Introduction to ECGs and

their interpretation
Dr David Harniess
MBChB MRCGP MSc DCH DRCOG DGP Med Ed
Clinical Skills 2 Teaching
Hashemite University
Learning Objectives for ECG Interpretation
• Understand the electrophysiology of a normal ECG
• Having a systematic method to interpret ECGs including
measuring the rate, rhythm and axis, measuring intervals and
looking at ST segment for infarction
• Being able to detect AV heart block
• Being able to detect life threatening arrhythmias
• Being able to detect ischaemia and a myocardial infarction
Normal ECG trace
• Y axis=voltage, 1 mm (small box) = 0.1 mV
• X axis=time, 1 mm (small box) = 0.04 seconds
 Summary
• P wave relates to atrial depolarisation
(normal time length 0.12 sec = 3 small squares on ECG trace)
• QRS complex relates to ventricular depolarisation
(normal time length 0.12sec = 3 small squares on ECG trace)
• T wave relates to ventricular repolarisation
(no strict criteria for width but need to look at ST segment for changes –
myocardial ischaemia or infarction)
• PR interval (measured from beginning of P wave to beginning of QRS
complex) should be between 0.12-0.21 sec (equivalent to 3-5 small squares).

Represents time taken for atrial depolarisation and pass message to

ventricles (involves SA node, atrial tissue and AV node)
 Stepwise Approach to looking at an ECG
1) Check patient’s ID and age
2) Check rate – normal, fast (tachycardia) or slow (bradycardia)?
Calculate the heart rate by dividing 300 by the number of big boxes between R waves
3) Check rhythm – sinus or not?
Sinus rhythm has a P wave followed by a QRS complex and every QRS complex has a preceding
P wave
4) Check axis – normal or not?
If the QRS in Leads I and aVF are positive, the axis is normal
5) Check Intervals – long or short?
PR interval prolonged in heart blocks, short in Wolff Parkinson White (WPW)
QRS interval prolonged and wide - ventricular bundle branch block
QT interval prolonged with certain drugs – potentially dangerous
6) Check for ischaemia or infarction?
ST segment depression or elevation, Q waves or T wave inversion
7) Check for left ventricular hypertrophy
 Step 2 - Check the rate
• Check rate – normal, fast (tachycardia) or slow (bradycardia)?
Calculate the heart rate by dividing 300 by the number of big boxes between R waves

R – R wave is 8.5 big boxes

Rate = 300 / number of big boxes
Rate = 300 / 8.5 = 35 beats per minute
1a. What is the rate in this ECG?
1b. What arrhythmia does this often signify?
2a. What is the rate in this ECG?
2b. What do you need to check clinically?
 Step 3 – Check the rhythm
3a) Is this sinus rhythm?
3b) If not what is it?
 Premature ventricular ectopic
Sinus rhythm has a P wave followed by a QRS complex and every QRS complex has a preceding P wave
4a) What does this ECG show?
4b) What would you do if you saw this ECG in the clinical situation?
Step 4 – What is the axis?
You need a 12 lead ECG to work out the axis
What is a normal axis?

•Normal is anything
from -30 to 110°

•If the QRS in Leads I

and aVF are positive,
the axis is normal
Quick look at axis use Leads I, II and III –
where is the QRS complex more positive?
Left Axis Deviation
Right Axis Deviation
 Causes of axis deviation

Left Axis Deviation Right Axis Deviation

• Normal variation • Arrhythmias
• Left ventricular hypertrophy (LVH) • Right Ventricular Hypertrophy
• Mechanical shift e.g. ascites, • Mechanical shifts e.g. COPD
abdominal tumour, pregnancy…
• Pulmonary Embolus
• Left anterior hemiblock
• Left posterior hemiblock
• Left Bundle Branch Block (LBBB)
• Right Bundle Branch Block (RBBB)
• Wolff Parkinson White (WPW)
• WPW
• Hyperkalaemia
Summary of axis
If the QRS complex in Leads I and aVF are positive, the axis is normal

If Lead I is positive and aVF negative it is likely Left Axis Deviation

If Lead I is negative and aVF positive it is likely Right Axis Deviation
Step 5 – Check intervals
• PR interval of 0.12-0.20 sec
(3-5 small squares) is normal

• QRS interval less than 0.10-

0.12sec (2.5-3 squares) is
normal

• QT interval less than half the

R-R rate is grossly normal
(depends on heart rate) –
less than 0.445 sec (11 small
squares) is normal
Short PR interval – Wolf-Parkinson White
Prolonged PR interval – AV heart block
• 1st degree AV block = PR>0.20s, no variation

• 2nd degree AV block

• 2nd degree AV block (Mobitz I) = progressive lengthening of PR with
eventual dropped QRS
Prolonged PR interval - Heart Block
• 2nd degree AV heart block (Mobitz II) = fixed PR with dropped QRS

• 3rd degree AV heart block = complete dissociation of P and QRS

 QRS interval prolonged

Normal variant, IHD, right IHD, MI, hypertension,

ventricular hypertrophy, PE, dilated cardiomyopathy,
aortic stenosis, Lenegre disease,
congenital disease e.g. VSD hyperkalaemia, digoxin toxicity
Prolonged QT interval
If QT is grossly more than half the R-R distance
it is abnormal
Risk factor for faints, blackouts and sudden death

Common drugs that cause QT prolongation

• Some antihistamines e.g. loratadine, terfinadine
• Some antibiotics e.g. erythromycin, clarithromycin, chloroquine
• Tricyclic antidepressants e.g. amitriptyline, imipramine
• Other antidepressants e.g. venlaflaxine, citalopram, escitalopram
• Antipsychotics e.g. quetiapine, haloperidol, olanzapine
Step 6 – Review ST segment – ischaemia or not?
Classical natural progression of MI on ECG
Which leads relate to which part of the heart?
ST segment changes
ST depression occurs in myocardial
ischaemia or Non-ST Elevation MI
(non-STEMI)

Criteria for ST Elevation MI (STEMI)

• Increase of 0.1mV (1 small squares)
in two subsequent leads II, III, aVF or
I, aVL
• Increase of 0.2mV (2 small squares)
in two subsequent leads V2-V6
• New LBBB
5) Which leads show myocardial ischaemia?
6a) In which leads do you suspect an acute MI?
6b) Which coronary artery does this correspond to?
7a) In which leads do you suspect an acute MI?
7b) Which coronary artery does this correspond to?
8) Where is this ST Elevated MI (STEMI) located?
This is an ECG of a patient who has been on the Coronary Care Unit for 3 days
9) Where did he have his myocardial infarction?
10) What does this ECG show?
Step 7 – Left Ventricular Hypertrophy (for your info only!)
ECG Mini-Quiz Qu 11
ECG Qu 12
ECG Qu 13
ECG Qu 14
 Answers to ECG questions
1a) 300/2 (R-R – 2 big squares) - 150 beats per minute STEMI myocardial infarction too (refer back to initial slide
on ST segment checks)!
1b) Atrial flutter – 2:1
6a) Inferior leads II, III and aVF
2a) 300/1.5 (1.5 big squares) – 200 beats per minute
6b) Right coronary artery
2b) These are wide QRS complexes signifying Ventricular
Tachycardia – the first thing you need to do is check for a 7a) Anterior leads V2- V6
pulse. Is this pulseless VT or pulse VT?
7b) LAD – Left anterior descending coronary artery
3a) No as there are no distinct `p’ waves and the R-R
length varies 8) Inferolateral MI - inferior leads II, III and aVF, and
lateral leads V4-V6
3b) This is atrial fibrillation – irregular irregular pattern.
You can mark the R waves using a piece of paper and 9 Anterior MI – Q waves prominent V1-V3 and T waves
move it along the rhythm strip to test this. Lead II is inversion V1 – V6
usually the best lead to look at for rhythm 10) Q waves in leads III, aVF, flattened T wave lead II and
4a) Ventricular fibrillation – polymorphic wide QRS T wave inversion in leads III, aVF – old inferior MI
complexes 11) Atrial fibrillation
4b) Call for help, call 911 if outside and start CPR. Use a 12) Anterolateral MI
defibrillator as soon as possible
13) Type 2 (Mobitz I) AV heart block
5 Inferior leads III and aVF show ST depression – this is
what you may find in an angina attack or if you put 14) Ventricular Fibrillation
someone on a treadmill test. It can also be part of a non-
Extra reading and resources

• Student BMJ articles on ECG interpretation – `Mind your P’s and Q’s,
`Bradycardia’, `Tachycardia’
• ECG interpretation practice:
www.ecg-quiz.com/ecg-quiz/mini-test-quiz/