious, then that’s called notching.

These changes in R-wave morphology indicate that depolarization of the ventricles is delayed.

When the QRS duration is between 0.10 and 0.12 seconds, that’s called incomplete bundle branch block,
which causes notching of the QRS complex. Incomplete bundle branch block may be caused by dilatation
of the ventricles. It’s also referred to as volume overload.

In complete bundle branch block, conduction through the left or right bundle branch is completely blocked.
Depolarization of the ventricles therefore takes longer than normal, and the QRS complex is lengthened to
0.12 seconds or longer.

To find out whether the left or the right bundle branch is affected, we need to look at the chest leads:

M shape over the left ventricle

V1 V2 V3

≥0.12 s
left bundle branch block

V4 V5 V6

In complete left bundle branch block (LBBB), the QRS duration is ≥0.12 seconds and an M pattern (notching) is seen over the left
ventricle (V5 or V6).

Level 5 The chest leads—100% confidence

42

V1 V2 V3 broad S wave over the left

ventricle marked in red

>0.12 s
right bundle branch block V4 V5 V6

In complete right bundle branch block (RBBB), the QRS duration is ≥0.12 seconds and an M pattern (or notching) is seen over the
right ventricle (V1 or V2).

There’s one important pathologic condition that could be confused with bundle branch block because QRS
duration is also lengthened. You have already learned about this disease in Level 3. Here’s an example.
Can you spot the problem?

V1 V2 V3 V4 V5 V6

In this example, the QRS duration is lengthened to ≥0.12 seconds and there’s notching in lead V1. Is this a case of right bundle
branch block?

You might have already realized what’s wrong with this ECG. There are a few
problems: the QRS is lengthened, the PR interval is too short, AND the begin-
ning of the QRS looks kind of funny.

practically no pause in between the P and the QRS

V4

Level 5 The chest leads—100% confidence

 43

V1 V2 V3 V4 V5 V6

This is a clear case of WPW syndrome: the QRS is lengthened, the PR interval is shortened, and a delta
wave is present. You’ll get the chance to see a lot more examples of this disease in the quizzes.

Sometimes WPW syndrome may look like LBBB with predominant R waves over the left ventricle and pre-
dominant S waves over the right ventricle:

steep upstroke
V1 V2 V3

V4 V5 V6

Complete LBBB

short PR interval slurred upstroke

WPW syndrome

V1 V2 V3 V4 V5 V6
delta waves in red

In LBBB, the upstroke of the QRS is steeper than that in WPW syndrome. The short PR interval will also give you a clue into the direc-
tion of WPW.

Level 5 The chest leads—100% confidence

 44

Level 5

ECG 2
ECG 1

V1
V1

V1
V1

Level 5 Quiz section

V2
V2
QUIZ SECTION

V2
V2

V4

V4
Now it’s time for some exercises...

V3
V3

V3
V3

V5

V5
V4

V4

V6

V6
V6

V6
V5

V5
Complete right bundle branch block

Complete left bundle branch block

Volume overload right ventricle

Diagnosis

Volume overload left ventricle

WPW syndrome
V1

V1

Duration of the QRS complex

(V1) QRS shape

(V6) QRS shape

V2

Duration of the PR interval

V2
Diagnostic criteria

Delta wave in leads:

V3

V3
V4

V4
V5

V5
 4

V6
V6
V5

ECG 4
ECG 3

V1
V1

V1
V2

V2

V2
I
V4
V3

V3

II

V3
II
V4

V5

V4
III
V5

III

V6

V5
R
V6

L
Complete right bundle branch block

Complete left bundle branch block

V6
F
Volume overload right ventricle
Diagnosis

Volume overload left ventricle

WPW syndrome

Duration of the QRS complex

(V1) QRS shape

(V6) QRS shape

V1
I
Duration of the PR interval

V1
Diagnostic criteria

Delta wave in leads:

Level 5 Quiz section

45

V2
V2

V3
V3

II
 V3

V1
V4
46

V2
ECG 6
ECG 5
V5

V4
V1
V1

Level 5 Quiz section

V3
V6

V2
V2

V5
V4
V4

V3
V3

V6
V5
V5
V1

V6
V6
V2

Complete right bundle branch block

V3

Complete left bundle branch block

Volume overload right ventricle

Diagnosis

Volume overload left ventricle

V1
WPW syndrome
V4

Duration of the QRS complex

(V1) QRS shape

V2
(V6) QRS shape
V5

Duration of the PR interval

V4
V1
Diagnostic criteria

Delta wave in leads:

V3
V6

V2

V5
V4
V3

V6
V5
 V5
V1

V6
V2
V3

ECG 7
V1
V4

V2
V5

V4
V1

V3
V6

V2

V5
V4
V3

V6
V5

Complete right bundle branch block

V6

Complete left bundle branch block

Volume overload right ventricle

Diagnosis

Volume overload left ventricle

WPW syndrome

Duration of the QRS complex

(V1) QRS shape

(V6) QRS shape

Duration of the PR interval

Diagnostic criteria

Delta wave in leads:

Level 5 Quiz section

47
Level 6

What you really need to know

about ventricular hypertrophy
The ECG is an important tool for the identification of
ventricular hypertrophy. In this chapter, you’ll learn
what to look for.

Key concepts
We learned in Level 4 that R waves increase as we go from right (V1) to left (V6). The size of the R wave is
a reflection of the myocardial mass underneath the lead. That’s why the R waves over the thin-walled right
ventricle (V1 and V2) are smaller than the R waves over the muscular left ventricle (V5 and V6).
The waves of the ECG are a product of electrical depolarization. If depolarization moves toward a lead,
the respective segment of the ECG wave will be positive. If depolarization moves away from the lead, the
deflection will be negative.

When a depolarization wave moves

A away from an electrode, the lead records
a negative deflection.

When the wave moves towards the

B electrode, the recording shows a positive
deflection (an R wave).

If the muscle mass in a particular area

C is increased (hypertrophy), the depola-
rization produces a spike of increased
amplitude (a tall R wave).

When the fiber length is increased (dila-

tation), the depolarization wave takes
D longer, and the resulting spike is wider.

It follows that a strong electrical vector that points in the direction of V5 and V6 produces a large R wave
in V5 or V6 and a deep S wave in the opposite leads V1 and V2. In other words, the S wave in V1 and V2 is
more or less a mirror image of the R wave in V5 and V6.

Level 6 What you really need to know about ventricular hypertrophy

 51
V8

V7

V6

V5

V1, V2
V4
V1 V2 V3

So remember these two important points:

• The higher the R wave over the left ventricle, the larger the muscular mass of the left ventricle
(a direct sign of left ventricular hypertrophy).
• The deeper the S wave over the right ventricle, the larger the muscular mass of the left ventricle
(an indirect sign of left ventricular hypertrophy).

The Sokolow index

Under normal circumstances the left ventricle has a higher muscular mass than the right ventricle. To
assess whether (abnormal) left ventricular hypertrophy is present, the Sokolow index can be used. It basi-
cally takes the preceding two statements and turns them into numbers. Here is how it’s done:

1. Take the R wave (mV) in V5 or V6 (whichever one is taller).

2. Add the S wave (mV) in V1 or V2 (whichever one is deeper).
3. If the resulting number is more than 3.5 mV, left ventricular hypertrophy is probably present.

Sometimes the R wave in a left ventricular lead alone exceeds 2.5 mV; this can also be interpreted as a
sign of left ventricular hypertrophy.

The following example illustrates how to use the Sokolow index:

V1 V2
2.4 mV

V5 V6 Use the R in V5 because it’s taller than the R

in V6. The amplitude of that R wave is 2.4 mV.
Then measure the S in V2 because it’s deeper
than the S in V1. That S wave is 3.3 mV. Then
3.3 mV
add up those numbers: 2.4 + 3.3 = 5.7 mV.
Since 5.7 is larger than 3.5, left ventricular
hypertrophy is probably present.

Level 6 What you really need to know about ventricular hypertrophy

52

However, this technique should be used with caution. False-positive and

false-negative results may occur. Also, this method is not suitable for pa-
tients younger than 35 years. A lot of people in this age group will exceed
the threshold of 3.5 mV without having left ventricular hypertrophy (which
means high rates of false positives!).

Now, let’s turn to right ventricular hypertrophy…

The ECG can also be used to assess right ventricular hypertrophy. However, all too often, clinicians forget
about it—probably because it’s just a little bit trickier than the assessment of left ventricular hypertrophy.

There are a couple of ECG findings that can be used for the assessment of right ventricular hypertrophy.
Here are the ones that we find most useful—we call them our RSS criteria:

• Criteria #1: Look at the R wave in V1; present if it’s ≥0.5 mV

• Criteria #2: Look at the S wave in relation to the R wave in V1; present if the R/S ratio in V1 is ≥1
• Criteria #3: Look at the S wave in V5: present if it’s ≥0.5 mV

If two of the three criteria are present, right ventricular hypertrophy is probably present. If right-axis devi-
ation (taught in Level 11) or an incomplete right bundle branch block is also present, the likelihood of right
ventricular hypertrophy increases even further.

Here‘s an example:

normal patient

normal V1 normal V5

RRS right ventricular hypertrophy

#1: R (V1) = 0.6 mV present
#2: R/S (V1) = 0.6/0.4 = 1.5 present
V1 #3: S (V5) = 1.3 mV present

V5

In this example, all RSS criteria are present. So

right ventricular hypertrophy is probably present.

Note that this suspicion always has to

be confirmed with echocardiography.

Level 6 What you really need to know about ventricular hypertrophy

 53

Level 6

QUIZ SECTION
Use the above method to complete the following examples.
Fill in your measurements (R waves, S waves, R/S rati-
os) on the lines below the leads. You don’t need to mark
the measurements below every lead—just the ones that
are relevant. It should be quite obvious from what we’ve
discussed in this level what the relevant leads are. After
you’ve performed the measurements, choose from the four
possible diagnoses given on the right side of each examp-
le. Use the method taught in Level 4 for the assessment of
rotation.

Rotation

Right ventricular

Right ventricular
volume overload

volume overload
Left ventricular

Left ventricular
hypertrophy

hypertrophy

Counterclockwise

transition zone
Clockwise

Normal
V1 V2 V3
V1 V2 V3

V4 V5 V6 V4 V5

V1 V2 V3
ECG 1

R (mV)
S (mV)
R/S ratio

V4 V5

Level 6 Quiz section

V1 V2 V3 V4 V5 V6
 V6
54

ECG 3
ECG 2

S (mV)
S (mV)

R (mV)
R (mV)

V1
V1

R/S ratio
R/S ratio
V1
V1

Level 6 Quiz section

V2
V2
V2

V2

V4
V4

V4
V3
V3
V3

V3

V5
V5
V4

V5
V5

V6
V6
V6
V6

Left ventricular
hypertrophy

Right ventricular
hypertrophy

Left ventricular
volume overload

Right ventricular
volume overload

Counterclockwise

Clockwise

V1
V1
Rotation

Normal
transition zone
V2

V2
V4

V4
V3

V3
V5

V5
 V5
V6

V6

ECG 5
ECG 4

S (mV)
S (mV)

R (mV)
R (mV)

R/S ratio
R/S ratio

V1

V1
V1
V1

V2
V2

V2
V2
V4

V4

V4
V4

V3
V3

V3
V3
V5

V5
V5
V5
V6
V6

V6

V6
Left ventricular
hypertrophy

Right ventricular
hypertrophy

Left ventricular
volume overload

Right ventricular
volume overload

Counterclockwise

Clockwise
V1

V1
Rotation

Normal
transition zone

Level 6 Quiz section

55

V2

V4

V2

V4
V5
V3

V3

V
 56

ECG 7
ECG 6

S (mV)
S (mV)

R (mV)
R (mV)

R/S ratio
R/S ratio
V1

V1
V1

V1

Level 6 Quiz section

V2

V2
V2

V4

V2

V4
V4

V4
V3

V3
V5
V3

V3

V5
V5

V5
V6

V6

V6
V6
Left ventricular
hypertrophy

Right ventricular
hypertrophy

Left ventricular
volume overload

Right ventricular
volume overload

Counterclockwise

Clockwise
V1
Rotation

V1
Normal
transition zone
V2

V4

V2

V4
V5
V3

V3

V5
V6
 6

ECG 8

S (mV)
R (mV)
V1

V1

R/S ratio
V2

V2

V4
V3

V3

V5
V4

V6
V5

Left ventricular
hypertrophy
V6

Right ventricular
hypertrophy

Left ventricular
volume overload

Right ventricular
volume overload

Counterclockwise

Clockwise
Rotation

Normal
transition zone

Level 6 Quiz section

57
Level 7

ST depression and T negativity—

a simple approach
ST depression and T-wave negativity are commonly as-
sociated with debilitating and potentially life-threatening
diseases. Every ECG student should be able to recognize
and interpret them. So pay close attention.

Key concepts
Let’s start off with two simple principles:

Principle #1:
The ST segment is normally located
at the level of the isoelectric line.

By definition, the isoelectric line is

located at the level of the ECG curve
that comes after the T wave, before isoelectric line
the next P wave.

ST
Principle #2:
Except for V1, the T wave is
normally positive.

V1 V2 V3 V4 V5 V6

Once you recognize the presence of ST depressions or T-wave inversions, you should look at two things:

1. Their location (which leads are affected).

2. Their shape.

In Level 4, you learned what leads depict which parts of the ventricle. So if ST depression is present in V5
and V6, for example, you know that the lateral wall is the problem.

Level 7 ST depression and T negativity—a simple approach

 61

The different forms of ST depressions

In our experience, you can tell a lot about the underlying diseases if you know how they change the ap-
pearance of the ST segment. Here are some examples:

ST depressions

1. ventricular 2. digoxin 5. coronary 6. sympathetic tone 8. severe

hypertrophy 3. hypokalemia insufficiency 7. coronary ischemia
4. coronary insufficiency
insufficiency (possible)

NORMAL A B C D E

• Example A: A descending ST depression is usually associated with ventricular hypertrophy.

• Examples B, C and D: These are only relevant over the left ventricle. (One exception to this rule is
mirror images of a posterior wall ST elevation myocardial infarction, which will also produce similar ST
depressions in V1, V2, and V3. More about that in Level 9.)

• Example B: ST depression with a sagging shape—this may be caused by coronary insufficiency (angi-
na), digoxin, or hypokalemia.

• Example C: Horizontal ST depression, typically seen in patients with coronary insufficiency (i.e., symp-
tomatic coronary heart disease).

• Examples B and C: Commonly seen in patients with exercise-induced angina undergoing stress test.

• Example D: Ascending ST depression may be caused by high sympathetic tone, but also by physical
activity. During physical activity, ascending ST depressions do not necessarily mean that ischemia is
present.

• Example E: Deep horizontal ST depressions are often seen in several corresponding leads in the set-
ting of severe ischemia.

Level 7 ST depression and T negativity—a simple approach

62

Patterns of negative T waves (also known as T-wave inversions)

Here are the most important patterns of inverted T waves:

asymmetric negativity symmetric negativity

NORMAL A B C D

Different patterns of T-wave inversions.

On the far left side, you can see a normal T wave for comparison. The other four patterns are negative and
therefore abnormal. There’s an important distinction that you need to make here:

• The T waves in examples A and B are asymmetric. They are slowly downward sloping with an abrupt
return to the isoelectric line.
• The negative T waves in examples C and D, on the other hand, are symmetric.

This distinction is important because these changes frequently occur in two distinct settings with very
different implications:

• Asymmetric T-wave inversion usually occurs in the setting of ventricular hypertrophy. When the left
ventricle is hypertrophic, the inversions are located somewhere between V4 and V6. When the right
ventricle is affected, they can be seen somewhere between V1 and V3.
• Symmetric T-wave inversion occurs in a setting in which myocardial cells are dying off—usually in the
setting of myocardial ischemia or myocarditis.

T-wave inversion can also be biphasic, as in example A, in which we see a negative–positive pattern,
whereas in example D we see a positive–negative pattern (terminally negative). Terminal negativity of the
T wave has a high specificity for coronary artery disease, especially when the terminal part is symmetric.
T waves are also abnormal if they are not positive enough. With predominant R waves, T waves should be
at least 1/8 the size of the R wave. T waves may also be abnormal if they are flat or even horizontal.

In right and left bundle branch block, repolarization is also impaired. There-
fore, we can see negative T waves and ST depressions in leads V1 to V3 in
right bundle branch block and in V4 to V6 in left bundle branch block. Two
other common problems associated with negative T waves and ST depres-
sions are premature ventricular beats and Wolff-Parkinson-White syndrome.

Level 7 ST depression and T negativity—a simple approach

 63

Level 7

QUIZ SECTION
In the following exercises, please describe the pattern of ST-
segment changes (e.g., horizontal, descending, etc.) as well
as T-wave changes (e.g., symmetric, asymmetric, biphasic,
etc.) and decide what the underlying diagnosis could be.

V1 V2 V3
ST depression T negativity Diagnosis

Complete right bundle branch

Right ventricular hypertrophy
Complete left bundle branch
Left ventricular hypertrophy

Coronary T-wave inversion

Negative–positive biphasic

Positive–negative biphasic
Asymmetrically negative

Coronary ST depression
Symmetrically negative
Sagging or U-shaped

WPW syndrome
Descending

Horizontal
Ascending
None

None
Flat
V1 V2 V3 V1

V4 V5 V6

V4 V5 V6
ECG 1

Level 7 Quiz section

 V6
V2

V4
V3

V5
64

ECG 3
ECG 2

V1
V1

Level 7 Quiz section

V6
V2

V2
V4

V4
V3
V3

V5

V5
V6
V6
Descending
Sagging or U-shaped
Horizontal
Ascending
ST depression

None
Flat
Negative–positive biphasic
Asymmetrically negative
V1

Symmetrically negative
T negativity

Positive–negative biphasic
None
Left ventricular hypertrophy
Right ventricular hypertrophy
Complete left bundle branch
V2

Complete right bundle branch

V4
Diagnosis

WPW syndrome
Coronary ST depression
Coronary T-wave inversion
V3

V5
V6
 ECG 5
ECG 4

V1
V1

V1
V1

V2
V2

V2
V2

V4
V4

V4
V4

V3
V3

V3
V3

V5
V5

V5
V5

V6
V6
V6
V6
Descending
Sagging or U-shaped
Horizontal
Ascending
ST depression

None
Flat
Negative–positive biphasic
Asymmetrically negative
Symmetrically negative
T negativity

Positive–negative biphasic
None
Left ventricular hypertrophy
Right ventricular hypertrophy
Complete left bundle branch
Complete right bundle branch
V1
V1
Diagnosis

WPW syndrome
Coronary ST depression

Level 7 Quiz section

65

Coronary T-wave inversion

V2
V2

V4

V4
V3
V3

V5

V5
 66

ECG 7
ECG 6
V1

V1

V1
V1

Level 7 Quiz section

V2

V2

V2
V2
V4

V4
V4

V4
V3

V3

V3
V3

V5
V5

V5

V5
V6
V6

V6
V6
Descending
Sagging or U-shaped
Horizontal
Ascending
ST depression

None
Flat
Negative–positive biphasic
Asymmetrically negative
Symmetrically negative
T negativity

Positive–negative biphasic
None
Left ventricular hypertrophy
Right ventricular hypertrophy
Complete left bundle branch
V1

Complete right bundle branch

V1

Diagnosis

WPW syndrome
Coronary ST depression
Coronary T-wave inversion
V2
V2

V4

V4
V3
V3

V5

V5
V
Level 8

What everybody ought to know about

myocardial infarction and the QRS complex
In this chapter, you will learn how myocardial infarction affects the appearance
of the QRS complex.

Drowning in negativity
There’s one big idea that you have to keep in without infarction

mind to remember what myocardial infarction

does to the QRS complex. And the big idea is
with infarction
this: drowning in negativity.

Drowning means that certain parts of the

QRS become negative (Q waves) while other
parts will decrease in size (R waves). In other
words, one or more of the following things can
happen:

• A preexisting R wave decreases in size

• A preexisting Q wave gets deeper
• A new Q wave develops

The resulting pattern is highly dependent on the initial form of the QRS complex. As we’ve said before, if
you know what the QRS complex in each lead looks like, you’ll also know when something’s wrong.

Let’s have a look at some examples:

Example A: In this example, there’s an initial Q wave

even without myocardial infarction. This could be
V5 or V6 where we would typically see a small Q
wave even in normal patients. When myocardial
infarction develops, the Q wave gets much deeper
than before—here it’s 1/3 the size of the R wave.

without infarction with infarction

Level 8 What everybody ought to know about myocardial infarction and the QRS complex
 71

Small Q waves can be present in leads V5, V6, I, aVL, II,

and III of healthy patients.

Example B: Here we have a small initial

R wave. This is the typical appearance of
leads V1 or V2. When myocardial infarction
develops, the R gets lost and we end up
with one deep QS complex.

without infarction with infarction

Example C: In this example, the R wave is already

pretty tall (left side, without infarction), while the
S is still fairly deep (R/S ratio <1). So this must be
an area under leads V2 to V4. In these leads we
usually don’t see any Q waves. But when myo-
cardial infarction develops, there’s a new Q wave
at the beginning of the QRS complex—the initial R
wave is lost.

without infarction with infarction

These changes appear over the parts of the ventricle

that are affected by myocardial infarction, which makes
localization of the affected area fairly easy.

It’s useful to know that these changes to the QRS complex can be seen in both acute and old myocardial
infarctions. When you observe them in a patient who does not have any symptoms of acute myocardial
infarction, this probably means that you are dealing with an old infarct.

Level 8 What everybody ought to know about myocardial infarction and the QRS complex
72

Pathologic or not pathologic—that is the question

It can sometimes be tricky to differentiate between normal Q waves and pathologic Q waves.
Pathologic Q waves in the setting of myocardial infarction are usually deeper and wider than
normal Q waves. The criteria for pathologic Q waves are:

• The depth of the Q wave is ≥1/4 the size of the R wave in the same lead.

or

• The Q-wave duration is >0.04 seconds (1 small box on the ECG paper).

There are a couple of additional criteria, but these are the ones you should remember for now.

One other trick that you can use in the precordial leads is to look at the Q-wave progression in
leads V4 to V6. Under normal conditions, the depth of the Q wave increases as we go from V4
(where in most cases there is no Q-wave yet) to V6, as seen in the following example:

normal

Q waves increase

V4 V5 V6

However, when there’s an infarct in the area of V4 and V5, Q waves will decrease in size as we go
from V4 to V6, as seen in the following example:

infarction

Q waves decrease

V4 V5 V6

Level 8 What everybody ought to know about myocardial infarction and the QRS complex
 73

The following image shows an infarct at the anterolateral region. In this example, there will be pathologic
Q waves in V4 and V5 that will be bigger and more pronounced than the small Q wave in lead V6.

V6

V5

V4
V1 V2 V3

zone of infarction

So remember, when Q waves get smaller from V4 to V6, myocardial

infarction is probably present in the area around V4.

Now let’s have a look at the normal appearance of the precordial leads again:

V1 V2 V3 V4 V5 V6

Level 8 What everybody ought to know about myocardial infarction and the QRS complex
74

Two important tricks for your toolbox

You’ll have to learn two important facts that are critical for ECG mastery:

Fact #1 says leads V1, V2, and V3 usually start with an initial R wave.

V1 can sometimes come without an initial R wave, but from V2 onward we almost always see it.
In V3 the R wave is usually already pretty big.

Small initial R wave

seen in V1 and V2

Now take a look at this example:

Small initial Q wave

Beware of anything that looks

like this in leads V1, V2, or V3!

This QRS complex also has a small R wave, but there’s a small Q wave preceding it. If you see something
like this in leads V1, V2, or V3, you should always remember fact #1. Myocardial infarction is very likely in
these cases.

Fact #2 says R-wave amplitudes normally increase as we go from V1 to V6.

If R-wave amplitude does not increase from V1 to V3 or if R wave amplitude even decreases, we also have
to think about the possibility of myocardial infarction in the anterior wall.

Level 8 What everybody ought to know about myocardial infarction and the QRS complex
 75

Now we’ll look at some examples:

normal

V1 V2 V3 V4 V5 V6

• Example a: There are abnormal Q waves in leads V4 to V6. Also, R-wave amplitude decreases from V3
to V4. These are clear signs of myocardial infarction of the anterolateral region (V4 = anterior wall, V5
and V6 = lateral wall).
• Example b: The R wave seen in V1 gets completely lost in V2, where we see a large QS complex. Fur-
thermore, pathologic Q waves can be seen in V3 and V4. This is a clear case of an anterior wall myo-
cardial infarction (V2 to V4 = anterior wall).
• Example c: Here the signs of myocardial infarction are more subtle than in the previous examples. R-
wave amplitude decreases as we go from V1 to V2 and stays the same from V2 to V3. R-wave pro-
gression in V4 is normal again. This is probably a case of myocardial infarction of the basal septum
(V2 and V3 = basal septum).
Level 8 What everybody ought to know about myocardial infarction and the QRS complex
 76

Level 8

again!

Level 8 Quiz section

QUIZ SECTION
Now it’s time for some exercises

Changes in QRS morphology related to

Which additional ECG
myocardial infarction (pathologic Q wave,
Infarction Localization changes can be found?
QS pattern, reduced initial R wave)
(write them down)
can be found in leads

V1 V2 V3 V4 V5 V6 V7 V8
Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
Posterolateral region

V1 V2 V3 V4 V5 V6

V2 V3 V4 V5 V6 V7 V8

ECG 1

V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6
 V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6

Changes in QRS morphology related to

Which additional ECG
myocardial infarction (pathologic Q wave,
V2
QS pattern, reduced initial R wave)
V3 V4
Infarction Localization changes
V5 can be found?V6 V7 V8
(write them down)
can be found in leads
V2 V3 V4 V5 V6 V7 V8
V1 V2 V3 V4 V5 V6 V7 V8

Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
Posterolateral region

V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6

ECG 2

V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6 V7
V1 V2 V3 V4 V5 V6 V7

ECG 3

Level 8 Quiz section

77
 78
Changes in QRS morphology related to
Which additional ECG
myocardial infarction (pathologic Q wave,
Infarction Localization changes can be found?
QS pattern, reduced initial R wave)
(write them down)
can be found in leads

Level 8 Quiz section

V1 V2 V3 V4 V5 V6 V7 V8

Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
Posterolateral region

V6
4 V5 V6 V2 V3 V4 V5

V2 V3 V4 V5 V6 V7 V8
V6 V7 V8

ECG 4

5 V6
V5 V6 V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6

ECG 5
V6 V1 V2 V3 V4
4 V5 V6

V1 V2 V3 V4 V5 V6 V7

V5 V6 V7
V5 V6 V2 V3 V4 V5

V6 V7 V8

Changes in QRS morphology related to

V5 V6 Which additional ECG
myocardial infarction (pathologic Q wave,
V1 V2 V3 V4 V5 V6QS pattern, reduced initial R wave) Infarction Localization changes can be found?
(write them down)
can be found in leads

V1 V2 V3 V4 V5 V6 V7 V8
Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
Posterolateral region

V5 V6 V1 V2 V3 V4

V5 V6 V7

ECG 6

Level 8 Quiz section

79
Level 9

Inferior wall myocardial infarction—

pearls and pitfalls
In the previous chapters, we focused on the precordial leads
(chest leads). Learning the ECG works best if you have a thorough
understanding of the precordial leads before learning about the
limb leads. But now it’s time to move on.

The limb leads

The limb leads and the precordial leads view the heart from two different perspectives. The precordial
leads more or less show the horizontal plane, whereas the limb leads show the frontal plane.

cut plane

Limb Leads: Frontal Plane

Precordial Leads: Horizontal Plane

cut plane

Level 9 Inferior wall myocardial infarction—pearls and pitfalls

 83

The limb leads consist of: Four wires are needed to record these leads:

• Three standard leads called I, II, and III • The red wire goes onto the right arm.
• Three augmented leads called aVR (right • The yellow wire goes onto the left arm.
arm), aVL (left arm), and aVF (foot) • The green wire goes onto the left foot.
• The black wire goes onto the right foot.

You can remember this sequence by

picturing a traffic light with a red light
on top, a yellow light in the middle,
and a green light on the bottom:

Using these wires, you can now record the limb leads. As we said, these leads look at the electrical
activity of the heart in a frontal plane:

lateral wall

aVR aVL

inferior wall

III II

aVF

The figure shows that changes of the lateral wall (red area), like myocardial infarction, are depicted by
leads I and aVL. Changes in the inferior wall (green area) are depicted by leads II, III, and aVF.

Lead aVR is only occasionally used and you do not need to worry about it for now.

As we already learned, precordial leads V5 and V6 also depict the lateral wall. So we don’t absolutely need
leads I and aVL to make the diagnosis of problems of the lateral wall like myocardial infarction.

Conversely, the precordial leads don’t show the inferior wall—at least not directly. So we need leads II, III,
and aVF to evaluate the inferior wall.

Occasionally, leads II, III, and aVF will not detect inferior wall infarction, especially when it’s small. That’s
when a little trick comes in handy.

Level 9 Inferior wall myocardial infarction—pearls and pitfalls

84

Looking at mirror images

The direct electrical image of an inferior wall myocardial infarction is visualized in II, III, and aVF. Leads V1,
V2, and V3 view the heart from the opposite side and can therefore produce so-called mirror images:

V1, V2, V3 mirror image

V1, V2, V3
II, III, aVF direct image

II, III, aVF

Example of an inferior wall myocardial infarction. Direct changes can be seen in leads II, III, and aVF: deep and broad Q wave, ST ele-
vation, and negative T wave. A mirror image can be seen in leads V1, V2, and V3: broad R wave, ST depression, and positive T wave.

So we have to update our knowledge about the precordial leads. V1, V2,
and V3 not only give you information about the right ventricle and the basal
septum but also about the inferior wall…in the form of mirror images. A lot of
people don’t know about this!

Updating our knowledge about the Q-wave criteria

Let’s quickly recap the criteria for pathologic Q waves from Level 8. We said that Q waves are pathologic if:

• The depth of the Q wave is ≥1/4 the size of the R wave in the same lead.

or

• The Q wave is >0.04 seconds (1 small box on the ECG paper).

Now there are two more criteria for pathologic Q waves:

• Any Q waves in leads V1 to V3 (even if ≤0.04 s) are abnormal.

• In all cases, Q waves have to be present in two contiguous (neighboring) leads. Contiguous leads are I
and aVL; II, III, and aVF; and V1 to V6 (e.g., V1 and V2 are contiguous, V3 and V4 are contiguous, etc.).

Level 9 Inferior wall myocardial infarction—pearls and pitfalls

 85

Q-wave and non–Q-wave infarctions

Not every patient with myocardial infarction develops Q waves. There are Q-wave and non–Q-wave in-
farctions. The presence and size of Q waves correlate with the extent of myocardial scarring; however, this
correlation is far from perfect.

In the olden days, people thought that Q-wave infarctions were transmural
(involving the entire thickness of the ventricle) and that non–Q-wave infarc-
tions were only subendocardial. However, pathologic studies have found that
this reasoning is flawed and that there were transmural infarctions that did
not develop Q waves and subendocardial infarctions that did.

transmural subendocardial

In the next chapter, you will learn how to diagnose myocardial infarction if Q waves are absent.

Please welcome ... the ECG cookbook!

Now, it’s time to introduce you to our ECG cookbook. The cookbook will provide you with a step-
by-step approach for evaluating an actual ECG without missing anything. There are a total of
11 steps in the cookbook. You should be able to complete 5 of them with the knowledge you’ve
acquired so far. We’ll add more steps to the cookbook as we progress. We recommend that you
make it a habit to go through all the steps of the cookbook when evaluating an ECG. That way
you’ll make sure not to miss anything, you’ll improve the odds of coming up with the right diag-
nosis, and you’ll develop a habit, which will become second nature within a short time.

So without further ado, here’s the cookbook….

Level 9 Inferior wall myocardial infarction—pearls and pitfalls

86

Question Answer Diagnosis

1. Rhythm [coming later] [coming later]

2. Heart rate [coming later] [coming later]

3. P waves [coming later] [coming later]

4. PR interval a) >0.2 s (if PR interval constant for all beats and each P wave I° AV block
is followed by a QRS complex)

b) <0.12 s and QRS complex normal LGL syndrome

c) <0.12 s and visible delta wave WPW syndrome

5. QRS axis [coming later] [coming later]

6. QRS duration a) ≥0.12 s (always think of WPW syndrome as a differential) complete bundle
branch block

b) >0.1 s and <0.12 s with typical bundle branch block incomplete bundle
appearance (notching) branch block

7. Rotation Rotation is defined according to the heart’s transition zone. Nor- transition zone at V5-V6:
mally the transition zone is located at V4, which means that right clockwise rotation
ventricular myocardium is located at V1–V3 and left ventricular
myocardium is at V5–V6. transition zone at V1-V3:
counterclockwise rotation

NOTE: don’t 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 abnormal Q waves, QS waves, missing R-wave progression myocardial infarction;
signs localization according to
affected leads

10. ST-T seg- [coming later] [coming later]

ment

11. QT duration, [coming later] [coming later]

T-U waves

Level 9 Inferior wall myocardial infarction—pearls and pitfalls

 L

L
V5
F

F
V6

Level 9 Quiz section

ECG 2
ECG 1

V1I
V1
I

V1
II
V2
II

V2

V2
V3
III

V3III

III
V3
R
R

V4
V4

R
V4
L

V5
V5
V5

L
F

V6
V6
V6

F
I° AV block
PR

WPW syndrome
LGL syndrome
Complete RBBB
Complete LBBB
QRS

Dilated right ventricle

V1
duration

Dilated left ventricle

V1
Normal transition zone
Clockwise rotation
Rotation

Counterclockwise rotation
Right ventricular hypertrophy

V2

II
trophy
Hyper-

V2
Left ventricular hypertrophy
Anteroseptal region
Anterior wall
Anterolateral region

V3
Lateral region

V3
III
Posterolateral region
Infarction

Posterior wall
Inferior wall

V4
And now it’s time for some exercises using our cookbook.

V4
QUIZ SECTION
Level 9

V5

V5
87

V6

V6
 4

4
4
L

V5
V5

V5
F

V6
V6

V6

Level 9 Quiz section

ECG 4
ECG 3
V1

I
V1
I

V1
I

V1
V1
II
V2

II

V2

II

V2
V2
V2
V3

V3
III

III

V3
V3
III

V3
R
R

V4

V4

V4
V4
R

V4
L

L
V5

V5
V5
L

V5
V5
F

V6
V6

V6
F

V6
V6
I° AV block
PR

WPW-syndrome
LGL-syndrome
V1

Complete RBBB

V1
Complete LBBB
QRS

Dilated right ventricle

duration

Dilated left ventricle

Normal transition zone
V2

Clockwise rotation

II
Rotation

Counterclockwise rotation

V2
Right ventricular hypertrophy
trophy
Hyper-

Left ventricular hypertrophy

V3

Anteroseptal region
Anterior wall

V3
III
Anterolateral region
Lateral region
Posterolateral region
Infarction

Posterior wall

V4
Inferior wall

V4
88

V5

V5
V6

V6
Level 9 Quiz section
ECG 5
I
V1
I

V1
V1
II
II

V2

V2
V2
V3
III

III

V3
V3
R
R

V4

V4
V4
L

V5
V5

V5
F

V6
V6

V6
I° AV block
PR

WPW-syndrome
WPW syndrome
LGL-syndrome
LGL syndrome
V1

Complete
complete RBBB

V1
Complete
complete LBBB
QRS

Dilated
dilated right ventricle
duration

Dilated
dilated left ventricle
Normal
normal transition zone
V2

Clockwise
clockwise rotation

II
Rotation

Counterclockwise
counterclockwise rotation

V2
Right
right ventricular hypertrophy
ventricular hypertrophy
trophy
Hyper-

Left
left ventricular
ventricular hypertrophy
hypertrophy
Anteroseptal
anteroseptal region

V3
Anterior
anterior wall

V3
III
Anterolateral
anterolateral region
Lateral
lateral region
region
Posterolateral region
posterolateral

Infarction
posterior
Posterior wall

V4
Inferior
inferior wall

V4
89

V5

V5
V6

V6
Level 10

Acute coronary syndromes—

mastering the ST segment
In this chapter you’ll learn about the acute coronary
syndromes and how they affect the ST segment.

The acute coronary syndromes

In the previous chapters we discussed what happens to the QRS complex in the setting of myocardial
infarction. You learned that the QRS complex “drowns in negativity” when myocardial infarction occurs,
which means that R-wave amplitudes decrease and Q waves emerge.

These QRS changes are signs of myocardial necrosis and/or scarring. Scars are usually irreversible, so
these changes to the QRS complex are also irreversible.

However, myocardial infarction not only affects the QRS complex but also the ST segment, and these
changes are usually transient.

Acute myocardial infarction is part of the so-called acute coronary syndromes (ACS). Acute coronary syn-
dromes result from coronary arteries that are (partly) occluded either by a thrombus or ruptured plaque.

If you want to become a true master of the ST segment, you’ll need a thorough understanding of the differ-
ent acute coronary syndromes. So here they are.

ACUTE CORONARY SYNDROMES

TROPONIN

STEMI NSTEMI UNSTABLE

ANGINA

ST depression

ST elevation
T-wave inversion

both

STEMI = ST elevation myocardial infarction

NSTEMI = non-STEMI

Level 10 Acute coronary syndromes—mastering the ST segment

 93

A few things to remember:

1. Both STEMIs and NSTEMIs are characterized by an elevation of troponin in the blood. Troponin is ele-
vated because myocardial cells are dying off.
2. As the name implies, STEMI comes with an elevation of the ST segment (duh!), which discriminates it
from NSTEMI and unstable angina.
3. In NSTEMI and unstable angina, changes to the ST segment can be subtle; there can be ST depression,
T-wave inversion, or both.
4. ST changes are very similar in unstable angina and NSTEMI. However, in unstable angina, troponin
(and other cardiac enzymes) are NOT elevated.

The terms “STEMI,” “acute myocardial infarction,” and “ACS with ST elevation” are
sometimes used interchangeably. However, ACS doesn’t necessarily lead to myocar-
dial infarction (i.e., necrosis). Therefore, you should think of ST elevation as a sign of
acute ischemia rather than infarction, although in general it is its first step.

The figure below shows the different pathways and different stages of acute coronary syndromes.

III
no symptoms

symptoms

IIIA IV

Pathways are shown

by roman numerals.

I II

IIIB

B
ACS without ST evelation

ACS with ST evelation

Level 10 Acute coronary syndromes—mastering the ST segment

94

Pathways I and II—ACS with ST elevation

We start off with the normal heart, shown in yellow.

As symptoms develop, ST-segment elevation appears (ischemia). Now three pathways are possible (I, II,
and IV). Let’s first take a look at ST elevations with Q waves (pathway I in the previous illustration).

A few hours after the beginning of myocardial ischemia, pathologic Q waves appear as a sign of necrosis
(IA in the illustration).

As mentioned above, ST elevation is a transient phenomenon. The process from ST elevation to its resolu-
tion is called ST-segment resolution. It starts with the ST segment going down and the T wave becoming
negative (IB).

In the subacute phase of myocardial infarction (IC), the ST segment has returned to the isoelectric line,
and the T wave has become negative. In some patients, this pattern persists forever.

In the chronic phase of myocardial infarction (ID), the T wave becomes positive again. There is no residu-
al sign of infarction in the ST segment or T wave. The myocardial scar is only visible as a Q wave or QS
complex.

Time until complete ST-segment resolution is variable. It strongly depends on time

to revascularization. Usually, the ST segment starts to go down immediately after
complete revascularization. In other cases ST elevation disappears only after several
days. Persistence of ST-segment elevations for weeks after myocardial infarction is
alarming as it is often caused by a left ventricular aneurysm.

myocardial aneurysm

The time-dependent pattern of changes seen in the ST segment and T wave

can also be observed in non–Q-wave infarction (and in patients with peri-
myocarditis)—this is pathway II in the illustration.

Pathway III—ACS without ST elevation

In NSTEMI and unstable angina, symptoms are associated with ST depression (IIIA in the illustration) or T-
wave inversion (IIIB). To differentiate between NSTEMI and unstable angina, you’ll have to look at whether
cardiac enzymes are elevated.

Level 10 Acute coronary syndromes—mastering the ST segment

 95

V1 V2 V3 V4 V5 V6

NSTEMI in the territory of the left anterior descending artery (LAD). Leads V2, V3, and V4 are affected. Could also be diagnosed as
unstable angina if troponin stays within normal limits.

Pathway IV—Prinzmetal angina: a special case

There is a form of myocardial ischemia that’s commonly associated with ST elevation. This disease is
called variant angina or Prinzmetal angina. Chest pain is typically of short duration (15 to 20 minutes) and
appears at rest or even during sleep. Unlike other forms of angina, ST elevation returns to baseline imme-
diately after symptoms disappear. Coronary occlusion is thought to be caused by coronary spasm in these
cases.

Return to baseline after

symptom resolution

Perimyocarditis
In perimyocarditis, the ST segment is usually also elevated and shows the stages we have seen in IIA
through IID. Perimyocarditis is a diffuse disease, and unlike infarction, it’s not limited to the perfusion terri-
tory of one coronary artery. So it can be seen in most limb leads and many of the precordial leads.

Whenever you see ST elevations in areas that are not supplied by one single
artery, you should think of perimyocarditis.

Typically, the ST elevation is not convex, as in myocardial infarction, but rather concave (as seen in the
following figure). Furthermore, the ST segment usually originates from the ascending part of the QRS com-
plex in perimyocarditis, whereas in STEMI it usually originates from the descending part of the QRS.

Level 10 Acute coronary syndromes—mastering the ST segment

96

Perimyocarditis STEMI
convex

concave

ascending part of descending part of the QRS complex

the QRS complex

In perimyocarditis you can also see the time-dependent

changes in ACS with ST elevation, ST resolution, T-wave
inversion, etc.

Vagotonia
And finally, there’s one more form of ST-segment elevation that’s rather innocent compared with the previ-
ous ones. This type of ST elevation can be seen in the setting of vagotonia (i.e., an increase in vagal tone).
The elevation is up to 0.2 mV in amplitude, and it’s usually accompanied by a tall and peaked T wave, as
well as a low heart rate of <60 beats per minute.

V1 V2 V3 V4 V5 V6

Case of vagotonia with ST elevation and a tall, peaked T wave.

With this knowledge in mind, we can now add the eval-

uation of the ST segment to the steps of our cookbook.
Note that the ST segment should always be evaluated in
combination with the QRS complex.

Level 10 Acute coronary syndromes—mastering the ST segment

 97

Question Answer Diagnosis

1. Rhythm [coming later] [coming later]

2. Heart rate [coming later] [coming later]

3. P waves [coming later] [coming later]

4. PR interval a) >0.2 s (if PR interval constant for all beats and each P I° AV block
wave is followed by a QRS complex)

b) <0.12 s and QRS complex normal LGL syndrome

c) <0.12 s and visible delta wave WPW syndrome

5. QRS axis Determine the axis according to leads I, II, and aVF normal axis
left axis deviation
right axis deviation
north-west axis

6. QRS duration a) ≥0.12 s (always think of WPW syndrome as a complete bundle

differential) branch block

b) >0.1 s and <0.12 s with typical bundle branch block incomplete bundle
appearance (notching) branch block

7. Rotation Rotation is defined according to the heart’s transition transition zone at V5-V6:
zone. Normally the transition zone is located at V4, which clockwise rotation
means 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: don’t 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

Level 10 Acute coronary syndromes—mastering the ST segment

98

10. ST-T segment

tall T wave ST depression ST depression ST elevation negative T

hyperkalemia,
QRS normal vagotonia

probably ischemia
QRS normal (DD: digitalis)

nonspecific
repolarization
QRS normal
abnormality

acute ischemia,
QRS normal perimyocarditis,
variant angina

STEMI/
QRS normal perimyocarditis in
resolution

STEMI subacute,
NSTEMI,
QRS normal perimyocarditis

STEMI acute,
STEMI in reso-
QRS with Q wave
lution, STEMI
subacute

left ventricular
QRS: left ventricular
hypertrophy
hypertrophy
with abnormal
repolarization

In these situations
an ST-segment
deviation is
QRS: right ventricular
hypertrophy, bundle almost always
branch block, or WPW present and can-
syndrome not be interpreted
in and of itself.
It has to be left
out in the
ECG report

11. QT duration, [coming later] [coming later]

T-U waves

Level 10 Acute coronary syndromes—mastering the ST segment

 Level 10 Quiz section
ECG 1
V1
Feb 19

March 16

V1
V2

V2
V3

V3
V4

V4
V5

V5
V6

V6
Q-wave STEMI
Non-Q-wave STEMI
on the first ECG
Acute coronary
syndrome/NSTEMI

on the follow-up ECG

Pathology

Perimyocarditis
None of the pathologies
mentioned
Acute
In resolution
Chronic
(only applies to STEMI) Phase
Nomenclature
cannot be applied
segment.
the evaluation of the ST
use our cookbook including
For the following exercises,

Which additional

(use our cookbook)

pathologies can be found?
QUIZ SECTION
Level 10
99
 V1 V2 V3 V4 V5 V6

100
Pathology Phase

Which additional
pathologies can be found?

Level 10 Quiz section

Acute
(use our cookbook)

Chronic

mentioned
In resolution

Q-wave STEMI
Acute coronary
Perimyocarditis

syndrome/NSTEMI
Nomenclature

Non-Q-wave STEMI
(only applies to STEMI)
cannot be applied

None of the pathologies

V1 V2 V3 V4 V5 V6

This is a patient who

presents to you with
chest pain. He never
had an ST elevation.
ECG 2

V1 V2 V3 V4 V5 V6

ECG 3

I II III R L F

V1 V2 V3 V4 V5 V6
 L
V5

V5
V6

V6
F

Level 10 Quiz section

ECG 5
ECG 4
I

V1
V1

V1
V2
II
V2

V2
V3

V3

V3
III
V4

V4

V4
L
V5

V5

V5
V6

V6

V6
F

Q-wave STEMI
Non-Q-wave STEMI
Acute coronary
syndrome/NSTEMI
Pathology

V1
Perimyocarditis
None of the pathologies
mentioned
Acute

V2
In resolution
Chronic
Phase

(only applies to STEMI)

V3
Nomenclature
cannot be applied

V4
Which additional

(use our cookbook)

V5
pathologies can be found?
101

V6
 102
Pathology Phase

Which additional
pathologies can be found?

Level 10 Quiz section

Acute
(use our cookbook)

Chronic

In resolution

mentioned

Q-wave STEMI
Acute coronary
Perimyocarditis

syndrome/NSTEMI
Nomenclature

Non-Q-wave STEMI
I II III R L F

(only applies to STEMI)

I II III R L F

cannot be applied

None of the pathologies

I II III R L F
I II III R L F

V1 V2 V3 V4 V5 V6

V1 V2 V3 V4 V5 V6
ECG 6

V1 V2 V3 V4 V5 V6

V1 V2 V3 V4 V5 V6

ECG 7 V1 V2 V3 V4 V5 V6 I II III I II III

V1 V2 V3 V4 V5 V6 I II III I II III
5
L

V5

V6
V6
F

Level 10 Quiz section

ECG 8
June 4
June 1
I

I
V1
II

II
V2
III

III
V3

I
R

V4
L

II
V5

June 6

III
F

V6
Q-wave STEMI
Non-Q-wave STEMI
Acute coronary
syndrome/NSTEMI
Pathology

Perimyocarditis
None of the pathologies
mentioned
Acute
In resolution
Chronic
Phase

(only applies to STEMI)

Nomenclature
cannot be applied
Which additional

(use our cookbook)

pathologies can be found?
103
Level 11

The ECG trio—cardiac axis, atrial

hypertrophy, and low voltage
In this chapter, you will learn an easy and fast method for how
to determine the cardiac axis. The good news is, it’s much
easier than everyone tells you.

The shocking truth about the cardiac axis

If you’re like most ECG students, you find the evaluation of the cardiac axis utterly confusing, and you are
not sure why you have to learn it at all. Quite frankly, you are absolutely right.

When you compare the amount of time most folks spend studying the axis and the actual value it adds to
their reports, you’ll notice that the return on their time is humble. The good news is that there are only a
couple of things that are really important about the axis. In this section, we’ll teach you what they are.

With the complicated geometry of the ven-

tricles, you can imagine that at each point in
D
time there are vectors of different amplitudes
pointing in different directions inside the heart.
From all these momentary vectors, an average
A vector can be constructed for each point in
main vect
or
time.

We know that ventricular depolarization takes about 80

C to 100 ms (<0.1 s). In this image we have marked a few of
these instantaneous average vectors: A: vector at 5 ms; B:
vector at 30 ms; C: vector at 60 ms; D: vector at 80 ms. The
B dashed line connecting the tips of these vectors represents
the vector loop.

The strongest (i.e., longest) of these average vectors is called the main vector; it is the one that determines
the electrical axis of the heart in the frontal plane. In other words, the cardiac axis represents the direction
of the main electrical vector in the frontal plane.

The most precise way to determine the axis in the frontal plane would be to exactly calculate the direction
of the main vector. However, that’s too time consuming and not worth the effort because there are only a
few situations in which knowledge of the axis really makes a difference. You’ll learn what they are a little later.

What we should be able to do is to find the most important abnormalities of the electrical axis. Next we
outline a simple trick for doing so.
Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 107

Remember that a lead records a positive wave when the vector points into
the direction of that lead. When the vector points away from that lead, the
deflection will be mainly negative.

First, we have to learn the location of the leads (I, II, III, aVR, aVL, and aVF) on the Cabrera circle (or Cabrera
system). This system provides a convention for representing the limb leads in a logical sequence. The
location of each lead can be seen in the image below.
–90°
The degrees of the circle start near lead I with
0. When we go clockwise, the degrees are +60º,
+90º, etc., and when we go counterclockwise aVR aVL
they are negative (-30º, etc.).

+/–180° 0°I

III II
+90°
aVF

Let us now consider what

this means for lead I:

I I

Deflection is negative when vectors Deflection is positive when vectors

point away from lead I point in the direction of lead I

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
108

Let’s see what happens when leads I and II are mainly positive:

II
Lead I is mainly positive, so Lead II is also mainly
the main vector points into positive, so the main
the direction of lead I vector points into the
–90
direction of lead II

–30

0 I

+150

+60
+90 II

We can see that lead I and lead II will be po-

sitive if the main electrical vector points into
the intersection of the yellow and blue areas

The area between –30° and +90° is called a “normal axis”

So we know that if leads I and II are positive, the vector points at the area between –30° to +90°. Most
electrical vectors in humans are located in that sector and that’s why we call it a normal axis. The termi-
nology varies in different medical schools and countries. We will use the terms mostly used in British and
American textbooks.

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 109

Now let’s see what happens when lead I is positive and lead II is negative:

–90

–30

I 0

II
Lead I is mainly positive, so Lead II is mainly negative,
the main vector points into so the main vector points
the direction of lead I away from lead II
–90

–30

0 I

+150

+60
+90 II

So the main electrical vector has to point

into the direction of the intersection of
the yellow and gray areas

The area between –30° and –90° is called “left axis deviation”

If lead I is negative, you should look at lead aVF instead of lead II to determine the axis.

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 110

Now let’s see what happens when lead I is negative and aVF is positive:

–90 –90

+/–180 0 +/–180 0
I
I

+90 +90
Lead I is mainly negative, so
the main vector points away aVF
from lead I

Lead aVF is mainly positive,

so the main vector points
–90 into the direction of lead aVF

+/–180 0

+90

aVF

The main vector has to point at the

intersection of the gray and blue areas

The area between +90° and +/–180° is called “right axis deviation”

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 111

And what’s the matter when both leads I and aVF are negative?

–90 –90

+/–180 0 +/–180 0

+90 +90
Lead I is mainly negative, so
the main vector points away
from lead I aVF

Lead aVF is mainly negative,

so the main vector points
–90 away from lead aVF

+/–180 0

+90

aVF

The main vector has to point at the

intersection of the grey and blue areas

The area between –90° and +/–180° is called a “northwest axis”

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
112

You should only care about left axis deviation and right axis deviation for now. Why? Because when the
axis is normal, that won’t really help you in refining your diagnosis. A northwest axis is extremely rare—you
won’t encounter it much as a novice. But you will encounter left axis deviation and right axis deviation, and
they will help you in your diagnosis.
–90
So here’s an overview:

LEFT AXIS
–30
NORTHWEST DEVIATION
AXIS

+/–180 0

RIGHT AXIS NORMAL

DEVIATION AXIS
+150

+90 +60

So how can you determine the cardiac axis really easily? Here’s how…

All you have to do to determine the cardiac axis is to hold the ECG printout in your hands. Your left thumb
should be next to lead I. If lead I is positive, lead II should be next to your right thumb. If lead I is mainly
negative, lead aVF should be next to your right thumb:

–90 –90
If lead I is mainly positive,
look at lead II LEFT AXIS
–30 –30
DEVIATION

+/–180 0 +/–180 0

NORMAL
AXIS
+150 +150

+90 +60 +90 +60

I II I II

If both leads are mainly positive, If the left lead is mainly positive and the right
it’s a normal axis lead is mainly negative, it’s a left axis deviation
Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 113
–90 –90
If lead I is mainly negative,
look at lead aVF
–30 –30

NORTHWEST
AXIS
+/–180 0 +/–180 0

RIGHT AXIS
+150 DEVIATION +150

+90 +60 +90 +60

I aVF I aVF

If the right lead is mainly positive and the left If both leads are mainly negative,
lead is mainly negative, it’s right axis deviation it’s a northwest axis

You’ll get plenty of opportunities to assess the axis in the exercises!

Now let’s turn to the clinical situations in which knowledge of the cardiac axis makes a difference.

Situation #1

For ventricular depolarization, impulses

left bundle branch (LBB)
are conducted down into the ventricles
through the so-called bundle branches.
His bundle
There’s a right bundle branch (RBB) left anterior
fascicle (LAF)
and a left bundle branch (LBB). The
right bundle
left bundle branch is subdivided into
branch (RBB)
a left anterior fascicle (LAF) and a left left posterior fascicle
posterior fascicle (LPF) as shown in the (LPF)

image:

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
114

We have already learned that the QRS complex broadens when either the right or the left bundle branch
is blocked. Sometimes what happens in right bundle branch block is that one of the left fascicles is also
blocked. That’s called a bifascicular block. It’s a pretty dangerous situation because there’s only one fas-
cicle that’s left for the impulse to reach the ventricles. If this last fascicle gets blocked as well, the patient
ends up in complete heart block, a potentially life-threatening situation.

How can you tell whether bifascicular block is present? Well, if you have a typical picture of a right bundle
branch block in the precordial leads and you also have left axis deviation, the patient has bifascicular block
involving the left anterior fascicle (also called “right bundle branch block with left anterior hemiblock”):

I II
V1 V2

right bundle branch

+ = block with block of the

left anterior fascicle

right bundle branch block left axis deviation

The abbreviation for the left anterior fascicle is LAF. So there’s a straightforward mnemonic for
this situation:

Left axis deviation = LAF(T) block

When the patient has right bundle branch block plus right axis deviation, she probably also has
bifascicular block with involvement of the left posterior fascicle:

I aVF
V1 V2

right bundle branch

+ = block with block of the
left posterior fascicle

right bundle branch block right axis deviation

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 115

Situation #2

Whenever you suspect right ventricular hypertrophy from looking at the precordial leads, it often helps to
look for the presence of right axis deviation, which would reinforce your suspicion. So whenever the RSS
criteria are positive (e.g., you have a patient with a tall R in V1 and a deep S in V5) and this patient also has
right axis deviation, then you can be almost certain that something’s wrong with the right heart:

signs of right
increases likelihood of right
ventricular hypertrophy
in precordial leads
+ right axis deviation
ventricular hypertrophy

Situation #3

When there are signs of left ventricular hypertrophy in the ECG and the patient also has right axis devia-
tion, you should think of biventricular hypertrophy. As the name implies, this is a situation in which both
the left and the right ventricles are hypertrophic.

2.2 mV I aVF
V1 V2

biventricular
V5 V6 + = hypertrophy

3.1 mV

left ventricular hypertrophy right axis deviation

Great! Now you know when knowledge of the cardiac axis really
makes a difference. You should now integrate the evaluation of
cardiac axis into the steps of the cookbook. Congrats, you’ve al-
most made it through the training!

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
116

Atrial hypertrophy
Hypertrophy of the atria can be evaluated by looking at the P waves in the standard leads.

Left atrial hypertrophy

The P wave has two peaks, and usually the second peak is taller than the first one. P-wave duration is
greater than 0.1 seconds. These changes are most pronounced in leads I and II. This type of P wave is
called P mitrale:

P mitrale

P mitrale can also be nicely depicted in lead V1, where we would typically see a biphasic (i.e., positive–
negative) P wave. The negative part of the P wave corresponds to the enlarged left atrium. If the nega-
tive part is longer than 1 small box (or >0.04 s), then P mitrale is present:

>1 small box

(0.04 s)

Right atrial hypertrophy

This is best seen in leads II, III, and aVF. The P wave is peaked and exceeds 0.25 mV in amplitude. These
peaked P waves are called P pulmonale.

P pulmonale

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 117

Here are the criteria again:

V1 II criteria

Normal

right atrial enlargement P > 2.5 mm in II

P pulmonale

left atrial enlargement negative P in V1 >0.04 s

P mitrale and/or P-wave duration
>0.12 s in most cases

With this knowledge in mind, you should now add the evaluation of P waves
to your cookbook approach!

Low voltage
Low voltage refers to a situation in which none of the QRS complexes in the standard leads (i.e., leads I, II,
and III) is higher than 0.5 mV. Possible reasons for this finding are peripheral edema, pulmonary emphyse-
ma, large pericardial effusion, or severe myocardial damage, among others. The ECG cannot provide you
with a definitive diagnosis; it can just give you a hint that further workups are necessary.

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
118

Question Answer Diagnosis

1. Rhythm [coming later] [coming later]

2. Heart rate [coming later] [coming later]

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 V1 (1 mm) and P left atrial enlargement

wave with 2 peaks in II, P-wave duration >0.12 s

4. PR interval a) >0.2 s (if PR interval constant for all beats and each P I° AV block
wave is followed by a QRS complex)

b) <0.12 s and QRS complex normal LGL syndrome

c) <0.12 s and visible delta wave WPW syndrome

5. QRS axis Determine the axis according to leads I, II, and aVF normal axis
left axis deviation
right axis deviation
north-west axis

6. QRS duration a) ≥0.12 s (always think of WPW syndrome as a complete bundle

differential) branch block

b) >0.1 s and <0.12 s with typical bundle branch block incomplete bundle
appearance (notching) branch block

7. Rotation Rotation is defined according to the heart’s transition transition zone at V5-V6:
zone. Normally the transition zone is located at V4, which clockwise rotation
means 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: don’t 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

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 119

10. ST-T segment

tall T wave ST depression ST depression ST elevation negative T

hyperkalemia,
QRS normal vagotonia

probably ischemia
QRS normal (DD: digitalis)

nonspecific
repolarization
QRS normal
abnormality

acute ischemia,
QRS normal perimyocarditis,
variant angina

STEMI/
QRS normal perimyocarditis in
resolution

STEMI subacute,
NSTEMI,
QRS normal perimyocarditis

STEMI acute, STE-

MI in resolution,
QRS with Q wave
STEMI subacute

left ventricular
QRS: left ventricular
hypertrophy
hypertrophy
with abnormal
repolarization

In these situations
an ST-segment
deviation is
QRS: right ventricular
hypertrophy, bundle almost always
branch block, or WPW present and can-
syndrome not be interpreted
in and of itself.
It has to be left
out in the
ECG report

11. QT duration, [coming later] [coming later]

T-U waves

Level 11 The ECG trio—cardiac axis, atrial hypertrophy, and low voltage
 120

Level 11

exercises...

Level 11 Quiz section

QUIZ SECTION
And now it’s time for some

Electrical axis

Which additional changes

can be found?
(use our cookbook!)

Normal axis
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

I II III R L F
I II III R L F

V1 V2 V3 V4 V5 V6
V1 V2 V4 V5 V6
V3

ECG 1

I II III R L F I II III

V1 V2 V3 V4 V5 V6
 I II III R L F
I II III R L F

V1 V2 V3 V4 V5 V6
Electrical
V1 axis V2 V4 V5 V6
V3

Which additional changes

can be found?
(use our cookbook!)

Normal axis
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

I II III R L F I II III

V1 V2 V3 V4 V5 V6

V1 V2 V3 V4 V5 V6
ECG 2

Level 11 Quiz section

121
 122

Level 11 Quiz section

Electrical axis

Which additional changes

can be found?
(use our cookbook!)

Normal axis
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

I II III R L F
L F

V5 V6
V1 V2 V4 V5 V6
V3

ECG 3

F I II III

V1 V2 V3 V4 V5 V6

5 V6
 I II III R L F
L F

V5 V6 Electrical axis
V1 V2 V4 V5 V6
V3
Which additional changes
can be found?
(use our cookbook!)

Normal axis
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

L F I II III

V1 V2 V3 V4 V5 V6

5 V6
ECG 4

Level 11 Quiz section

123
 124

Level 11 Quiz section

Electrical axis

Which additional changes

can be found?
(use our cookbook!)

Normal axis
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

I II III R L F I II III R L F

V1 V2 V3 V4 V5 V6

ECG 5

V1 V2 V3 V4 V5 V6

I II III V1 V3 V5

I II III I II III
 I II III R L F I II III R L F

V1 V2 V3 V4 V5 V6
Electrical axis

Which additional changes

can be found?
(use our cookbook!)

Normal axis
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

V1 V2 V3 V4 V5 V6

I II III V1 V3 V5

I II III I II III

ECG 6

Level 11 Quiz section

125
Level 12

A short story about electrolytes

and heart rate
The ECG can help you detect various kinds of electrolyte
disturbances. Some of them are potentially life threatening.

Hyperkalemia and hypokalemia

Hyperkalemia (as seen in renal failure) is characterized by a tall and “tented” T wave (A in the illustration
below). Sometimes the ECG can lead to a diagnosis of chronic renal failure even in patients who don’t
exhibit any symptoms yet. In more severe cases (B in the illustration), the P wave gets lost and the QRS
complex gets broader.

Remember that in vagotonia we can also see tall T waves. But these T waves
are not as tall and sharp as the ones seen in hyperkalemia. Measurement of
potassium levels will give you the answer.

hyperkalemia hypokalemia

normal

T U

T U

QT

QU

Level 12 A short story about electrolytes and heart rate

 129

ECG changes seen in hypokalemia are a sign of cellular potassium loss. They are seen even before blood
levels start to drop. That’s why ECG changes associated with hypokalemia correlate less well with potas-
sium levels than changes associated with hyperkalemia.

The typical ECG changes seen in hypokalemia are flattening of the T wave, appearance of a U wave, and
ST depression. A U wave is a second positive deflection that comes after the T wave. Note that hypokale-
mia does not lead to a prolongation of the QT interval. The QT interval starts at the beginning of the QRS
complex and ends at the end of the T wave.

Don’t confuse the QU interval with the QT interval!

So remember:

• Hyperkalemia = tall T
Hyperkalemia • Hypokalemia = small T
tall T wave

Hypokalemia
small T wave

Hypocalcemia and hypercalcemia Normal

In hypercalcemia, the QT interval can be

shortened, whereas in hypocalcemia, the QT
interval can be prolonged.

And how will you know whether a patient’s QT

Hypocalcemia
interval is normal or not? Well, the normal QT
time varies with heart rate. When heart rate is
fast, the QT time shortens. When heart rate is
slow, QT time becomes longer. So there’s no
single normal value.
Hypercalcemia

Level 12 A short story about electrolytes and heart rate

130

So how can you know whether your patient’s QT interval is normal or not? There are two
approaches that you should know for now:

1. Most ECG machines will calculate the QTc time for you. That’s the corrected QT
interval normalized for a heart rate of 60 beats/min. The QTc is prolonged if it’s >0.44
seconds in men and >0.46 seconds in women.
2. And the quick and dirty method goes like this:

Normal QT interval

1/2

QT interval too long

1/2

Take an RR interval and “cut” it in half. If the T wave ends in the first half of the RR in-
terval (as in the top example), the QT interval is normal. If the T wave ends in the sec-
ond half of the RR interval (as in the lower example), the QT time is prolonged. If the QT
interval is prolonged, you should then calculate the QTc to verify your suspicion.

Heart rate quick tip

An easy way to assess heart rate is to divide 300 by the number of big boxes between two QRS complexes:

1 2 3 4 5

The distance from one QRS complex to the next is bet-

ween 4 and 5 boxes in length. 300/4 would be 75 beats/
min; 300/5 would be 60 beats/min. So the heart rate is
between 75 and 60 (probably around 65 beats/min).

Level 12 A short story about electrolytes and heart rate

 131

You should now add the evaluation of heart rate, T waves, U

waves, and the QT interval into your cookbook approach!

Question Answer Diagnosis

1. Rhythm [coming later] [coming later]

2. Heart rate Estimate heart rate: 300/number of large boxes between heart rate in beats per min
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 V1 (1 mm) and P left atrial enlargement

wave with 2 peaks in II, P-wave duration >0.12 s

4. PR interval a) >0.2 s (if PR interval constant for all beats and each P I° AV block
wave is followed by a QRS complex)

b) <0.12 s and QRS complex normal LGL syndrome

c) <0.12 s and visible delta wave 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 s (always think of WPW syndrome as a complete bundle

differential) branch block

b) >0.1 s and <0.12 s with typical bundle branch block incomplete bundle
appearance (notching) branch block

7. Rotation Rotation is defined according to the heart’s transition transition zone at V5-V6:
zone. Normally the transition zone is located at V4, which clockwise rotation
means 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: don’t 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

Level 12 A short story about electrolytes and heart rate

132

10. ST-T segment

tall T wave ST depression ST depression ST elevation negative T

hyperkalemia,
QRS normal vagotonia

probably ischemia
QRS normal (DD: digitalis)

nonspecific repo-
larization abnor-
QRS normal
mality

acute ischemia,
QRS normal perimyocarditis,
variant angina

STEMI/
QRS normal perimyocarditis in
resolution

STEMI subacute,
NSTEMI,
QRS normal
perimyocarditis

STEMI acute, STEMI

QRS with Q wave
in resolution, STEMI
subacute

left ventricular
QRS: left ventricular
hypertrophy
hypertrophy with abnormal
repolarization

In these situations
an ST-segment
deviation is almost
QRS: right ventricular
always present and
hypertrophy, bundle
branch block, or WPW
cannot be interpre-
syndrome ted in and of itself.
It has to be left out
in 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

Level 12 A short story about electrolytes and heart rate

 133

Level 12

QUIZ SECTION
Please use the updated cookbook for the following exercises and go through all
the steps that we have covered so far. (You can download the cookbook from www.
medmastery.com, as described in the Introduction.) The numbers in the table below
the ECGs correspond to the steps in the cookbook. If at one step during your evaluati-
on you find that something is wrong (e.g., PR interval, QRS width, etc.), just tick off the
respective number. You should estimate the heart rate and the axis for each ECG.

I II II III

I II

V1 V2 V3 V4
V1 V2 V3 V4 V5 V6

ECG 1

I II II III I
2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c

_________________ /min _________________________________________

Diagnosis:

V1 V2 V

V1 V2 V3 V4 V5 V6

Level 12 Quiz section

 V1 V2 V3 V4
V1 V2 V3 V4 V5 V6

134

I II II III I
ECG 2

V1 V2 V3 V

V1 V2 V3 V4 V5 V6

2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c

_________________ /min _________________________________________

Diagnosis:

III

I II III aVR aVL aVF

ECG 3

V1 V2 V3 V4 V5 V6 V7 V8
V5 V6
2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c
III I II III

_________________ /min _________________________________________

Diagnosis:

Level 12 Quiz section

V1 V2 V3 V4 V5 V6

5 V6
 V1 V2 V3 V4 V5 V6 V7 V8
4 V5 V6

135

II III ECG 4 I II III

V1 V2 V3 V4 V5 V6

4 V5 V6
2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c

_________________ /min _________________________________________

Diagnosis:

I
ECG 5 I II III

V1 V2

V1 V2 V3 V4 V5 V6

2 3 4 5 6 7 8 9 10 11
I
a b a b c a b a b c
I II III R L F

_________________ /min _________________________________________

Diagnosis:

Level 12 Quiz section

V1 V2 V3 V4 V5 V6 V1 V2
 V1 V2 V3 V4

V1 V2 V3 V4 V5 V6

136 I II III

ECG 6
I II III R L F

V1 V2 V3 V4 V5 V6 V1 V2 V3 V4

2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c

_________________ /min _________________________________________

Diagnosis:

ECG 7 I II III
III

V1 V2 V3 V4 V5 V6

V6
2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c
I II III R L F

L F _________________ /min _________________________________________

Diagnosis:

Level 12 Quiz section

V6 V1 V2 V3 V4 V5 V6
 V1 V2 V3 V4 V5 V6

V4 V5 V6
137

ECG 8
I II III R L F

III R L F

V4 V5 V6 V1 V2 V3 V4 V5 V6

2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c

_________________ /min _________________________________________

Diagnosis:

Level 12 Quiz section

Level 13

Rhythm 101—the sinus rhythm

If you want to be able to diagnose rhythm problems,
you’ll first have to learn what constitutes a sinus
rhythm (the healthy heart‘s normal rhythm). In sinus
rhythm there’s a regular sequence of P waves and
QRS complexes.

Criteria for sinus rhythm

All of the following four criteria need to be met in order for sinus rhythm to be present: (1) P waves are
positive in leads I and II; (2) every P wave is followed by a QRS complex; (3) the distance between each P
wave and the following QRS is constant; and (4) the distance between the QRS complexes is constant.
Let’s check the example below for the presence of sinus rhythm.

P
Sinus rhythm is present if the following
QRS criteria are met:

T 1. P waves are positive in leads I and II

2. Every P wave is followed by a QRS
I
complex
3. The distance between each P wave
II and the following QRS complex is
constant
4. The distance between the QRS
III
complexes is constant

Sinus Rhythm
L

Note that apart from the limb leads, we also show

you lead V1 here. This lead is located in close
proximity to the right atrium and is therefore ideally
F
suited for the assessment of atrial depolarization.
The P wave is usually biphasic in lead V1, the initial
positive deflection corresponds to right atrial depo-
V1 larization, and the second (negative) part corre-
sponds to left atrial depolarization.

Level 13 Rhythm 101—the sinus rhythm

 141

We have now covered all the steps of the cookbook! You’re almost done with the final
level. You are now able to speak the ECG language. You understand the most impor-
tant principles and are able to carry out a basic evaluation of the ECG. Great job!

Question Answer Diagnosis

1. Rhythm Criteria for sinus rhythm: sinus rhythm or
no sinus rhythm?
1. Are the P waves positive in 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: 300/number of large boxes between heart rate in beats per min
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 V1 (1 mm) and P left atrial enlargement

wave with 2 peaks in II, P-wave duration >0.12 s

4. PR interval a) >0.2 s (if PR interval constant for all beats and each P I° AV block
wave is followed by a QRS complex)

b) <0.12 s and QRS complex normal LGL syndrome

c) <0.12 s and visible delta wave 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 s (always think of WPW syndrome as a complete bundle

differential) branch block

b) >0.1 s and <0.12 s with typical bundle branch block incomplete bundle
appearance (notching) branch block

7. Rotation Rotation is defined according to the heart’s transition transition zone at V5-V6:
zone. Normally the transition zone is located at V4, which clockwise rotation
means 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: don’t 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

Level 13 Rhythm 101—the sinus rhythm

142

10. ST-T segment

tall T wave ST depression ST depression ST elevation negative T

hyperkalemia,
QRS normal vagotonia

probably ischemia
QRS normal (DD: digitalis)

nonspecific repo-
larization abnor-
QRS normal
mality

acute ischemia,
QRS normal perimyocarditis,
variant angina

STEMI/
QRS normal perimyocarditis in
resolution

STEMI subacute,
NSTEMI,
QRS normal
perimyocarditis

STEMI acute, STEMI

QRS with Q wave
in resolution, STEMI
subacute

left ventricular
QRS: left ventricular
hypertrophy
hypertrophy with abnormal
repolarization

In these situations
an ST-segment
deviation is almost
QRS: right ventricular
always present and
hypertrophy, bundle
branch block, or WPW
cannot be interpre-
syndrome ted in and of itself.
It has to be left out
in 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

Level 13 Rhythm 101—the sinus rhythm

 143

Level 13

QUIZ SECTION

additional diagnoses according

If there is sinus rhythm, make
Start by marking the P waves

to our cookbook.
and the QRS complexes, then
decide whether sinus rhythm
is present or not. Determine
the heart rate in each example.

III

V1
II
I
Heart

I
rate

III
I

II
no
Sinus

yes

V1

II
III

I
II
I
P
QRS
T

ECG 1

Level 13 Quiz section

 III

III
V1

I
V1

144
II
P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no III

Level 13 Quiz section

I

II
I

III
II

III
V1

ECG 2

V1

P
QRS
T

II

III

V1
ECG 3

II

III
 I

II

III
P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
I to our cookbook.
V1
T
yes no

II
I

III
II

V1

III

I
ECG 4

II
I

P
III
QRS II
T
III

I
V1

II

III

ECG 5 V1

Level 13 Quiz section

145
 146

Level 13 Quiz section

P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no

II

III

ECG 6
I

I II

II III

III
 I

II

III
P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
I
T
yes no

I II

II III

III

ECG 7

Level 13 Quiz section

147
 148
P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no

Level 13 Quiz section

I

II

III

ECG 8

P
QRS
T

II

III

ECG 9

II
 I

II
P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
III
T
yes no

II

III

ECG 10

Level 13 Quiz section

149
152

Level 1

QUIZ SOLUTION

P x x x x
QRS x x x x
T x x x x

ECG 1

This is an easy example, as P waves, QRS complexes, and T waves follow each other in a regular
fashion.

P x x x x x
QRS x x x x
T x x x x

ECG 2

As this is a more difficult example, use the technique of looking for the sharpest wave in order to
identify the QRS complexes (4 QRS complexes can be found in this example). The T wave appears
5–10 mm behind each QRS complex. The remaining 5 waves are not as sharp as the QRS complex,
but are sharper than the T wave and therefore must be P waves.

P x x x x x x x
QRS x x x x x x x x
T x x x x x x x x

ECG 3

It is important to note that the QRS complexes show 3 different morphologies in this example.
However, they can be identified as the sharpest waves. Furthermore, the T waves can be found
5–10 mm after each QRS complex. The P waves are not uniform and most are positive, but the 2nd
and the 4th P waves are negative.

Level 1 Quiz solution

 153

P x x x x x x
QRS x x x
T x x x

ECG 4

What makes this ECG a little bit tricky is the fact that P and QRS amplitudes are almost the same.
However, the QRS complexes have sharper edges than the P waves. Also, P and T waves inter-
fere with one another at some occasions (e.g., the 4th and the 6th P waves). Remember that the P
waves usually occur at very regular intervals. We should therefore be able to predict where the next
P wave should appear (this also applies to examples 1 and 2 above).

Level 1 Quiz solution

154

Level 2

QUIZ SOLUTION
Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

0.10 0.14 0.38

0.16 0.1 0.8
–0.12 –0.16 (0.52)

ECG 1 I

As the P wave does not start and end with a

sharp deflection but deviates from the isoelec-
tric line rather smoothly, it can sometimes be
hard to measure its exact duration. You may
get different results depending on which P wave
you are measuring (e.g., 2nd P wave 0.1 s, 3rd
P wave 0.12 s). If in doubt, you should perform
the measurements in different leads. The same
applies to the QT interval—the end of the T wave
is sometimes hard to determine. Whether the
positive deflection at the end was interpreted as
a U wave or as part of a biphasic T wave makes
a big difference (0.38 or 0.52 s). So always have
a look at several leads when performing tricky
measurements!

Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

0.08 0.08 0.08 0.36 0.15 1.3

ECG 2 I

Level 2 Quiz solution

 155
Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

0.44
0.08 0.08 0.12 0.1 1.1

I
–0.48

ECG 3

Also in this example, the end of the T wave is difficult to determine.

Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

T
0.38 2.5
0.10 0.30 0.08 0.1
–0.40 –2.7

ECG 4 P V5

This example is difficult because of the close proximity of the T and P waves. Look at the second beat—the
vertical line marks the beginning of the next P wave and the end of the preceding T wave. We need this
information in order to determine the QT duration (of the 1st beat). The amplitude of the QRS complex in
the 5 beats of this example varies between 2.5 and 2.7 mV. Such variation is common and usually reflects
changes in the heart’s position due to breathing.

Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

0.14 0.08 0.4 0.5

II 0.10
–0.16 –0.10
0.30
–0.5 –0.6

ECG 5

Level 2 Quiz solution

156
Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

I: 0.10 V1: 0.15

I: 1.1 V1: 0.25

0.14
0.14 0.10 0.44

V1
–0.16

ECG 6

The different time intervals (e.g., PR interval, QRS duration, QT interval) should be the same in all the leads
of the same ECG. For example, the P wave measures 0.14 s in lead I as well as in V1. The amplitudes of the
different waves of the ECG, however, vary greatly from lead to lead. Just have a look at the R wave of 1.1
mV in lead I and compare that to the R wave amplitude of 0.25 mV in V1.

Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

0.5
0.1 0.16 0.1 0.4 0.15
–0.6

ECG 7 I

Amplitude of the
Duration (s) highest positive
deflection (mV)

P PR QRS QT P QRS

0.1 0.26 0.20 0.42 0.15 0.45

ECG 8
II

Level 2 Quiz solution

 Level 3

ECG 3
ECG 2
ECG 1
QUIZ SOLUTION

I
I
I

P mitrale P mitrale P mitrale

I° AV block I° AV block I° AV block

x
LGL syndrome LGL syndrome LGL syndrome

x
WPW syndrome WPW syndrome WPW syndrome

Complete bundle Complete bundle Complete bundle

x

branch block branch block branch block

None of the None of the None of the

answers provided answers provided answers provided

Level 3 Quiz solution

157
158

answers provided
Complete bundle
WPW syndrome
LGL syndrome

branch block

None of the
I° AV block
P mitrale
V5

ECG 4

At first glance, especially looking at the third beat, one may suspect the presence of a P mitrale. The P
wave seems to be double-peaked with a length of 0.16 s. However, when looking at the first beat, you’ll
notice the fusion of the T and P waves. We added two vertical lines to the ECG. The first one indicates the
end of the T wave and the start of the following P wave. The second one indicates the end of the P wave.
So the P wave itself is not double-peaked, nor is it prolonged. On the other hand, the PR interval is clearly
lengthened, which indicates the presence of first degree AV block.

answers provided
Complete bundle
WPW syndrome
LGL syndrome

branch block

None of the
I° AV block
P mitrale

II
x

ECG 5

In this example, none of the suggested options is correct. You have certainly noticed that the P waves are
very sharp and exceptionally high (0.5 mV). As you will learn later, this may be due to right atrial hypertro-
phy.

Level 3 Quiz solution

 159

answers provided
Complete bundle
WPW syndrome
LGL syndrome

branch block

None of the
I° AV block
P mitrale
x

ECG 6
I V5

The P wave in this example is double-peaked and longer than normal (0.14 s in lead I). This is a typical
case of P mitrale resulting from volume overload and dilatation of the left atrium.

answers provided
Complete bundle
WPW syndrome
LGL syndrome

branch block

None of the
I° AV block
P mitrale

x x

ECG 7
II
In this example we can see a prolonged QRS complex (bundle branch block) and a prolonged PR duration
(first degree AV block).

Level 3 Quiz solution

160

Level 4

QUIZ SOLUTION

Which leads provide information on the...

V1 V2 V3 V4 V5 V6 V7 V8

Right ventricle x x x
Upper part of the septum x x
Left ventricle x x x x x x x
Anterior wall of the LV x x x
Lateral wall of the LV x x
Posterior wall of the LV x x

Which ventricle is represented by these leads under normal circumstances?

Right ventricle x x

Left ventricle x x

Level 4 Quiz solution

 161

Level 5

QUIZ SOLUTION
These examples demonstrate one important pheno-
menon: in bundle branch block, depolarization and
repolarization show in opposite directions. What does
that mean? Well, in right bundle branch block, the QRS
complexes in leads V1 and V2 are mainly positive but the
T waves are usually negative. And in left bundle branch
block, the QRS complexes in V5 and V6 are mainly
positive, while the T waves in these same leads are Diagnosis Diagnostic criteria

negative. This is true for examples 1, 2, 3, and 5. If you

Complete right bundle branch block

Complete left bundle branch block

Volume overload right ventricle

take a closer look at example 3, you’ll see that T waves

Volume overload left ventricle

Duration of the QRS complex

Duration of the PR interval

are also negative in leads V5 and V6, which cannot be

Delta wave in leads:

attributed to right bundle branch block. So there must be

(V1) QRS shape

(V6) QRS shape

WPW syndrome
some other cause for this repolarization problem, like, for
example, coronary artery disease.

V1 V2 V3 V4 V5
V1 V2 V3 V4

x x x
V6

ECG 1

V1 V2 V3

V4 V5 V6

Level 5 Quiz solution

 V5
162

V1

ECG 3
ECG 2
V1
V1

Level 5 Quiz solution

V2
V2
V2

V3
V4
V3
V3

V4
V5
V4

V5
V6
V6
V5

V6

x
x
Complete right bundle branch block

Complete left bundle branch block

Volume overload right ventricle

Diagnosis

Volume overload left ventricle

WPW syndrome

x
x
V1

Duration of the QRS complex

x
x

(V1) QRS shape

(V6) QRS shape

Duration of the PR interval

V2
Diagnostic criteria

Delta wave in leads:

V3
V4
V5
 163

Diagnosis Diagnostic criteria

Complete right bundle branch block

Complete left bundle branch block

Volume overload right ventricle

Volume overload left ventricle

Duration of the QRS complex

Duration of the PR interval

Delta wave in leads:

(V1) QRS shape

(V6) QRS shape

WPW syndrome
I

I
II III

V1 V2 V3
x x

V4 V5 V6
V1 V2 V3

ECG 4

I II

The notching of the QRSI complex seen

II in lead V1III
is called a R
right ventricular
L Fconduction delay. This RV
conduction delay may be a normal finding in young healthy individuals (under the age of 20 years).

V1 V2 V3 V4 V5 V6 V1 V2 V3

Level 5 Quiz solution

 164

Diagnosis Diagnostic criteria

Complete right bundle branch block

Complete left bundle branch block

Volume overload right ventricle

Volume overload left ventricle

Duration of the QRS complex

Duration of the PR interval

V1 V2 V3 V4 V5 V6

Delta wave in leads:

(V1) QRS shape

(V6) QRS shape

WPW syndrome
V1 V2 V3 V1 V2 V3

x x x
V3 V4 V5 V6 V4 V5 V6 V4 V5

ECG 5

V1 V2 V3

V1 V2 V3

V4 V5 V6
V1 - V6

x x x
V4 V5 V6

ECG 6

V1 V2broad and V3
The notched QRS complex in V1 may be misinterpreted as right bundle branch block. When in
fact, the first R wave corresponds to the delta wave, which can be even more clearly appreciated from V2
onward.

V4
Level 5 Quiz solution V5 V6
 V5
V1

V6
V2
V3

ECG 7
V1
V4

V2
V5

V4
V1

V3
V6

V2

V5
V4
V3

V6
V5

Complete right bundle branch block

V6

Complete left bundle branch block

Volume overload right ventricle

Diagnosis

Volume overload left ventricle

WPW syndrome
x

Duration of the QRS complex

(V1) QRS shape

x

(V6) QRS shape

Duration of the PR interval

Diagnostic criteria

Delta wave in leads:

Level 5 Quiz solution

165
166

Level 6

QUIZ SOLUTION

Rotation

Right ventricular

Right ventricular
volume overload

volume overload
Left ventricular

Left ventricular
hypertrophy

hypertrophy

Counterclockwise

transition zone
Clockwise

Normal
V1 V2 V3
V1 V2 V3

V4 V5 V6 V4 V5

x x

V1 V2 V3
ECG 1

R (mV) 3.2 2.2 1.8

S (mV) 2.9 3.2
R/S

Calculation of the Sokolow index suggests that left ventricular hypertrophy is present (SV1 + RV5 = 5.1 mV, V4 V5 V
SV2 + RV6 = 5 mV, SV1 + RV6 = 4.7 mV, SV2 + RV5 = 5.4 mV). Usually only the highest value will be used,
in this case SV2 + RV5. Some authors propose using only SV2 + RV6 or SV1 + RV5, which leads to a lower
sensitivity and a higher specificity. You should always try to confirm your suspicion of ventricular hyper-
trophy with echocardiography.

V1 V2 V3 V4 V5 V6

Level 6 Quiz solution

 167

Rotation

Right ventricular

Right ventricular
volume overload

volume overload
Left ventricular

Left ventricular
hypertrophy

hypertrophy

Counterclockwise

transition zone
Clockwise

Normal
V1 V2 V3

V6 V4 V5 V6 x x x

ECG 2

R (mV) 1.9
S (mV) 2.4
R/S
V1 V2 V3
High likelihood of left ventricular hypertrophy. The Sokolow index is 4.3 mV (SV2 + RV5 = 4.3 mV). This
case shows that we cannot always make a clear-cut diagnosis of the transition zone. In V3 the S wave is
still dominant, but in V4 the R wave is dominant, so the transition zone will be between V3 and V4. Thus it
is a borderline case.

V4 V5 V6

V5 V6

Level 6 Quiz solution

168 V4 V5 V6

Rotation
V1 V2 V3

Right ventricular

Right ventricular
volume overload

volume overload
Left ventricular

Left ventricular
V1 V2 V3

hypertrophy

hypertrophy

Counterclockwise

transition zone
Clockwise

Normal
V1 V2 V3
V4 V5

V4 V5 V6 V1 V2 V3
x x ?

V4 V5

ECG 3

R (mV) 0.6 3.1 3.4 2.7

S (mV) 0.8 1.8 1.4
R/S 0.75

This is a rare example with signs of right and left ventricular hypertrophy: the high R/S ratio (0.75) along
with a deep S wave in V5 suggests right ventricular hypertrophy. Also, the Sokolow index is positive, indi-
cating left ventricular hypertrophy (SV2 + RV5 = 5.2 mV). So this is a case of biventricular hypertrophy. In
this setting, diagnosis of rotation is not really possible.

Level 6 Quiz solution

 V1 V2 V3

169

V6 V4 V5 V6

Rotation

Right ventricular

Right ventricular
volume overload

volume overload
The high R/S ratio in V1, together with a deep S wave in V5 and an

Left ventricular

Left ventricular
hypertrophy

hypertrophy

Counterclockwise

transition zone
M shape of the QRS complex in V1, suggests the presence of right

Clockwise

Normal
ventricular hypertrophy.

V1 V2 V3

V4 V5 V6
x x x

ECG 4

V5 V6 R (mV) 0.6 1.2

S (mV) 0.3 1.3
R/S 2.0
V1 V2 V3
V1 V2 V3

V4 V5 V6
x x x
V4 V5

ECG 5

R (mV) 0.05 3.0 2.8 2.5

S (mV) 2.4
V1 V2 V3
R/S 0.02
V1 V2 V3

Level 6 Quiz solution

V4 V5 V6

V4 V
170

Rotation

Right ventricular

Right ventricular
volume overload

volume overload
Left ventricular

Left ventricular
hypertrophy

hypertrophy

Counterclockwise

transition zone
Clockwise

Normal
V1 V2 V3

V4 V5 V6 x x

ECG 6

R (mV) 0.2 2.5 2.4 2.3

V1 V2 V3
S (mV) 1.5 2.4
R/S 0.13

The Sokolow index (SV2 + RV5 = 4.8 mV) suggests left ventricular hypertrophy. Note that left ventricular
hypertrophy may be associated with normal repolarization in the ECG (positive T waves in leads with more
prominent R waves than S waves, as can be seen in examples 2 and 8). However, some patients with ven-
tricular hypertrophy do have negative T waves, such as here.
V4 V5 V6

Level 6 Quiz solution

 V1 V2 V3
V1 V2 V3

V4 V5 V6

171 V4 V5
Rotation

Right ventricular

Right ventricular
volume overload

volume overload
Left ventricular

Left ventricular
hypertrophy

hypertrophy

Counterclockwise

transition zone
Clockwise

Normal
V1 V2 V3

V1 V2 V3

V1 V2 V3 V4 V5 V6

V4 V5 V6
x x

V4
ECG 7

6
R (mV) 1.5–1.6 0.9
S (mV) 0 0.9
R/S ∞

V1 V2 V3

V4 V5 V6 x x

ECG 8

R (mV) 0.15 3.4 3.5

S (mV) 1.3
R/S 0.115

The Sokolow index suggests left ventricular hypertrophy. Furthermore, counterclockwise rotation is also
present in this patient.
Level 6 Quiz solution
172

Level 7

QUIZ SOLUTION
V1 V2 V3
ST depression T negativity Diagnosis

Complete right bundle branch

Right ventricular hypertrophy
Complete left bundle branch
Left ventricular hypertrophy

Coronary T-wave inversion

Negative–positive biphasic

Positive–negative biphasic
Asymmetrically negative

Coronary ST depression
Symmetrically negative
Sagging or U-shaped

WPW syndrome
Descending

Horizontal
Ascending
None

None
Flat
V1 V2 V3 V1 V2

V4 V5 V6

V5 V5 V6 x V4
V6

V4 V5 V6
ECG 1

A left bundle branch block is present (M shape in V5 and V6; QRS > 0.12 s). As expected in left bundle
branch block, there are ST depressions and negative T waves in V5 and V6 as signs of impaired
repolarization. The T wave is biphasic (negative–positive) in V5. Note that the ST depression over the
left ventricle (V5, V6) is accompanied by an ST elevation in V1, V2 (mirror image). You can find similar
changes in examples 2, 4, 5, and 7.

Level 7 Quiz solution

 173

ST depression T negativity Diagnosis

Complete right bundle branch

Right ventricular hypertrophy
Complete left bundle branch
Left ventricular hypertrophy

Coronary T-wave inversion

Negative–positive biphasic

Positive–negative biphasic
Asymmetrically negative

Coronary ST depression
Symmetrically negative
Sagging or U-shaped

WPW syndrome
Descending

Horizontal
Ascending
None

None
Flat
V1 V2 V3

V5 V5 V6 x
V6

V1 V2 V3 V1 V2 V3

ECG 2
V4 V5 V6

Typical ECG changes associated with left ventricular hypertrophy: high R wave in V4, deep S wave in V1.
Here we can use V4 for the calculation of the Sokolow index because the counterclockwise rotation of the
heart (transition zone between V2 and V3) proves that V4 is definitely already left ventricle. The descend-
ing ST depressions and asymmetric T-wave inversions are signs of impaired repolarization in the setting
V4 V5 V6
of ventricular hypertrophy.

V4 V5 V6

Level 7 Quiz solution

 174
ST depression T negativity Diagnosis

Complete right bundle branch

Right ventricular hypertrophy
Complete left bundle branch
Left ventricular hypertrophy

Coronary T-wave inversion

Negative–positive biphasic

Positive–negative biphasic
Asymmetrically negative

Coronary ST depression
Symmetrically negative
Sagging or U-shaped

WPW syndrome
Descending

Horizontal
Ascending
None

None
Flat
V1 V2 V3

V6

V1
V2
x x x
V4 V5 V6 V3
V4

ECG 3

In this example, right ventricular hypertrophy (high R/S ratio in V1, deep S wave in V5) is present. Repolar-
ization is impaired over the right ventricle (negative T waves in V1–V4). Left ventricular hypertrophy also
seems to be present (positive Sokolow index). Repolarization over the left ventricle is normal.

Level 7 Quiz solution

 175

ST depression T negativity Diagnosis

Complete right bundle branch

Right ventricular hypertrophy
Complete left bundle branch
Left ventricular hypertrophy

Coronary T-wave inversion

Negative–positive biphasic

Positive–negative biphasic
Asymmetrically negative

Coronary ST depression
The T waves in this example are normal although a bit

Symmetrically negative
Sagging or U-shaped
flat in V5 and V6. Note the concave or horizontal ST

WPW syndrome
depressions over the left ventricle, which could be a

Descending

Horizontal
Ascending
sign of coronary artery disease.

None

None
Flat
V1 V2 V3

V1 V2 V3

V5 V6 V4 x x

V4 V5

V4 V5 V6
ECG 4

V1 V2 V3 V1 V2 V3

V1 V2 V3

V5
V5 V6 x
V6

V4 V5 V6 V4 V5

V4 V5 V6
ECG 5

There are several interesting findings in this ECG: ST elevation in V2, ST depression in V5 and V6, a short
PR interval, and a slurred upstroke of the QRS complex. A delta wave is clearly visible in leads V3–V5. This
is a case of WPW syndrome in which repolarization is almost always impaired.
V1 V2 V3

Level 7 Quiz solution

V4 V5 V6
 V1 V2 V3

V1 V2 V3

176

ST depression T negativity Diagnosis

Complete right bundle branch

Right ventricular hypertrophy
Complete left bundle branch
Left ventricular hypertrophy

Coronary T-wave inversion

Negative–positive biphasic

Positive–negative biphasic
Asymmetrically negative

Coronary ST depression
These terminally negative biphasic T waves may be due

Symmetrically negative
V4 V5

Sagging or U-shaped
to ACS or non-Q infarction in resolution. These changes

WPW syndrome
can also be present in pericarditis.

Descending
V4 V5 V6

Horizontal
Ascending
None

None
Flat
V1 V2 V3 V1 V2 V3
V1 V2 V3

V4
x V5 x
V6

V4 V5 V6 V4 V5 V
V4 V5 V6
ECG 6

V1 V2 V3

V4 V4
V2
V5 V5 x x
V3
V6 V6

V4 V5 V6

ECG 7

Left ventricular hypertrophy (positive Sokolow index) with accompanying ST-T wave changes in leads
V5 and V6. Also, there’s an old anteroseptal infarct (loss of R wave in V2 and Q wave in V3) with T-wave
negativity in V2 and V3. So we have two different types of T-wave changes in this example—one due to left
ventricular hypertrophy, the other one due to myocardial ischemia.

Level 7 Quiz solution

 Level 8

QUIZ SOLUTION

There’s an R wave in V1, but in V2 it’s missing. The QS morphology in Changes in QRS morphology related to
Which additional ECG
myocardial infarction (pathologic Q wave,
V2 is compatible with an old anteroseptal infarct. The Q wave in V4 Infarction Localization changes can be found?
QS pattern, reduced initial R wave)
(write them down)
can be found in leads
may be normal. As a consequence, the T waves are negative over the
V1 V2 V3 V4 V5 V6 V7 V8
left ventricle. Furthermore the PR interval is prolonged to 0.28 s. First
degree AV block is therefore present. The Sokolow index (SV1 + RV5
= 3.4 mV) is borderline, but the R wave in V4 alone exceeds 2.5 mV, so
left ventricular hypertrophy becomes very probable.
Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
Posterolateral region

V1 V2 V3 V4 V5 V6

First degree
V2 V3 V4 V5 AV block,
V6 left V7 V8
x x (x) x ventricular
hypertrophy

ECG 1

V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6

Level 8 Quiz solution

177
 V1 V2 V3 V4 V5 V6

178
Changes in QRS morphology related to
Which additional ECG
myocardial infarction (pathologic Q wave,
Infarction Localization changes can be found?
QS pattern, reduced initial R wave)
(write them down)
can be found in leads
V2 V3 V4 V5 V6 V7 V8
V1 V2 V3 V4 V5 V6 V1 V2 V3 V4 V5 V6 V7 V8

Level 8 Quiz solution

Note the Q waves (of 0.04 s) in V4–V6 suggesting anterolateral myocar-
dial infarction. Also, the QRS complex is broadened to >0.12 s and has an
M shape in V1. Right bundle branch block is therefore present. V2 V3 V4 V5 V6 V7 V8

Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
Posterolateral region

V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6
Complete right
x x x x bundle
branch block

ECG 2 V1 V2 V3 V4 V5 V6
V1 V2 V3 V4 V5 V6

The diagnosis in this case can be based on the loss of the initial R wave
between V1 and V2. There is an R wave in V2, but it only appears after a
V1 V2 V3 V4 V5 V6
Q wave and cannot be called an “initial R wave.” The Q wave in V4 may
be normal again. There is remarkable ST elevation in V2 and V3, and also V1 V2 V3 V4 V5 V6 V7
slightly in V4, indicating the acute phase of the infarction.

V1 V2 V3 V4 V5 V6

V1 V2 V3 V4 V5 V6 V7

x x (x) x acute phase

ECG 3
 Take a careful look at the Q waves in V5–V8. They appear small, but
Changes in QRS morphology related to
Which additional ECG
their amplitude has to be judged in comparison to the R waves of the myocardial infarction (pathologic Q wave,
Infarction Localization changes can be found?
QS pattern, reduced initial R wave)
(write them down)
same lead. Here the amplitude of the Q waves is as high as that of the R can be found in leads

waves. Furthermore the duration of the Q waves (0.04 s) is significantly V1 V2 V3 V4 V5 V6 V7 V8

prolonged. Compared with the small amplitude of the QRS complex in

V6, V7, and V8, the ST segment must also be considered to be elevated.
This would classify the infarct as acute, which is strongly supported by
the mirror image of ST depression in V2, V3, and V4.
Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
Posterolateral region

4 V5 V6 V2 V3 V4 V5

x x x x x
V6 V7 V8

ECG 4

Level 8 Quiz solution

179

V5 V6
V1 V2 V3 V4 V5 V6
 V6

180
Changes in QRS morphology related to
Which additional ECG
The loss of the initial R wave (in V2), the negative T waves in V2 and V3, myocardial infarction (pathologic Q wave,
Infarction Localization changes can be found?
QS pattern, reduced initial R wave)
(write them down)
V2 and the presence
V3 wave in V3 are
of a QV4 V5 signs of anteroseptal
V6 myocardi-
V7 V8 can be found in leads

al infarction. When we also consider the Q wave in V4 as pathologic (Q V1 V2 V3 V4 V5 V6 V7 V8

Level 8 Quiz solution

V5 V6 are decreasing
waves V2 V3from V4 to V6!),
V4 this would
V5 mean that the complete
anterior wall is infarcted. The diagnosis of left ventricular hypertrophy is
based on the Sokolow index (SV1 + RV5). The negative T waves over the
left ventricle are a consequence of left ventricular hypertrophy.

Anteroseptal
Anterior wall
Lateral wall
Anterolateral region
Posterior wall
V6 V7 V8 Posterolateral region
5 V6
V1 V2 V3 V4 V5 V6

Left ventricular
x x x x hypertrophy

V5 V6
V1 V2 V3 V4 V5 V6

ECG 5

V6

V1Broad Q waves
V2 can be found
V3 in V1–V4 V4plus a Q wave
V5 in V5, suggesting
V6 V7
anterolateral myocardial infarction. Right bundle branch block is also
present (QRS duration >0.12 s, M shape in V1).

V5 V6 V1 V2 V3 V4

Complete right
x x x x x bundle
branch block
V5 V6 V7

ECG 6
 QRS Hyper-
Level 9
PR Rotation Infarction
duration trophy

I° AV block
QUIZ SOLUTION

Inferior wall

Anterior wall
Posterior wall

Lateral region

LGL syndrome
Complete LBBB
Complete RBBB

WPW syndrome
Clockwise rotation
Anteroseptal region
Anterolateral region

Dilated left ventricle

Posterolateral region

Dilated right ventricle

Normal transition zone
Counterclockwise rotation
Left ventricular hypertrophy
I II III R L F Right ventricular hypertrophy

V1 V2 V3
x x ? x

V1 V2 V3 V4 V5 V6
There is another pathology that
won‘t allow me to evaluate rotation.

ECG 1
V4 V5 V6

The QRS width is between 0.12 and 0.14 s, leading to the diagnosis of complete
I II III R L F
BBB. The QRS complex in V1 is M shaped, so this must be RBBB. Pathologic Q
waves can be detected in leads II, III, and aVF as well as V4 to V6. So this must be
an infarct of the inferior and lateral walls. If we also had V7 and V8 available, we
III R L F
might see Q waves there as well, which would indicate that the posterior wall was
affected as well. The transitional zone in this example is located at V2 and V3, so
we might suspect counterclockwise rotation. However, we have already learned
that you cannot evaluate rotation in cases of BBB or myocardial infarction. I II
V1 V2 V3 V4 V5 V6

Level 9 Quiz solution

181

V1 V2 V3 V4 V5 V6
 4
L

V5
V5

V5
F

V6
V6

V6

Level 9 Quiz solution

ECG 2
V1

V1
repolarization).
V2

II

V2
V3

V3
III
V4

V4
V5

V5
V6

V6
According to the Sokolow index, this must be left ventricular hypertrophy (with disturbed
I° AV block
PR

WPW-syndrome
LGL-syndrome
Complete RBBB
Complete LBBB
QRS

Dilated right ventricle

duration

Dilated left ventricle

x
Normal transition zone
Clockwise rotation
Rotation

Counterclockwise rotation
Right ventricular hypertrophy

x
trophy
Hyper-

Left ventricular hypertrophy

Anteroseptal region
Anterior wall
Anterolateral region
Lateral region
Posterolateral region
Infarction
Posterior wall
Inferior wall
182
 4

4
4
L

V5
V5

V5
F

V6
V6

V6

Level 9 Quiz solution

ECG 3
V1

V1
V2

II

V2
V3

wave inversions in leads II, III, and aVF.

V3
III
V4

V4
V5

V5
V6

V6

As we’ve already learned, you should not evaluate rotation in the setting of myocardial
infarction. Note the very high T waves in leads V2 and V3, representing mirror images of T-
I° AV block
PR

WPW-syndrome
WPW syndrome
LGL-syndrome
LGL syndrome
Complete
complete RBBB
Complete
complete LBBB
QRS

Dilated
dilated right ventricle
duration

Dilated
dilated left ventricle
Normal
normal transition zone
There‘s another pathology that
Clockwise
clockwise rotation
won‘t allow me to evaluate rotation
Rotation

Counterclockwise
counterclockwise rotation
Right
right ventricular hypertrophy
ventricular hypertrophy
trophy
Hyper-

Left
left ventricular
ventricular hypertrophy
hypertrophy
Anteroseptal
anteroseptal region
Anterior
anterior wall
Anterolateral
anterolateral region
Lateral
lateral region
region
Posterolateral region
posterolateral
Infarction
posterior
Posterior wall

x
Inferior
inferior wall
183
 Level 9 Quiz solution
ECG 4
I
V1
I

V1
V1
II
II

V2

V2
V2
V3
III

III

V3
V3
R
R

V4

V4
V4
L

V5
V5

V5

nosis does not allow statements of rotation, hypertrophy, infarction, etc.

F

V6
V6

V6

Making the diagnosis of WPW syndrome must be a piece of cake for you by now! This diag-
I°I°AV
AVblock
block

x
PR

WPW syndrome
WPW-syndrome
LGL syndrome
LGL-syndrome
V1

Complete
completeRBBB
RBBB
I

V1
Complete
completeLBBB
LBBB
QRS

Dilated
dilatedright
rightventricle
ventricle
duration

Dilated
dilatedleft
leftventricle
ventricle
There‘s another pathology that Normal
normaltransition
transitionzone
zone
V2

won‘t allow me to evaluate Clockwise

clockwiserotation
rotation
rotation II
Rotation

Counterclockwise
counterclockwiserotation
rotation

V2
Right ventricular
right hypertrophy
ventricular hypertro-
trophy
Hyper-

Left
leftventricular
ventricularhypertrophy
hypertrophy
V3

Anteroseptal
anteroseptalregion
region
Anterior
anteriorwall
wall

V3
III
Anterolateral
anterolateralregion
region
Lateral
lateralregion
region
Posterolateral
posterolateralregion
region
Infarction
Posterior
posteriorwall
wall
V4

Inferior
inferiorwall
wall

V4
184
V5

V5
V6

V6
 I II III R L F
QRS Hyper-
PR Rotation Infarction
duration trophy

V1 V2 V3

hypertrophy
hypertrophy
region

I° AV block
inferior wall
Inferior

anterior wall
Anterior
lateral region
Posterior wall
posterior

Lateral

LGL syndrome
complete LBBB
complete RBBB
LGL-syndrome
Complete
Complete

WPW syndrome
WPW-syndrome
ventricular hypertrophy

clockwise rotation
Clockwise
ventricular hypertrophy
anteroseptal region
anterolateral region

Anteroseptal

dilated left ventricle

Anterolateral

Dilated
V1 V2 V3 V4 V5 V6
Posterolateral region
posterolateral

dilated right ventricle

Dilated
normal transition zone
Normal
counterclockwise rotation
Counterclockwise
left ventricular
Left

right ventricular
Right

V4 V5 V6

I II III R L F

III R L F
x x x

I II
V1 V2 V3 V4 V5 V6
There‘s another pathology that
won‘t allow me to evaluate rotation

ECG 5

Changes in QRS morphology typical for myocardial infarction in the anteroseptal and lateral
segments (QS in leads V2 and V3 and pathologic Q waves in leads V4 and V5). Furthermore,
note the Q waves in leads I, II, III, aVL, and AVF. The Q waves in leads I and aVL represent lat-
eral wall myocardial infarction, whereas the changes in leads II, III, and aVF indicate that the V1 V2 V3 V4 V5 V6
inferior wall also has a problem. You will learn later that the ST elevations in leads II, III, and
V1 V2 V3 V4 V5 V6
aVF indicate the presence of acute inferior wall myocardial infarction.

Level 9 Quiz solution

185
 186

Level 10

Level 10 Quiz solution

In this example we cannot find changes in the QRS complex typical of
QUIZ SOLUTION
myocardial infarction. On Feb 19, there were ST elevations in leads V2 to
V5. On March 16, the ST segment has nearly returned to the isoelectric
line and there remains a biphasic T wave in leads V4 to V6. There are two Pathology Phase

explanations for these changes: 1) perimyocarditis or 2) acute myocardial

infarction without the development of Q waves. The extensive ST changes
Which additional
without the subsequent development of Q waves suggests an inflam- pathologies can be found?

Acute
Chronic (use our cookbook)
matory cause. Finally, the patient was an 18-year-old male, which makes
In resolution

mentioned

Q-wave STEMI
Acute coronary
Perimyocarditis
an acute coronary syndrome rather unlikely.

syndrome/NSTEMI
Nomenclature

Non-Q-wave STEMI
(only applies to STEMI)
cannot be applied

None of the pathologies

on the first ECG

Feb 19

x x

V1 V2 V3 V4 V5 V6

on the follow-up ECG

March 16

x x

ECG 1

V1 V2 V3 V4 V5 V6
 V1 V2 V3 V4 V5 V6

Pathology Phase

Impressive T-wave inversions in leads V2 to V6 but no changes to the QRS

Which additional
complex. The ECG is recorded immediately after chest pain (duration of 30 pathologies can be found?

Acute
(use our cookbook)

Chronic
minutes). Because the patient has no history of coronary heart disease, this

mentioned
In resolution

Q-wave STEMI
Acute coronary
Perimyocarditis

syndrome/NSTEMI
would be a clear indication for invasive workup.

Nomenclature

Non-Q-wave STEMI
(only applies to STEMI)
cannot be applied

None of the pathologies

V1 V2 V3 V4 V5 V6

x x

This is a patient who

presents to you with
chest pain. He never
had an ST elevation.
ECG 2

x x
V1 V2 V3 V4 V5 V6

ECG 3

In addition to the acute ST-segment changes over the anterior wall, there are T-wave inversions in
lead V6, suggesting preexisting repolarization problems in addition to the acute ischemic event.

Level 10 Quiz solution

187

I II III R L F

V1 V2 V3 V4 V5 V6
 188
Pathology Phase

V1 V2 V3 V4 V5 V6
Note the mirror images of an acute inferior ischemia in leads V2, V3, aVR, and
Which additional
aVL. The Q waves in leads II, III, and aVF are not deep and wide enough to make pathologies can be found?

Acute

Level 10 Quiz solution

(use our cookbook)

Chronic
the diagnosis of Q-wave STEMI, but it is a typical pattern of acute ischemia,

In resolution

mentioned

Q-wave STEMI
Acute coronary
Perimyocarditis

syndrome/NSTEMI
Nomenclature
which may show Q waves within the next hour or so.

Non-Q-wave STEMI
(only applies to STEMI)
cannot be applied

None of the pathologies

I II III R L F
V5 V6

V1 V2 V3 V4 V5 V6 There is a helpful
mirror image in
? ? x V2-V4

L F

V1 V2 V3 V4 V5 V6
ECG 4
V5 V6

x x

ECG 5 V1 V2 V3 V4 V5 V6

Extensive subacute anterolateral myocardial infarction (STEMI in resolution).

 Pathology Phase

Which additional
Chronic (old) anterolateral myocardial infarction in combination with an acute pathologies can be found?

Acute
(use our cookbook)

Chronic
inferior myocardial infarction (ST elevations in leads II, III, and aVF) with mirror

mentioned
In resolution

Q-wave STEMI
Acute coronary
I II III R L F

Perimyocarditis
I R L F

syndrome/NSTEMI
Nomenclature
images (ST depressions in
II leads V2 and
IIIV3).

Non-Q-wave STEMI
(only applies to STEMI)
cannot be applied

None of the pathologies

I II III R L F
I II III R L F

x (inferior) x

V1 V2 V3 V4 V5 V6
x (anterolateral) x

V1 V2 V3 V4 V5 V6
ECG 6

V1 V2 V3 V4 V5 V6

V1 V2 V3 V4 V5 V6
left ventricular
x x hypertrophy with
volume overload

ECG 7 V1 V2 V3 V4 V5 V6 I II III I II III

No signs of myocardial infarction can be detected in this example, but left ventricular hypertrophy is present with a notched R

Level 10 Quiz solution

189

wave in lead
V1 V6 and aV2 V3
delayed intrinsicoid V4
deflection (60 ms).
V5 In this case,
V6left ventricular volume overload
I is probably
II present. III I II III
5
L

V5

V6
V6
F

Level 10 Quiz solution

ECG 8
June 4
June 1
I

I
V1
II

II
V2
III

III
V3

I
R

V4
L

II
V5

June 6

III
F

V6
Q-wave STEMI

x
x

Non-Q-wave STEMI
Acute coronary
syndrome NSTEMI
Pathology

Perimyocarditis
None of the pathologies
mentioned
x Acute

x
In resolution
Chronic
Phase

(only applies to STEMI)

Nomenclature
cannot be applied

block
complete left
bundle branch
Which additional

(use our cookbook)

pathologies can be found?
190
 191

This is a rare and tricky ECG: we have learned

that in the case of preexisting LBBB the diag-
nosis of hypertrophy or myocardial infarction
is impossible most of the time. However, in
this example the time-dependent changes of
the ST elevations in leads II, III, and aVF, and
to a lesser extent in leads V5 and V6 (June
1), allow us to make the diagnosis of STEMI
anyway.

We have learned that in LBBB in leads V5

and 6, we have to expect ST depression and
negative T waves. Here we find a moderate
ST elevation instead, which is clearly patho-
logic, suggesting acute coronary ischemia. Of
course we may not expect any QRS signs of
infarction (Q waves) because the QRS complex
is already massively deformed by the BBB.
This example shows you that comparison of
ECGs over time can give you very important
clues that you might miss otherwise!

Level 10 Quiz solution

 192

Level 11

Level 11 Quiz solution

QUIZ SOLUTION

Electrical axis

Which additional changes

can be found?
(use our cookbook!)
Lead I is mainly positive, lead II is neither positive nor negative. The axis

Normal axis
northwest axis/

must therefore be in between a normal axis and left axis deviation.

Left axis deviation

Right axis deviation
extreme axis deviation

I II III R L F
I II III R L F

V1 V2 V3 V4 V5 V6 in between acute anterolateral STEMI

x V1 V2 V4 V5 V6
V3

ECG 1

I II III R L F I II III

V1 V2 V3 V4 V5 V6
 At first glance one may diagnose a right axis deviation in this example. How-
ever, something’s puzzling here. The P wave and QRS complex in lead aVR
are positive, which is almost never the case. Maybe this person has situs in-
versus? But in that case, the precordial leads would look totally different. This
ECG was taken by the new medical student, so we should suspect misplace- I II III R L F
II
ment of the Iextremity leads. III
After sending R
the student L
back to obtain F
another
ECG, this is what he came back with:

V1 V2 V3 V4 V5 V6
axis
ElectricalV1 V2 V4 V5 V6
V3

Which additional changes

can be found?
You can see that the axis is normal now. He had misplaced the electrodes (use our cookbook!)

Normal axis
(right arm and left arm) and that’s what caused the right axis deviation.
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

I II III R L F I II III

V1 V2 V3 V4 V5 V6
wrong lead anteroseptal STEMI
placement in resolution

V1 V2 V3 V4 V5 V6
ECG 2

Level 11 Quiz solution

193
 194

Level 11 Quiz solution

This example shows RBBB along with left axis deviation, indicating that the Electrical axis
left anterior fascicle is also blocked (remember the mnemonic LAFT!). In
addition, first degree AV block is also present. When bifascicular block (RBBB
+ block of left anterior fascicle) is combined with first degree AV block, then Which additional changes
can be found?
that’s called trifascicular block, which indicates that the left posterior fascicle (use our cookbook!)

Normal axis
could also have a problem. The disturbed left ventricular repolarization may

northwest axis/

Left axis deviation

Right axis deviation
be caused by digoxin.
extreme axis deviation

I II III R L F
L F

RBBB plus left axis deviation =

bifascicular block

V5 V6 x In addition, there is first

V1 V2 V4 V5 V6 degree AV block, so this is a
case of incomplete
V3 trifascicular block

ECG 3

F I II III

V1 V2 V3 V4 V5 V6

5 V6
 I II III R L F
L F

V5 V6 Electrical axis
V1 V2 V4 V5 V6
V3
Which additional changes
can be found?
(use our cookbook!)
This is a clear case of P mitrale—prolonged and biphasic in leads I, II, and III.

Normal axis
northwest axis/
Also note the large negative P wave in lead V1 of more than 1 box!

Left axis deviation

Right axis deviation
extreme axis deviation

L F I II III

V1 V2 V3 V4 V5 V6
P mitrale
x Biventricular hypertrophy

5 V6
ECG 4

Level 11 Quiz solution

195
 196

Level 11 Quiz solution

Electrical axis

Which additional changes

can be found?
(use our cookbook!)

Normal axis
northwest axis/

Left axis deviation

Right axis deviation
extreme axis deviation

I II III R L F I II III R L F

acute inferior + lateral wall

V1 V2 V3 V4 V5 V6 myocardial infarction +
x mirror image

ECG 5

V1 V2 V3 V4 V5 V6

I II III V1 V3 V5

I II III I II III
 I II III R L F I II III R L F

V1 V2 V3 V4 V5 V6
Electrical axis

The tall R wave in lead V1 plus deep S wave in lead V5 point to RVH. This is
supported by the high P wave in leads II and III (P pulmonale) and the right Which additional changes
can be found?
axis deviation. Even though we do not have lead aVF, we can say that with a
(use our cookbook!)
negative QRS complex in lead I and mainly positive QRS complex in leads II

Normal axis
northwest axis/

and III, the axis must be right.

Left axis deviation

Right axis deviation
extreme axis deviation

V1 V2 V3 V4 V5 V6

I II III V1 V3 V5
definite right ventricular
hypertrophy
x
right atrial
hypertrophy

I II III I II III

ECG 6

Level 11 Quiz solution

197
198

Level 12

QUIZ SOLUTION

ECG 1 I II II III

I II III

V1 V2 V3 V4
V1 V2 V3 V4 V5 V6

I II II III I
2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c
x x x

95 /min
_________________ left axis deviation
_________________________________________

Diagnosis:

right atrial hypertrophy V1 V2 V3 V

clockwise rotation
hyperkalemia
V1 V2 V3 V4 V5 V6

The high P-wave amplitude in lead II of 0.3 mV is compatible with right atrial hypertro-
phy. The very high T waves in leads V2 to V6 could be caused by hyperkalemia. This
was confirmed by a plasma potassium level of 6.5 mmol/L.

Level 12 Quiz solution

 I II II III

I II

199

V1 V2 V3
V1 V2 V3 V4 V5 V6

ECG 2

I II II III I

V1 V2

V1 V2 V3 V4 V5 V6

2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c
x x x x

115 /min
_________________ right axis deviation
_________________________________________

Diagnosis:

right atrial hypertrophy

clockwise rotation
right ventricular hypertrophy

Here we have clockwise rotation plus right ventricular hypertrophy. The transition zone
is between leads V5 and V6, so leads V1 to V5 are over the right ventricle: clockwise
rotation. The T-wave inversions from leads V1 to V6 most likely stem from right ventri-
cular hypertrophy and are not associated with pathologic changes of the left ventricle.

Level 12 Quiz solution

 200

III ECG 3

I II III aVR aVL aVF

V1 V2 V3 V4 V5 V6 V7 V8
V5 V6

2 3 4 5 6 7 8 9 10 11
III I II III

a b a b c a b a b c
x x x

80 /min
_________________ right axis deviation
_________________________________________

Diagnosis:

P mitrale
RBBB + right axis deviation = bifascicular block
V1
chronic inferior V2
wall myocardial V3
infarction V4 V5 V6

5 V6
The notched P wave in leads I and II is a consequence of left atrial hypertrophy (P mi-
trale). The right axis deviation along with the RBBB leads to the diagnosis of a left pos-
terior fascicular block (or bifascicular block). Large Q waves (>0.04 s) in lead III and
also in leads II and aVF point to the presence of old inferior wall myocardial infarction.

Level 12 Quiz solution

 II III

I II III aVR aVL aVF

201

V1 V2 V3 V4 V5 V6 V7 V8
4 V5 V6

ECG 4

II III I II III

V1 V2 V3 V4 V5 V6

4 V5 V6

2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c
x x x x

90 /min
_________________ normal axis
_________________________________________

Diagnosis:

P mitrale
slight clockwise rotation
ST depression + U wave V3–V6
hypokalemia?

In this ECG of a patient with hypokalemia, we note the typical ST-T depression along
with a prominent U wave in leads V3 and V4.

Level 12 Quiz solution

202

ECG 5

I
I II III

V1 V2 V3 V4

V1 V2 V3 V4 V5 V6

I II III
2 3 4 5 6 7 8 9 10 11

I II III R L F
a b a b c a b a b c
x (x) x

67 /min
_________________ normal right?
_________________________________________

Diagnosis:

right
V1 ventricular
V2 conduction
V3 delay V4 V5 V6 V1 V2 V3 V4
(volume overload?)
possible right ventricular hypertrophy

Especially in V5 the notched QRS complex (RSRS pattern) is typical for right ventricular
dilatation. Because lead I is neither clearly positive nor negative, the main vector must
point exactly to +90°, i.e., just between normal and right axis.

Level 12 Quiz solution

 I
I II III

203
V1 V2

V1 V2 V3 V4 V5 V6

ECG 6 I

I II III R L F

V1 V2 V3 V4 V5 V6 V1 V2

2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c
x x

150 /min
_________________ right axis deviation
_________________________________________

Diagnosis:

RBBB

First of all, there’s RBBB. In lead III, we note a pathologic Q wave and a slightly eleva-
ted ST segment, as well as T-wave inversion. This is a pattern, that would be compa-
tible with an inferior myocardial infarction. But note that we also have a deep S wave in
lead I (a so-called SIQIII pattern—typical for pulmonary embolism). Unfortunately, the
patient died because of massive pulmonary embolism a few hours later.

Level 12 Quiz solution

 204

ECG 7

I II III
III

V1 V2 V3 V4 V5 V6

V6

I II III R L F
2 3 4 5 6 7 8 9 10 11

L F
a b a b c a b a b c
x x x

100 /min
_________________ left axis deviation
_________________________________________

Diagnosis:

bifascicular block
V6 V1 anteriorV2
acute V3 STEMI
wall Q-wave V4 V5 V6

The left axis deviation along with the RBBB (bifascicular block) were caused by an
anterior wall myocardial infarction leading to conduction abnormalities.

Level 12 Quiz solution

 I II III
I II III

205

V1 V2 V3 V4 V5 V6

V4 V5 V6

ECG 8
I II III R L F

III R L F

V4 V5 V6 V1 V2 V3 V4 V5 V6

2 3 4 5 6 7 8 9 10 11

a b a b c a b a b c
x x

95 /min
_________________ in between normal and left axis
_________________________________________ deviation

Diagnosis:

WPW syndrome

The short PQ interval along with the typical delta wave in leads I, aVL, and V2 to V6
lead to the diagnosis of WPW syndrome. Remember that after the diagnosis of WPW
syndrome has been established, no additional disturbances of repolarization or patho-
logic Q waves must be diagnosed.

Level 12 Quiz solution

 206
P If there is sinus rhythm, make
Heart

Level 13
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no

Level 13 Quiz solution

I
I
QUIZ SOLUTION
II
II

III
flattening of T waves
III x ~105
in lead I
V1

I
V1

II

ECG 1

III
We can find P waves in this example. However, there’s not only one P wave in
I
front of each QRS complex but several of them. Furthermore, we can’t really
tell whether P waves are positive or negative in lead II. So there are a couple
II
of reasons why this can’t be sinus rhythm.
I

III
II

III
V1

V1
 I
I

II
II

III

III
V1

I
V1

II
P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no III

II
P mitrale (most pro-
I
minently seen in V1).
First degree AV block
III x 75
(PR 0.24 s) with left axis
II deviation and RBBB (i.e.,
trifascicular block).
III
V1

ECG 2

V1

Level 13 Quiz solution

207
 208

Level 13 Quiz solution

P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no

II
flattening of T waves
x ~75
in lead I
III

V1
ECG 3

I
Sinus rhythm doesn’t always have to be completely rhythmic as we can see
in this example. The RR intervals are different from beat to beat in this case
(maximum
II RR interval: 0.84 s, minimum RR interval: 0.68 s). This is called
sinus arrhythmia. Furthermore, there are signs of right atrial enlargement (P
pulmonale), and the axis is right in between a normal axis and right axis devi-
ation. The
III notching in lead V1 (without RBBB) is indicative of right ventricular
volume overload.

II

III

V1
 I

II

III If there is sinus rhythm, make

P
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T V1
yes no

II ~500
x ?

III

ECG 4

Completely
I irregular tracing. No distinct curves can be identified. This can’t
be sinus rhythm.

II

III

V1

Level 13 Quiz solution

209
 II

III

V1

210
II

Level 13 Quiz solution

P If there is sinus rhythm, make
Heart
QRS III Sinus
rate
additional diagnoses according
to our cookbook.
T
yes no

II
x ~145
III

V1
ECG 5

This is sinus rhythm with a heart rate of 145 beats/min, which is also called
sinus tachycardia. The axis is right between a normal axis and right axis
deviation. The QRS complex is widened to 0.14 s, and with the RSRS pattern
in lead V1 we can diagnose RBBB. This was a young man presenting to the
ER in shock with massive pulmonary embolism. He died shortly thereafter.
Notice the typical SIQIII pattern as in a previous example!
 P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no

x 80
II

III

ECG 6
I

Normal axis. ST elevation in leads II and III but also in lead I. There are no
Q waves. This could be (1) perimyocarditis, or (2) acute ischemia. In fact,
thisI patient had STEMI, the extent of which was much better seen in the II

precordial leads, and he was treated by stent placement.

II III

Level 13 Quiz solution

211

III
 I

212
II

III

Level 13 Quiz solution

P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
I
T
yes no

I II

II III

x 280

III

ECG 7

No P waves are visible in this tracing. This cannot be sinus rhythm.

 P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no

II

x 47

III

ECG 8

Sinus rhythm with a heart rate of <50 beats/min is called sinus bradycardia.
The axis is normal. Sinus bradycardia does not have to be pathologic. To the
contrary, it can be a sign of good physical fitness. In older individuals, sinus
bradycardia (without adequate response to exertion) can cause problems like
dizziness and falls and can even lead to pacemaker implantation.

Level 13 Quiz solution

213
 214

Level 13 Quiz solution

P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
T
yes no

x ~90
II

III

ECG 9

The heart rate in this patient with sinus rhythm varies between 70 and 100 beats/min.
There seems to be a pattern…heart rate is slower in the beginning of the tracing, gets faster,
I
and slows down again at the end. This type of sinus arrhythmia is called respiratory sinus
arrhythmia (heart rate increases on inspiration and decreases on expiration). This form of ar-
rhythmia is very common in young individuals and is not pathologic. Also, the axis changes
slightly with respiration.

II

III
 I

II
P If there is sinus rhythm, make
Heart
Sinus additional diagnoses according
QRS rate
to our cookbook.
III
T
yes no

II
x 70

III

ECG 10

There are P waves in this tracing, but they do not occur at a fixed interval
before each QRS complex. So this cannot be sinus rhythm.

Level 13 Quiz solution

215
ECG Mastery: The Simplest Way to Learn the ECG

by Peter Kühn, MD, Clemens Lang, and Franz Wiesbauer, MD MPH

Copyright © 2014 by Medmastery GmbH

All rights reserved.

Although the author and publisher have made every effort to
ensure that the information in this book was correct at press time,
the author and publisher do not assume and hereby disclaim any
liability to any party for any loss, damage, or disruption caused by
errors or omissions, whether such errors or omissions result from
negligence, accident, or any other cause.

ISBN: 978-3-9503944-0-5

Cover and interior design: Philipp Gärtner

Layout: Brigitte Mair
Editor and proofreader: Mary L. Tod, PhD, ELS
Project manager: Bonnie Bills

http://www.medmastery.com