EKG Interpretation

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Objectives
 The Basics
 Interpretation
 Clinical Pearls
 Practice Recognition

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MI Definition
 A result of occlusion of arterial flow to
the myocardium.
 Ischemia, injury and necrosis is result
 Occlusion occurs via spasm, blood clot
or stenosis

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The 12-Lead view
 Each limb lead I, II, III, AVR, AVL, AVF
records from a different angle
 All six limb leads intersect and visualize a
frontal plane
 The six chest leads (precordial) V1, V2, V3,
V4, V5, V6 view the body in the horizontal
plane to the AV node
 The 12 lead ECG forms a camera view from
12 angles

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Views from Augmented and
Limb Leads- Frontal

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Precordial lead snapshots
 Think of each
precordial lead as a
horizontal view of
the heart at the AV
node
 With the limb leads
and the precordial
leads you have a
snapshot of heart
portions

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Unipolar and Bipolar
 Limb leads I, II, III are bipolar and have a
negative and positive pole
 Electrical potential differences are measured
between the poles
 AVR, AVL and AVF are unipolar
 No negative lead
 The heart is the negative pole
 Electrical potential difference is measured
betweeen the lead and the heart
 Chest leads are unipolar
 The heart also is the negative pole
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Limb leads
 Leads I, II and III are called the limb leads. The electrodes that form
these signals are located on the limbs—one on each arm and one on
the left leg. The limb leads form the points of what is known as
Einthoven's triangle.
 Lead I is the voltage between the (positive) left arm (LA) electrode and
right arm (RA) electrode:
 Lead II is the voltage between the (positive) left leg (LL) electrode and
the right arm (RA) electrode:
 Lead III is the voltage between the (positive) left leg (LL) electrode
and the left arm (LA) electrode:

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Precordial Leads

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 I and AVL
V3 & v4

V1 & v2
V5 & v6
II, III and AVF Where the positive electrode is
positioned, determines what
part of the heart is seen! 12
 The ECG Tracing: Waves
 P- wave
 Marks the beginning of the cardiac cycle and
measures the electrical impulse that causes atrial
depolarization and mechanical contraction
 QRS- Complex
 Measures the impulse that causes ventricular
depolarization
 Q-wave- may or may not be evident on the ECG
 R-wave- first upward deflection following P wave
 S-wave- the first downward deflection following the R-
wave
 T- wave
 Marks ventricular repolarization that ends the
cardiac cycle 13
Intervals and Segments
 P-R interval-
 Time interval for impulse to go from the SA to the AV node
 normal 0.12-0.20 secs
 QRS Interval
 Time interval for impulse to go from AV node to stimulate
Purkinjie fibers
 Less than 0.12 secs
 QT Interval
 Time interval from beginning of depolarization to the end of
repolarization
 Should not exceed ½ the length of the R-R
 ST segment
 end of the S to the beginning of the T
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The ECG Tracing

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ECG Changes : Ischemia
 T-wave inversion ( flipped T)
 ST segment depression
 T wave flattening
 Biphasic T-waves

Baseline

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 ECG Changes: Injury
 ST segment elevation of greater than 1mm in at least
2 contiguous leads
 Heightened or peaked T waves
 Directly related to portions of myocardium rendered
electrically inactive

Baseline

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Evolving MI and Hallmarks of
AMI

Q wave
ST Elevation
1 year T wave
inversion 18
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Dissecting the 12 Lead ECG
 Horizontal marks time
 Vertical marks amplitude
 6 limb leads
 6 precordial leads
 Positioning measures 12 perspectives or
views of the heart
 The 12 perspectives are arranged in vertical
columns
 Limb leads are I, II, III, AVR, AVL, AVF
 Precordial leads are V1, V2, V3, V4, V5, V6
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The Normal Conduction System

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Lead Placement

aVF

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All Limb Leads

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Precordial Leads

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 EKG Distributions
 Anteroseptal: V1, V2, V3, V4
 Anterior: V1–V4
 Anterolateral: V4–V6, I, aVL
 Lateral: I and aVL
 Inferior: II, III, and aVF
 Inferolateral: II, III, aVF,
and V5 and V6

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Waveforms

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Interpretation
 Develop a systematic approach to
reading EKGs and use it every time
 The system we will practice is:
 Rate
 Rhythm (including intervals and blocks)
 Axis
 Hypertrophy
 Ischemia

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Rate
 Rule of 300- Divide 300 by the number
of boxes between each QRS = rate
Number of Rate
big boxes
1 300
2 150
3 100
4 75
5 60
6 50
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Rate
 HR of 60-100 per minute is normal
 HR > 100 = tachycardia
 HR < 60 = bradycardia

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What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm

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 Rhythm
 Sinus
 Originating from
SA node
 P wave before
every QRS
 P wave in same
direction as QRS

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What is this rhythm?
Normal sinus rhythm

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 Normal Intervals
 PR
 0.20 sec (less than one
large box)
 QRS
 0.08 – 0.10 sec (1-2
small boxes)
 QT
 450 ms in men, 460 ms
in women
 Based on sex / heart rate
 Half the R-R interval with
normal HR

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Blocks
 AV blocks
 First degree block
 PR interval fixed and > 0.2 sec
 Second degree block, Mobitz type 1
 PR gradually lengthened, then drop QRS
 Second degree block, Mobitz type 2
 PR fixed, but drop QRS randomly
 Type 3 block
 PR and QRS dissociated

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What is this rhythm?
First degree AV block
PR is fixed and longer than 0.2 sec

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 What is this rhythm?
Type 1 second degree block (Wenckebach)

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 What is this rhythm?
Type 2 second degree AV block
Dropped QRS

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What is this rhythm?
3rd degree heart block (complete)

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 The QRS Axis
 Represents the overall direction of the heart’s activity
 Axis of –30 to +90 degrees is normal

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 The Quadrant Approach
 QRS up in I and up in aVF = Normal

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What is the axis?
Normal- QRS up in I and aVF

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Hypertrophy
 Add the larger S wave of V1 or V2 in
mm, to the larger R wave of V5 or V6.
 Sum is > 35mm = LVH

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Ischemia
 Usually indicated by ST changes
 Elevation = Acute infarction
 Depression = Ischemia
 Can manifest as T wave changes
 Remote ischemia shown by q waves

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What is the diagnosis?
Acute inferior MI with ST elevation
in leads II, III, aVF

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 What do you see in this EKG?
ST depression II, III, aVF, V3-V6 = ischemia

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Let’s Practice
The sample EKGs were obtained from the following text:

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Normal Sinus Rhythm

Mattu, 2003

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First Degree Heart Block

PR interval >200ms

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Hyperkalemia

Tall, narrow and symmetric T waves

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Lateral MI

Reciprocal changes

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Inferolateral MI

ST elevation II, III, aVF

ST depression in aVL, V1-V3 are reciprocal changes
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