1 small box = 0.

04 sec
1 large box = 0.20 sec

How to interpret ECG? A superbly made easy ECG interpretation…

QT interval ≤2
7 small baby stepss large box
1. Patient’s ID and time taken
2. Rate
3. Rhythm
4. Axis
5. Wavess (P, QRS, T, U)
≤3 small box
6. Intervals (PR, QT)
7. Segment (ST)

3-5 small box

J point – point where QRS complex

joints the ST segment
-represent : end of vent depol &
begin onf vent repol

1. Patient’s ID and time taken

“This is an ECG of Puan Timah bt Abu take at 22 Dec 2012 at 2.00 pm”

2. Rate
Normal rate = 60-100 beat/min
300/(large box R-R) BradyC = <60min
e.g Rate = 300/4 = 75 beat/min TachyC = >100min

**if irregular rate : say in range (smallest 

largest)
e.g 75 to 150 min/beat

3. Rhythm
Types
a) SINUS
b) NOT-sinus
 : <60 beat/min
a) SINUS (spread of depol follow the normal activation of Causes
SAN) • athletic training
• fainting attack
6 criterias • HypoT
• rate : 60-100beat/min • myxedema
• rhythm : regular • immediately after MI
• P wave : only 1 precede each QRS wave – all same • hyperuracemia
size, shape, deflection)
• PR interval : 0.12 – 0.20 sec (3-5 small box)  = irregular rhythm (rate of
• QRS complex : 0.04 – 0.12 sec (1-3 SB) d/c SAN is influenced by vagus N and reflexes from
• QT interval : <0.4 sec (2 LB) lungs)
• 1 P wave / 1 QRS
 >100 beat/min • constant PR interval
Causes • progressive beat to beat change in R-R interval
• exercise • d/t to change if heart rate a/w respiration
• fear (common in children/young adult)
• pain • inspiration INCrease rate/expiration DECrease rate
• haemorrhage
• thyrotoxicosis

Credit to Gen03 (Sis Asma')

Edited by Gen05
 bradyC : <60 b/min
tachyC : >100 b/min
b) NOT-sinusss fibrillation : individual ms fibres
individually
• atrial rhythm = begin at atrial ms
(AF – no P wave)
• junctional / nodal rhythm = begin at region around AV node (VF – no QRS wave)
• ventricular rhythm = begin at ventricular muscle

**supravent – QRS narrow – looks like normal

**vent – QRS broad

 bradyarrhythmia
• e.g AV block
• asystole / PEA
• rx : rare – but need rx if haemodynamically stable

 tachyarrhythmia

 regular
• SVT  rx : adenosine
• atrial tachyC (>150 b/min)
• atrial flutter (>250 b/min)  saw-toothed appearance
• junctional (nodal) tachyC

 irregular
• AF (absent P wave)
• rx : stable – amiodarone (restore sinus rhyth > rapid), digoxin
• haemodynamically unstable – defib cardioversion (CV)

 regular
• VT (mcm bukit)
• rx : pulse  amiodarone
• pulseless  defib

 irregular
• VF (absent or irregular QRS complex)
• rx : defib
• torsades de pointes

4. Cardiac axis
look at lead I and III/aVF (QRS) causes of axis deviation
Rt
~minor : normal – in children + tall,
thin adult
~RVH
indeterminate ~pulm embolism
~chronic lung ds (w/out pulm HPT)

Lt
~minor : normal – fat, short ppl
~LVH
~conduction defect

Credit to Gen03 (Sis Asma')

‘salam’
Edited by Gen05
5. Waves (P, QRS, T)
 Absent : AF
 SHAPE
 P pulmonale (peaked tall P wave)  Broad and bifid P wave

RT ATRIAL HYPERTROPHY
d/t LEFT ATRIAL HYPERTROPHY
-tricuspid valve stenosis d/t
-pulm hypertension mitral stenosis
**remember ‘M’ mitral  bifid and broad features

 Absent : VF
 SHAPE
1. Width 2. Height
o HyperK
o Vent rhythm (broad QRS) • Vent Hypertrophy
o BBB RVH
look at V1 and V6  V1 : Tall R wave
LBBB ‘william’ – best seen at V6 with M pattern  V6 : Deep S wave
*W not often dev  T inversion (esp at Rt leads V1/2/3/4)
d/t LVH
• Atrial stenosis  V5/V6 : R wave > 25mm/5 LB or
• IHD V5/V6 (R wave) + V1/V2 (S wave) = >35mm/ 7 LB
RBBB ‘marrow’ – best seen at V1 with RSR pattern  LAD
d/t  T wave inversion (esp at Lf leads I, aVL, V5.V6, V4)
• ASD
• can be normal
LVH : R (V5/6) + S (V1/2) = > 35 SB/ & LB
RVH : V1/V2 : R/S > 0.5

• Pulmonary embolism
 peaked P wave
 RAD
 Tall R (V1)
 RBBB
 T inversion at V1V2

o Normal  d/t septal depolarization

o Abnormal
 width : > 1 ss
 height : > 2 mm
d/t patho Q wave – MI complete ms death

 Peak : HyperK / HyperMg

 Flat : HypoK / HypoMg
Normal : if followed normal T wave shape
 T inversion
d/t repolarization of papillary ms
>>Causes (NIVEBUD)
N – normal
Abnormal : if followed flat T wave
I – ischemia
d/t hypoK
V – Vent hypertrophy
E – Electrolyte imbalance
Bu – BBB
D – digoxin rx Credit to Gen03 (Sis Asma')
Edited by Gen05
6. Intervals
 PR intervals
 N : 3-5 SM (0.12 – 02 sec)
 Prolonged : > 0.2 sec / 1 LB
 d/t

I CARDEL

1 - 1st degree heart block

Ca – CAD
R – Acute rheumatic carditis
D – digoxin therapy
EL – electrolyte disturbance

 QT interval
 Normal < 2LB (0.4 sec)
 *if prolong > 0.45 sec may lead to VT

 Abnormal d/t calcium imbalance

 prolonged : HypoCa
 shorten : hyperCa

7. Segment

Abnormal
 ST elevation
d/t
 recent MI – certain lead
 pericarditis (involve all leads)

 ST depression
o Horizontal
d/t ischemia
o down-sloping ‘reversed-tick pattern’
d/t digoxin rx

ECG patterns of various STEMI locations

o Anteroseptal  V1 - V2
o Extensive ant  V1 – V6
o anterolateral  I, aVL, V5 – V6
o Inferior  II, III, aVF
o Rt vent  V4, V5

Credit to Gen03 (Sis Asma')

Edited by Gen05
 SPECIFIC ECG CHANGES

within hours within 24 hours within few days

-T wave peaked -T wave inverts -patho Q wave  appears as sign of full ms
-ST segment elevate -ST segment elevation begins to infarcts (patho Q wave may resolve 10%)
**sume mogok NAIK  resolve
**pasrah sume turun balik ☺
-ST elevation rarely persist *non Q wave infarcts (subendocardial infarcts)
(only if Lt vent aneurysm  have ST & T changes, but not patho Q wave
T wave may/may not persist *patho Q waves : when Q wave width > 1ss or
depth > 2mm

 1st degree (ddx : I CARDEL)

o prolonged PR interval (>5 SB @ > 0.20 s)

 2nd degree (ddx : I CARDEL

a) Mobitz 1 (wenkebach)
o progressive lengthening PR interval
o 1 non-conducted P wave (no QRS complex)
o followed by conducted beat shorter PR interval
o LONG, LONGER, LONGEST, DROP…

b) Mobitz II
o constant PR interval
o 1 non-conducted P wave (no QRS complex)
o SAME, SAME, SAME DROP

c) 2:1 / 3:1
o 2:1  2 P waves (alternaly conducted and non-conducted P wave)

 3rd degree
o atrial contraction normal but no beats conducted to ventricles (no relationship between P and QRS)
o d/t
 acute : MI
 chronic : fibrosis around bundle of His

Credit to Gen03 (Sis Asma')

Edited by Gen05
a) K+/Mg2+ (same presentation)
o Hyper  Peak T wave, ST segment disappear, QRS complex widened
o Hypo  flat T wave + U wave

b) Ca2+
o Hyper  shorten QT interval
o Hypo  Prolonged QT interval

o Prolonged PR interval (similar to 1st degree heart block)

o similar to 2nd degree heart block
o T inversion (remember NIVE BUD)
o ST segment down-slopong depression – reversed-tick pattern

Credit to Gen03 (Sis Asma')

Edited by Gen05