Basics of Electrocardiography

Basics of
Electrocardiography
What is an ECG?
An ECG is the recording (gram)
of the electrical activity(electro)
generated by the cells of the
heart(cardio) that reaches the body
surface.
Recording ECG
William Einthoven
Nobel prize 1924
Recording an ECG
An isoelectric line is recorded when:
A. There is no depolarization wave
B. There are two oposing depolarisation
waves
C. There is no repolarisation wave
D. There are two oposing repolarisation
waves
E. When the patient is dead
In ECG recording the vector of a wave
means:
A. The direction of propagation
independent of the initial polarity of the
membranes
B. The vector oriented from negative to
positive areas
C. The vector oriented from positive to
negative areas
In bipolar leads a positive wave is recorded
when:
A. The vector is oriented towards the
positive electrode of the lead
B. The vector is oriented towards the
negative electrode of the lead
C. The vector is oriented contrary to the
positive electrode of the lead
D. The vector is oriented contrary to the
negative electrode of the lead
The characteristics of an wave are:
A. Axis depends on the electrode position
B. Amplitude increases in the presence of
emphysema
C. Duration depends on calibration
D. Axis can shift with breathing
E. Amplitude increases in the presence of
pericardial efusion
Basics
ECG graphs:
– 1 mm squares
– 5 mm squares
Paper Speed:
– 25 mm/sec standard
Voltage Calibration:
– 10 mm/mV standard
ECG Paper: Dimensions
5 mm
1 mm
Voltage
~Mass
0.1 mV
0.04 sec
0.2 sec
Speed = rate
Ventricular depolarization is going from left to
right and caudo-cranial if the QRS complex
is:
A. +DI, +DII
B. -DI, -DII
C. -DI, +DII
D. +DI, -DII
In relationship with the triangle formed by
leads I, II and III the unipolar leads
represent:
A. bisectors
B. mediators
C. medians
ECG Leads
The standard ECG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads
The axis of a particular lead represents the viewpoint from

which it looks at the heart.
Summary of Leads
Limb Leads Precordial Leads
Bipolar I, II, III -

(standard limb leads)
Unipolar aVR, aVL, aVF V1-V6

(augmented limb leads)
Interpretation of an ECG
Steps involved
Heart Rate
Rhythm
Axis
Wave morphology
Intervals and segments analysis
Chamber enlargement
Specific changes
Cardiac Conduction: Cycle
Initiation
Cardiac Conduction: P Wave
Cardiac Conduction: AV Node
Cardiac Conduction: Bundle
Branches
Cardiac Conduction: Purkinje
Fibers
Cardiac Conduction: QRS
Complex
Cardiac Conduction: Plateau
Phase
Cardiac Conduction: T-Wave
Label the ECG
P – Wave: Atrial Depolarization.
• Can be positive, biphasic, negative.
QRS Complex: Ventricular Depolarization.

• Q – Wave: 1st negative deflection wave before R-Wave.
• R – Wave: The positive deflection wave.
• S – Wave: 1st negative deflection wave after R – wave.
T – Wave: Ventricular Repolarization.

• Can be positive, biphasic, negative.
Calculating Heart Rate
1) Measure Cycle Length (CL).
1) (# small boxes from R – R) (40ms) = CL .
2) Calculate HR
• 60,000/CL = “x” BPM
(20)(40ms) = 800ms
60,000/800 = 75 bpm
(25)(40ms) = 1000ms
60,000/1000 = 60 bpm
(12)(40ms) = 480ms
60,000/480 = 125 bpm
Calculating the Heart Rate
The Rule of 300
# of big Rate
boxes
1 300
2 150
3 100
4 75
5 60
6 50
The QRS Axis
The QRS axis represents the

net overall direction of the
heart’s electrical activity.
Abnormalities of axis can hint

at:
Ventricular enlargement
Conduction blocks (i.e.
hemiblocks)
The QRS Axis
By near-consensus, the
normal QRS axis is defined
as ranging from -30° to +90°.
-30° to -90° is referred to as a

left axis deviation (LAD)
+90° to +180° is referred to as

a right axis deviation (RAD)
Determining the Axis
The Quadrant Approach
The Equiphasic Approach

Determining the Axis
Predominantly Predominantly Equiphasic

Positive Negative
The Quadrant Approach
1. Examine the QRS complex in leads I and aVF to determine
if they are predominantly positive or predominantly
negative. The combination should place the axis into one
of the 4 quadrants below.
Example 1
Negative in I, positive in aVF  RAD

Example 2
Positive in I, negative in aVF  Predominantly positive in II 

Normal Axis (non-pathologic LAD)
Marked RAD -90°
-60°
-120°
LAD
aVR -30°
-150° aVL
180° 0°
I
150°
30°
120° II
III 60°
Normal Axis
90° aVF
-30° to +100°
RAD
Example 1
Equiphasic in aVF  Predominantly positive in I  QRS axis ≈ 0°

Example 2
Equiphasic in II  Predominantly negative in aVL  QRS axis ≈ +150°

Common causes of LAD
May be normal in the elderly and very obese
Due to high diaphragm during pregnancy,
ascites, or ABD tumors
Inferior wall MI
Left Anterior Hemiblock
Left Bundle Branch Block
WPW Syndrome
Congenital Lesions
RV Pacer or RV ectopic rhythms
Emphysema
Common causes of RAD
Normal variant
Right Ventricular Hypertrophy
Anterior MI
Right Bundle Branch Block
Left Posterior Hemiblock
Left Ventricular ectopic rhythms or pacing
WPW Syndrome
The Normal ECG
In normal sinus rhythm:
A. The left atrium is depolarised postero
anterior
B. The right atrium is depolarised postero-
anterior
C. There are no preferential bundles
Normal Sinus Rhythm
Originates in the sinus node
Rate between 60 and 100 beats per min
P wave axis of +45 to +65 degrees, ie.
Tallest p waves in Lead II
Monomorphic P waves
Normal PR interval of 120 to 200 msec
Normal relationship between P and QRS
Some sinus arrhythmia is normal
Normal P wave
Atrial depolarisation
Duration 80 to 100 msec
Maximum amplitude 2.5 mm
Axis +45 to +65
Biphasic in lead V1
Terminal deflection should not exceed 1
mm in depth and 0.03 sec in duration
Normal P wave
PR interval
AV node conduction
From the beginning of P wave to the
beginning of q wave
120-200 ms
The PR interval :
A. Deacreases with tachycardia
B. Is longer in older patients
C. Is increased in AV nodal PACs
Normal QRS complex
Completely negative in lead aVR , maximum
positivity in lead II
rS in right oriented leads and qR in left oriented
leads (septal vector)
Transition zone commonly in V3-V4
RV5 > RV6 normally
Normal duration 50-110 msec, not more than
120 msec
Physiological q wave not > 0.03 sec
ECG showing qR pattern in lead III
,disappears on deep inspiration  q wave
not significant
Mech:shift in the QRS axis
Amplitude of QRS
Depends on the following factors
1.electrical force generated by the
ventricular myocardium
2.distance of the sensing electrode from
the ventricles
3.Body build;a thin individual has larger
complexes when compared to obese
individuals
4.direction of the frontal QRS axis
QRS-T angle
The normal t wave axis is similar to the
QRS axis
Normally the QRS-T angle does not
exceed 60 deg
Why can the ST segment be elevated in V1,
V2 in normal individuals?
ST segment
Merges smoothly with the proximal limb of
the T wave
No true horizontality
Why does the T wave have the same polarity
as the QRS segment?
Normal T wave
Same direction as the preceding QRS
complex
Blunt apex with asymmetric limbs
Height < 5mm in limb leads and <10 mm
in precordial leads
Smooth contours
May be tall in athletes
What is the significance of U wave?
Normal u wave
Best seen in midprecordial leads
Height < 10% of preceding T wave
Isoelectric in lead aVL (useful to measure
QTc)
Rarely exceeds 1 mm in amplitude
May be tall in athletes (2mm)
QT interval
Normally corrected for heart rate
Bazett’s formula
Normal 350 to 430 msec
With a normal heart rate (60 to 100), the
QT interval should not exceed half of the
R-R interval roughly
Measurement of QT interval
The beginning of the QRS complex is best
determined in a lead with an initial q wave
 leads I,II, avL ,V5 or V6
QT interval shortens with tachycardia and
lengthens with bradycardia
Prolonged QTc
During sleep
Hypocalcemia
Ac myocarditis
AMI
Drugs like quinidine,procainamide,tricyclic
antidepressants
Hypothermia
HOCM
Advanced AV block or high degree AV
block
Jervell-Lange –Neilson syndrome
Romano-ward syndrome
Shortened QT
Digitalis effect
Hypercalcemia
Hyperthermia
Vagal stimulation
Normal Variants in the ECG
Sinus arrhythmia
Persistent juvenile pattern
Early repolarisation syndrome
Non specific T wave changes
Persistent juvenile pattern
Features of ERPS
Vagotonia / athletes’ heart
Prominent J point
Concave upwards, minimally elevated ST segments
Tall symmetrical T waves
Prominent q waves in left leads
Tall R waves in left oriented leads
Prominent u waves
Rapid precordial transition
Sinus bradycardia
Early Recognition Prevents Streptokinase infusion !

Reporting an ECG
1. Patient Details
“ Whose ECG is it ?!”

2. Standardisation and lead
placement
“Is it properly taken ?”

3. Analysis of Rate, Rhythm and
Axis
4. Segment and wave form
analysis
Final Impression
“ Does the ECG correlate with

the clinical scenario ?”
CHAMBER ENLARGEMENT
Chamber Enlargement
The ECG criteria for diagnosing right or left
ventricular hypertrophy are very insensitive (i.e.,
sensitivity ~50%, which means that ~50% of
patients with ventricular hypertrophy cannot be
recognized by ECG criteria). However, the
criteria are very specific (i.e., specificity >90%,
which means if the criteria are met, it is very
likely that ventricular hypertrophy is present).
LVH - 1
S in V1 + R in V5 or V6 > 35 mm
R in aVL >11 mm or, if left axis deviation,
R in aVL >13 mm plus S in III >15 mm
CORNELL Voltage Criteria for LVH
(sensitivity = 22%, specificity = 95%)
S in V3 + R in aVL > 24 mm (men)
S in V3 + R in aVL > 20 mm (women)
LVH - 2
ECG Criteria Points
R or S in limb leads Any criteria positive

ESTES Criteria for LVH > 20mm 3 points
S in V1 or V2 > 30mm
("diagnostic", >5 points; R in V5 or V6 > 30mm
"probable", 4 points) ST – T abnormalities

Without digoxin 3 points
With digoxin 1 point
Left Atrial Enlargement 3 points

inV1
Left Axis Deviation 2 points
QRS duration 0.09sec 1 point
Delayed intrinsicoid 1 point

deflection in V5 or V6
> 0.05SEC
RVH
V1 Lead:
- R/S ratio > 1 and negative T wave
- R > 6 mm, or S < 2mm,
- rSR' with R' >10 mm
R in V1 + S in V5 (or V6) > 10 mm
V5 or V6
- R/S ratio in V5 or V6 < 1
- R in V5 or V6 < 5 mm
- S in V5 or V6 > 7 mm
LAE
Sensitivity = 50%; Specificity = 90%
P wave duration > 0.12s in frontal plane

(usually lead II)
Terminal P negativity in lead V1 (i.e., "P-
terminal force") duration >0.04s, depth >1
mm.
RAE
P wave amplitude >2.5 mm in II and/or >1.5 mm
in V1 (Sensitivity = 50%; Specificity = 90%)
QRS voltage in V1 is <5 mm and V2/V1
voltage ratio is >6 (Sensitivity = 50%;
Specificity = 90%)
Criteria derived from the QRS complex are
due to both the high incidence of RVH
when RAE is present, and the RV
displacement by an enlarged right atrium.
BUNDLE BRANCH BLOCKS
Left Bundle Branch Block
Electrocardiographic Criteria
1.The QRS duration is >/- 120 ms
2.Leads V5,V6 and AVL show broad and notched
or slurred R waves
3.With the possible exception of lead AVL, the Q
wave is absent in left-sided leads
4.Reciprocal changes in V1 and V2
5.Left axis deviation may be present
Right Bundle Branch Block
The diagnostic criteria include
1.QRS duration is >/- 120 ms

2.An rsr’,rsR’ or rSR’ pattern in lead V1 or
V2 and occasionally a wide and notched R
wave.
3.Reciprocal changes in V5,V6,I and AVL
12 Lead ECG Basics
Bundle Branch Block
Step 1. Determine that the rhythm is
supraventricular in origin and has a QRS
that is > 0.12 secs in lead V1 or MCL1 .
Step 2. Locate the J point in the ECG cycle
(end of the QRS and beginning of the
ST).
Step 3. Draw a line backward into the
terminal component of the QRS.
Step 4. Shade in the triangle created by
this line and the terminal component of
the QRS.
12 Lead ECG Basics
Bundle Branch Block
Shade this area

Step 5. If the
triangle points up
then it is a Right
BBB.
12 Lead ECG Basics
Bundle Branch Block
Shade this area
Step 6. If the
triangle points
down then it is a
Left BBB.
Left Anterior Fascicular Block
Left axis deviation , usually -45 to -90 degrees
QRS duration usually <0.12s unless coexisting RBBB
Poor R wave progression in leads V1-V3 and deeper S

waves in leads V5 and V6
There is RS pattern with R wave in lead II > lead III

S wave in lead III > lead II
QR pattern in lead I and AVL,with small Q wave

No other causes of left axis deviation
Left Posterior Fascicular Block
Diagnostic Criteria include
1.QRS duration 100- <120 ms
2.No ST segment or T wave changes
3.Right axis deviation (100 degree)
4.QR pattern in inferior leads (II,III,AVF) small q
wave
5.RS patter in lead lead I and AVL(small R with
deep S)
6.No other causes of right axis deviation
Bifascicular Bundle Branch
Block
RBBB with either left anterior or left posterior
fascicular block
Diagnostic criteria
1.Prolongation of the QRS duration to 0.12 second
or longer
2.RSR’ pattern in lead V1,with the R’ being broad
and slurred
3.Wide,slurred S wave in leads I,V5 and V6
4.Left axis or right axis deviation
Trifascicular Block
The combination of RBBB, LAFB and long

PR interval
Implies that conduction is delayed in the

third fascicle
ST Elevation and non-ST Elevation MIs
When myocardial blood supply is abruptly

reduced or cut off to a region of the heart, a
sequence of injurious events occur beginning
with ischemia (inadequate tissue perfusion),
followed by necrosis (infarction), and eventual
fibrosis (scarring) if the blood supply isn't
restored in an appropriate period of time.
The ECG changes over time with each of

these events…
E
INFARCTION INJURY ISCHAEMIA

INFARCTED MYOCARDIUM
(STEMI)
myocardium electrically dead
The electrode lying over the area of

infarction has the effect of looking through
the infarcted area as a window. This
therefore will detect and record potentials
from the myocardium directly opposite.
INJURED MYOCARDIUM
myocardium is never completely polarized
The electrode lying over the area of injury

will record ST Segment elevation on the
ECG because of the myocardium retaining
its polarity.
ISCHAEMIC MYOCARDIUM
myocardium exhibits impaired

repolarisation
The electrode lying over the area of

ischaemia will record T wave changes on
the ECG
STAGE 1
ACUTE STAGE - HOURS OLD
Acute stage of injury – The myocardium is

not yet dead and unless rapid intervention
is possible then death of the affected area
of muscle will certainly follow. In the case
of rapid intervention then the area of death
may be reduced although even with
treatment some necrosis will take place
The typical shape of the ECG leads
which are positioned directly over the
injured area of myocardium will show
significant ST segment elevation of
greater than 2 mm, there may also be a
reduction in the size of the R wave.
There will be ST segment depression in

the areas of myocardium opposite the
injured area these are known as
RECIPROCAL CHANGES
STAGE 2
LATER PATTERN - DAYS OLD
In stage 2 the injured myocardium is now

starting to necrose and this results in Q
waves beginning to appear on the ECG
which are representations of
depolarization on the opposite wall of the
heart, this is due to the window effect over
the area of dead myocardium
The electrode is looking through the
electrical window where no electrical
activity occurs
The ST segment elevation will lessen as

the area of injury either becomes
Ischaemic or dies
T waves now begin to appear

representing the area of ischaemia
which is surrounding the infarcted
STAGE 3
LATE PATTERN - WEEKS OLD
In stage three, the zone of injury has now
evolved into infarcted myocardium
There is a pathological Q wave seen on the
ECG due to the electrical window being
present
The ST segment has now returned to
normal/Iso-electric line because the injured
area has now necrosed or become ischaemic
There is now a symmetrically inverted T wave
present on the ECG which represents
persistent ischaemia surrounding the area of
infarct
STAGE 4
OLD INFARCT -MONTHS TO YEARS
In stage 4 the zone of ischaemia has
recovered and the ECG returns to almost
normal
However there are changes which allow us
to identify a previous infarct on the ECG
The pathological Q wave is considered the
finger print for life of a previous myocardial
infarction
The R wave height is reduced in the leads
positioned directly over the area of infarct
ST Elevation Infarction
Here’s a diagram depicting an evolving infarction:
A. Normal ECG prior to MI
B. Ischemia from coronary artery occlusion

results in ST depression (not shown) and
peaked T-waves
C. Infarction from ongoing ischemia results in

marked ST elevation
D/E. Ongoing infarction with appearance of

pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Q-

waves, but normal ST segment and T-
waves
Here’s an ECG of an inferior MI:
Look at the
inferior leads
(II, III, aVF).
Question:
What ECG
changes do
you see?
ST elevation
and Q-waves
Extra credit:
What is the
rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!
Here’s an ECG of an inferior MI later in time:
Now what do
you see in the
inferior leads?
ST elevation,
Q-waves and
T-wave
inversion
Non-ST Elevation Infarction
The ECG changes seen with a non-ST elevation infarction are:
Before injury Normal ECG
Ischemia ST depression & T-wave inversion
Infarction ST depression & T-wave inversion
Fibrosis ST returns to baseline, but T-wave

inversion persists
Non-ST Elevation Infarction
Here’s an ECG of an evolving non-ST elevation MI:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.
Question:
What area of
the heart is
infarcting?
Anterolateral
ECG
ECG
ECG
ECG
ECG
ECG
ECG
ECG
Rhythm disorders
Normal Sinus Rhythm
Rate 60-100bpm
P-P Regularity Regular
R-R Regularity Regular
P wave Present
P:QRS Ratio 1:1, associated
PR Interval Normal
QRS Width Normal
Sinus Bradycardia
Rate Less than 60bpm

P wave Present
PR Interval Normal, gradually lengthens with HR decrease
QRS Width Normal
Sinus Tachycardia
Rate Greater than 100bpm, Gradual onset

P wave Present
PR Interval Normal, gradually shortens with HR increase
QRS Width Normal
Sinus Arrhythmia
Rate 60-100bpm
P-P Regularity Irregular
R-R Regularity Irregular
P wave Present
PR Interval Normal
QRS Width Normal
Sinus Pause/Arrest
Rate Varies
P wave Present, except during pause
PR Interval Normal
QRS Width Normal
Sinus Node Exit Block
Rate Varies
P wave Present, except during dropped beats
PR Interval Normal
QRS Width Normal
Sinus Rhythm w/ PAC
(Premature Atrial Contraction)
Rate Depends on underlying sinus rate

P wave Present, may be different morphology during PAC
PR Interval Normal, varies during PAC
QRS Width Normal
Atrial Tachycardia
Rate 100-180bpm, Sudden onset

P wave Morphology will differ from sinus p-wave
PR Interval Interval of ectopic focus will differ from sinus PR
QRS Width Normal, but can develop aberrant (wide) complexes
Multifocal Atrial Tachycardia
Rate Greater than 100bpm

P-P Regularity Irregularly irregular
R-R Regularity Irregularly irregular
P wave At least 3 different p-wave morphologies

PR Interval Varies
QRS Width Normal
Atrial Flutter
Atrial Rate Atrial Rate commonly 250-350bpm

Ventricular Rate Ventricular Rate will vary with conduction
R-R Regularity Usually regular, but may be variable
P wave “Saw-tooth” p-wave morphology
P:QRS Ratio Varies, can be 1:1, 2:1, 3:1, 4:1, etc.
PR Interval Varies
QRS Width Normal
Atrial Fibrillation
Rate Varies, ventricular response can be fast or slow

P-P Regularity Chaotic atrial activity
P wave No discernable p-waves
P:QRS Ratio None
PR Interval None
QRS Width Normal, but can develop aberrant (wide) complexes
Junctional Rhythm
Rate 40-60bpm
P-P Regularity None, or Regular if antegrade or retrograde
P wave Variable (none, antegrade, or retrograde)
P:QRS Ratio None, or 1:1 if antegrade or retrograde
PR Interval None, short, or retrograde
QRS Width Normal
Accelerated Junctional Rhythm
Supraventricular Tachycardia
(SVT)
60-100bpm (Accelerated Junctional Rhythm)

Rate
Greater than 100bpm (Supraventricular
Tachycardia)
P-P Regularity None, or Regular if antegrade or retrograde
P wave Variable (none, antegrade, or retrograde)
P:QRS Ratio None, or 1:1 if antegrade or retrograde
PR Interval None, short, or retrograde
QRS Width Normal
Sinus Rhythm w/ PVC
(Premature Ventricular Contraction)
Rate Depends on underlying sinus rate

P wave No P-waves with the PVC
P:QRS Ratio No P-waves with the PVC
PR Interval None
QRS Width Wide complex (>/= 0.12sec).
Ventricular Rhythm
Rate 20-40bpm
P-P Regularity None
P wave None
P:QRS Ratio None
PR Interval None
Accelerated Ventricular Rhythm
Rate 40-100bpm
P-P Regularity None
P wave None
P:QRS Ratio None
PR Interval None
Ventricular Tachycardia
Rate 100-200bpm
P-P Regularity Variable
P wave Dissociated atrial rate
P:QRS Ratio Variable
PR Interval None
Fast VT (Ventricular Flutter)
Rate 200-300bpm
P-P Regularity None
P wave None
P:QRS Ratio None
PR Interval None
Polymorphic VT (Torsades)
Rate 200-250bpm
P-P Regularity None
P wave None
P:QRS Ratio None
PR Interval None
QRS Width Variable with wide complexes
Ventricular Fibrillation
Rate Indeterminate
P-P Regularity None
R-R Regularity Chaotic Rhythm
P wave None
P:QRS Ratio None
PR Interval None
QRS Width None
Sinus Rhythm
w/ 1st Degree AV Block
Rate Depends on underlying rhythm

P wave Present, Normal
PR Interval Prolonged, > 0.20sec
QRS Width Normal
Sinus Rhythm
w/ 2nd Degree AV Block Type I (Wenckebach)

R-R Regularity Regularly irregular
P wave Present
P:QRS Ratio Variable; 2:1, 3:2, 4:3, etc
PR Interval Variable, gradually lengthens until dropped
QRS Width Normal
Sinus Rhythm
w/ 2nd Degree AV Block Type II

R-R Regularity Regularly irregular
P wave Present
P:QRS Ratio Variable; 2:1, 3:2, 4:3, etc
PR Interval Normal for conducted beats
QRS Width Normal
Sinus Rhythm
w/ 3rd Degree AV Block (Complete Heart Block)
Atrial Rate Atrial rate is the underlying rhythm (i.e, Sinus, Atrial Fib, etc.)
Ventricular Rate Ventricular rate is from the dissociated escape rhythm
P wave Present
P:QRS Ratio Variable, dissociated
PR Interval Variable, No pattern
QRS Width Normal (Junctional escape rhythm)
Wide (Ventricular escape rhythm)
Sinus Rhythm w/ BBB
(Bundle Branch Block)
Rate Depends on the underlying sinus rhythm

P wave Present
PR Interval Normal
QRS Width Wide (>0.12ms)
Atrial Fib w/ BBB
(Bundle Branch Block)
Rate Depends on the underlying Atrial Fibrillation,

Ventricular rate can be fast or slow.
P-P Regularity Chaotic atrial activity
P wave Present
P:QRS Ratio None
PR Interval None
QRS Width Wide (>0.12ms)
Knowledge Checkpoint
Identify the Rhythm:
A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
A. Ventricular Tachycardia
B. Sinus Bradycardia
C. Complete Heart Block
D. Atrial Fibrillation
E. Ventricular Fibrillation
PRACTICE RHYTHM STRIPS
Practice Rhythm
Strips
• On the following rhythm strips in subsequent slides,
determine rhythm presented.
• Consider the following:

 What is the atrial and ventricular rate? Is it normal?
 What is the regularity (P-P and R-R)
 Are any AV and/or Bundle branch blocks present?
 Does the rhythm have a clinical significance?
• Answers can be found in the notes section of the slides.

Practice Rhythm Strips
Thank you !

Basics of Electrocardiography

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Basics of Electrocardiography

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Basics of

The axis of a particular lead represents the viewpoint from

Limb Leads Precordial Leads

Bipolar I, II, III -

Unipolar aVR, aVL, aVF V1-V6

QRS Complex: Ventricular Depolarization.

• S – Wave: 1st negative deflection wave after R – wave.

T – Wave: Ventricular Repolarization.

The QRS axis represents the

Abnormalities of axis can hint

-30° to -90° is referred to as a

+90° to +180° is referred to as

The Quadrant Approach

The Equiphasic Approach

Predominantly Predominantly Equiphasic

Negative in I, positive in aVF  RAD

Positive in I, negative in aVF  Predominantly positive in II 

Equiphasic in aVF  Predominantly positive in I  QRS axis ≈ 0°

Equiphasic in II  Predominantly negative in aVL  QRS axis ≈ +150°

Early Recognition Prevents Streptokinase infusion !

“ Whose ECG is it ?!”

“Is it properly taken ?”

“ Does the ECG correlate with

R or S in limb leads Any criteria positive

"probable", 4 points) ST – T abnormalities

Left Atrial Enlargement 3 points

Left Axis Deviation 2 points

QRS duration 0.09sec 1 point

Delayed intrinsicoid 1 point

P wave duration > 0.12s in frontal plane

1.QRS duration is >/- 120 ms

Shade this area

Shade this area

QRS duration usually <0.12s unless coexisting RBBB

Poor R wave progression in leads V1-V3 and deeper S

There is RS pattern with R wave in lead II > lead III

QR pattern in lead I and AVL,with small Q wave

The combination of RBBB, LAFB and long

Implies that conduction is delayed in the

When myocardial blood supply is abruptly

The ECG changes over time with each of

INFARCTION INJURY ISCHAEMIA

The electrode lying over the area of

The electrode lying over the area of injury

myocardium exhibits impaired

The electrode lying over the area of

Acute stage of injury – The myocardium is

There will be ST segment depression in

In stage 2 the injured myocardium is now

The ST segment elevation will lessen as

T waves now begin to appear

B. Ischemia from coronary artery occlusion

C. Infarction from ongoing ischemia results in

D/E. Ongoing infarction with appearance of

F. Fibrosis (months later) with persistent Q-

Before injury Normal ECG

Ischemia ST depression & T-wave inversion

Infarction ST depression & T-wave inversion

Fibrosis ST returns to baseline, but T-wave

Rate Less than 60bpm

R-R Regularity Regular

Rate Greater than 100bpm, Gradual onset

Rate Depends on underlying sinus rate