ECG Procedure and Interpretation

K. Badjra Nadha
Cardiovascular Dept
Udayana University-Sanglah Hospital
 Basic Concepts
of ECG
Recording
system of ECG
ECG
Interpretation
Normal ECG
 Myocardial cells:
Different
composition of
ions intra and
extra cell: Na+/K+
Right Atrial Abnormality
Left Atrial Abnormality
L V H (Left Ventricle Hypertrophy)

LVH criteria:
A. Voltage criteria: deep S at V1,V2; high R at V5,V6
B. ST depression and T inversion at V6 (V5)
C. Prolonged ventricle activation time at V6 (V5)
LVH
 R wave amplitude at lead V5 or V6 + S wave at
lead V1 or V2 > 35 mm.
R wave amplitude at lead V5 > 26 mm.
R wave amplitude at lead V6 > 18 mm.
R wave amplitude at lead V6 > R wave amplitude
at lead V5
RVH

RVH criteria: reverse R/S ratio at V1 (V2) and V6 (V5)

RVH
RBBB

Widened QRS, wide and deep S at I and V6 (V5),

and RR morphology at V1 (V2)
LBBB

Widened QRS, R shape at I and V6,

deep S at V1 (V2, V3)
 Accessory pathways

Bundle of Kent Bundle of James Bundle of Mahaim

Bundle of Kent : WPW Syndrome

(Wolf Parkinson White Syndrome)

- Delta wave
- Widened QRS complex
- Shortening of PR Interval < 0,12 second

Two type:
1. Type A : Bundle of Kent at the left side
early activation at the left ventricle
ECG result similar to RBBB (high R at V1 and V2)

2. Type B : similar to LBBB,

negative deflection of QRS complex at V1 and V2
 Shortening of PR interval
Presence of delta wave, wide QRS

Pre-excitation on Bundle of Kent: WPW syndrome

Impulse from sinus undergo 2 pathway:
Pathway no. 1: normal pathway
Pathway no. 2: through Bundle of Kent
Impulse through pathway no. 2 reach ventricle earlier, and activate
an area (D) in ventricle, which on ECG appear as delta wave (D)
Followed by ventricle activation through pathway no. 1, so the end
result on ECG is fusion between activation pathway no. 1 and no. 2
 CAD
Ischemia area
Injury area

Necrosis area

Endocardium
Epicardium

Various Degree of Ischemia on Myocardial Infarction

 Ischemia
ST depression

T Inversion

U Inversion
 Injury

Myocardial injury
a. ST elevation convex upward, specific for injury (epicard)
b. ST elevation concave upward, not specific
c. Deep ST depression, showed subendocardial injury
 Necrosis

Myocardial necrosis. Generally assumed: Q showed the thickness of necrosis, R

showed viable myocardium

a. qR shape: necrosis with significant amount of viable myocardium

b. Qr shape: thick necrosis with minimum amount of viable myocardium
c. QS shape: necrosis through the thickness of myocardium, i.e. transmural
Inferior
High lateral
Anteroseptal
Anterior extensive
Anterolateral
Limited to Anterior
Right ventricle
Posterior only (mirror image)
 I. Impulse Generation Disorder

A : Sinus
-1. Sinus Tachycardia
-2. Sinus Bradycardia
-3. Sinus Arrhythmia
-4. Sinus Arrest
B : Atrium
-1. Atrial extra systole
-2. Atrial tachycardia

Arrhythmias -3. Atrial Flutter

-4. Atrial fibrillation
-5. Wondering Pace Maker
C : AV Node
-1. Nodal extra systole
-2. Nodal tachycardia
-3. Nodal Escape Rhythm
D : Ventricle
-1. VES
-2. Vent. Tachycardia
-3. Vent. Flutter
-4. Vent. Fibrillation
-5. Vent. Arrest
-6. Vent. Escape Rhythm
II Impulse Conduction Disorder

A. S A Block
-1. Type constant
-2. Type Wenchebach

B. AV Block
-1. 1st degree
-2. 2nd degree
- Mobitz I
- Mobitz II
- High Degree
-3. 3rd degree (Total AV Block)

C. Block Intra Ventricular

-1. IVCD
-2. LBBB
-3. RBBB
-4. Fascicular Block
How to record an ECG
ECG Procedures: Preparation
Devices:
ECG machine
Power cable
Ground cable
Electrode cables (limb and precordial)
Electrode plates for limb
Electrode balloon for precordial
Jelly
Tissue
Alcohol swab
ECG paper
Pen marker
ECG Procedures: Preparation
Patient:
Informed consent (why the examination is necessary)
Shirts should be taken off, and there is no metal object that
attached to the patient
Patient is asked to remain still (minimize movement) when ECG is
being recorded
ECG Procedures: How to record an ECG

Attach all cables to ECG machine

Turn on the ECG machine
Patient in supine position, arms and legs do not touch each other
Clean the surface of the chest, wrist, ankle, using alcohol swab (shave
if necessary)
Apply jelly to limb electrodes.
Apply chest electrodes by pressing the electrodes rubber
Position :
Ekstremitas Lead
left arm - (yellow)
right arm - (red)

left leg - (green)

right leg - (black)

Epicardiac :
V1 at right parasternal line, ICS 4, colored red
V2 at left parasternal line, ICS 4, colored yellow
V3 between V2 and V4
V4 at left midclavicular line, ICS 5, colored brown
V5 at left anterior axilla line, ICS 5, colored black
V6 at left mid axilla line, ICS 5, colored purple
 Adjust calibration if needed
Record 3-4 beats in each lead, and additional minimal 6 beats in lead II
If necessary, re-adjust calibration
Remove all electrodes, clean the remaining jelly
Inform to the patient that examination is finished
Turn off the ECG machine
Write down on ECG result: name of the patient, age, gender, time, date,
name of the person who did the ECG
Clean the ECG machine
 Standard :

Paper speed : 25 mm/second.

Calibration : 1 mv, appear as deflection 10 mm.
Recording : 12 lead,
I, II, III (Bipolar lead)
aVR, aVL, aVF (Unipolar Extremity lead)
V1 V6 (Unipolar Precordial lead)
.

ECG paper : Horizontal line, represent time

1 mm = 0,04 s.
Vertical line, represent voltage
1 mm = 0,1 mv.
Distance between small line
1 mm small square
bold line = 5 mm big square
5 big square = 1 s.
Remember :
ECG is merely a supporting diagnostic examination in diagnosing
heart disease, and the most important part is the clinical condition
of the patient

Wrong procedure of recording an ECG will result in wrong

interpretation of the ECG
The ECG shows:
Sinus rhythm Summary
Sinus arrhythmia Normal ECG with sinus arrhythmia.
Normal axis 43
Normal QRS complexes
Normal ST segments and T waves
Sinus tachycardia 110 x/ mnt
44
 Sinus rhythm
Atrial extrasystoles, identified by early beats Summary
with broad and abnormal P waves (best seen in leads V2 and V3)
Extrasystoles are followed by a 'compensatory pause' Sinus rhythm with atrial
Normal axis extrasystoles 45

There is an RSR pattern in lead III, but the QRS complex is narrow
The ST segments and T waves are normal
The ECG shows:
Sinus rhythm
Normal axis Summary
Small Q waves in lead III but not elsewhere Acute inferior myocardial
46
Elevated ST segments in leads II, III, VF, with upright T waves
T wave inversion in lead VL infarction
Suggestion of ST segment depression in leads V2-V3
The ECG shows:
Sinus rhythm
Right axis
Short PR interval (112ms) Summary
QRS complexes a little wide (124 ms) Wolff-Parkinson-White syndrome type A.
Slurred upstroke of QRS (delta wave) 47

Dominant R wave in lead V1

Widespread T wave inversion
 Summary
The ECG shows:
Sinus rhythm with first degree block
Sinus rhythm
Prolonged PR interval of 280 ms (best seen in leads
V1, V2) 48
Normal axis
Normal QRS complexes
The ECG shows:
Sinus rhythm, rate 48/min oo
Normal axis Left ventricular hypertrophy.
QRS duration normal, but the R wave height in 49
lead V5 is 30 mm, and the S wave depth in lead V2 is 25 mm
Inverted T waves in leads I, VL, V5-V6
The ECG shows:
Sinus rhythm Summary
Broad QRS complexes (140 ms) Sinus rhythm with left bundle branch
'M' pattern in lead V6 block 50

Inverted T waves in leads I, VL, V6

The ECG shows:
Sinus rhythm Summary
Normal axis Sinus rhythm with right bundle branch
Broad QRS complexes (140 ms) block.
RSR pattern in lead I 51
Wide and slurred S waves in lead V5
Normal ST segments and T waves
The ECG shows: Summary
Atrial flutter Atrial flutter with 2:1 conduction.
Ventricular rate 140/min
Left axis 52
Normal QRS complexes, except that there is an S
wave in lead V6
NSR, PVC salvo, VT paroksismal
53
VT

54