Analysis and Interpretation of the Electrocardiogram

A Self-Directed Learning Module

Technical Skills Program
Queens University
Department of Emergency Medicine

Introduction
The electrocardiogram (ECG) is one of the most useful diagnostic tests in emergency medicine !t is an easy and
ine"pensive test that is used routinely in the assessment of patients #ith chest pain The ECG is the cornerstone
for ma$ing the diagnosis of cardiac ischemia and is used for ma$ing decisions a%out eligi%ility for throm%olytic
therapy
To avoid misinterpreting the ECG& the clinician must have a systematic approach This module is designed to
guide the learner through a step#ise approach to ECG interpretation 'pecific e"amples of a variety of
a%normal ECG(s are included at the end along #ith a %rief )ui*
O!ecti"es
+y the end of this learning module you should have a systematic approach to interpreting the ECG and %e a%le
to identify common ECG a%normalities
The #$ lead E%&
The ,- lead ECG is made up of the three standard lim% leads (!& !! and !!!)& the augmented lim% leads (a./&
a.0 and a.1) and the si" precordial leads (.,& .-& .2& .3& .4 and .5)
'a"es and comple(es
Inter"als and segments
P) Inter"al* 1rom the start of the 6 #ave to the start of the Q/' comple"
P) Segment* 1rom the end of the 6 #ave to the start of the Q/' comple"
+ Point* The 7unction %et#een the Q/' comple" and the 'T segment
,T Inter"al* 1rom the start of the Q/' comple" to the end of the T #ave
,)S Inter"al* 1rom the start to the end of the Q/' comple"
ST Segment* 1rom the end of the Q/' comple" (8 point) to the start of the T #ave
-ormal "alues
9eart rate 5: ; ,:: %pm
6/ interval :,- ; :-: s
Q/' interval < :,- s
QT interval = half // interval (males = :3: s> females = :33 s)
6 #ave amplitude (in lead !!) < 2 m. (mm)
6 #ave terminal negative deflection (in lead
.,)
< , m. (mm)
Q #ave
= ::3 s (, mm) and = ,?2 of / #ave amplitude in the same
lead
Approach to the E%&
Developing a systematic approach to the interpretation of the ECG is a critical s$ill for all clinicians The
follo#ing outlines one such approach
Step #* Determine the heart rate
There are a num%er of strategies for determining the heart rate @ simple& )uic$ techni)ue is to find a Q/'
comple" that falls on a ma7or vertical grid;line (,)& then count the num%er of large s)uares to the ne"t Q/'
comple" (-) Dividing this num%er into 2:: gives you the heart rate !n the ECG %elo#& there are - large s)uares
%et#een Q/' comple"es 2::?- gives a heart rate of ,4: %eats per minute
Step $* Measure important inter"als
The measurement of important electrocardiographic intervals usually includes the 6/ interval& the Q/' interval
and the QT interval @t a standard paper speed of -4 mm?second& the #idth of each small s)uare (,mm)
represents ::3 seconds Ane large s)uare (4mm) represents :- seconds
Step .a* %alculate the electrical a(is
The mean Q/' a"is refers to the average orientation of the heart(s electrical activity !n most cases& an
appro"imation of the a"is #ill %e sufficient for the ECG interpretation There are many different approaches to
a"is determination& %ut this discussion #ill %e limited to a simple techni)ue #hich uses the leads ! and a.1 to
calculate an appro"imate a"is
/
e
c
a
l
l
Lead # Lead a/0 Description Interpretation A(is
ECGB,
0eads ! and a.1
e)ually positive The
a"is #ill %e mid#ay
%et#een :C and D:C

Eormal a"is F
3:C;4:C

ECGB-
0eads ! and a.1 %oth
positive 0ead ! more
positive than a.1
The a"is #ill
therefore %e oriented
more to#ard :C

Eormal a"is F
-:C ; 3:C

ECGB2
0ead ! positive 0ead
a.1 almost
e)uiphasic
Therefore& the a"is
#ill %e approaching
:C (Note: when a
lead is equiphasic,
the axis will be 90 to
that lead.)

Eormal a"is F
:C

ECGB3
0ead ! positive 0ead
a.1 negativeThe
a"is #ill %e oriented
negatively past :C

0eft a"is
deviation F
;2:C

ECGB4
0ead ! negative 0ead
a.1 positive The
a"is #ill %e oriented
positively past D:C

/ight a"is
deviation F
;,-:C

ECGB5
+oth leads ! and a.1
negative The a"is
#ill %e oriented
%et#een ;D:C and
;,G:C

!ndeterminate
a"is F ;,24C

that the a"is can %e considered in terms of four )uadrants& #ith lead ! oriented at :C& and a.1 oriented at
HD:C @n ECG #ith the Q/' a"is oriented to the )uadrant %et#een :C and D:C is said to %e normal
@n ECG #ith the Q/' a"is oriented to the )uadrant %et#een ;,C and ;D:C is said to have left a(is
de"iation
@n ECG #ith the Q/' oriented to the )uadrant %et#een HD,C and ,G:C is said to have right a(is
de"iation
@n ECG #ith the Q/' oriented to the )uadrant %et#een ;D,C and ;,G:C is said to have an
indeterminate a(is %ecause one cannot tell if it represents right or left a"is deviation
Step .* %alculate the electrical a(is
The mean Q/' a"is is oriented to#ards the lead #ith the greatest net Q/' deflection To calculate the net Q/'
deflection& add up the num%er of small s)uares that correspond to the height of the / #ave (positive deflection)&
and su%tract the num%er of small s)uares that correspond to the height of the Q and ' #aves (negative
deflection)

!n actual fact& the net Q/' deflection can %e
appro"imated #ithout resorting to counting s)uares
!n the e"ample sho#n here& one can easily see that
the net deflection is slightly more positive than
negative

Step .c* %alculate the electrical a(is
@ppro"imate the net Q/' deflection for leads ! and a.1 /emem%er that the mean Q/' a"is #ill %e oriented
to#ards the lead #ith the greatest positive net Q/' deflection !f the net deflection is positive for %oth& the a"is
lies %et#een leads ! and a.1 (:;D:C) and is therefore normal

Step 1* E"aluate the cardiac rhythm
!f the rhythm is regular& the // interval should %e constant throughout the ECG This can %e chec$ed using
calipers& or more simply %y mar$ing on a piece of paper the distance %et#een t#o / #aves& and comparing this
distance %et#een pairs of Q/' comple"es on the ECG Ee"t& chec$ to see if a 6 #ave is present %efore each of
the Q/' comple"es
Step 2* Inspect P 3a"es for atrial enlargement
The 6 #aves in leads !& !!& !!! and ., should %e inspected for evidence of right or left atrial enlargement
Usually& lead !! #ill have the clearest 6 #ave
6 #ave amplitude should not e"ceed 2 small s)uares (2 mm or :2m.) !f it does& this represents right
atrial enlargement
!n lead .,& the terminal negative deflection of the 6 #ave represents left atrial depolari*ation and should
not e"ceed , mm (:,m.) !f it does& this is indicative of left atrial enlargement


Step 4* Inspect ,)S comple(es for "entricular hypertrophy or lo3 "oltage
!n the setting of 0eft .entricular 9ypertrophy (0.9)& the left ventricle enlarges
and so the leads oriented to the left ventricle (.4& .5& a.0) #ill IseeI more
electrical activity moving towards them @s #ell& the leads oriented a#ay from
the left ventricle (.,& .-) #ill IseeI more activity moving away from them !n
0.9 therefore& leads .4& .5 and a.0 #ill have tall / #aves& #hile leads ., and
.- #ill have deep ' #aves (The arro# in the diagram on the right sho#s the
direction of the net electrical activity in 0.9)
., or .- .4& .5 or a.0
The voltage criteria for 0.9
are satisfied if the sum of the
amplitude of the deepest '
#ave in ., or .-& and the
amplitude of the tallest / #ave
in .4 or .5& is e)ual to or
greater than 24 mm (24 m.)
The voltage criteria are also
satisfied if the amplitude of the
/ #ave in lead a.0 is e)ual to
or greater than ,- mm
(,-m.)
Step 5a* Inspect ,)S comple(es for undle ranch lock or fascicular lock
The normal Q/' interval is :,- seconds (2 mm or 2 small s)uares) on the ECG To correctly determine the
Q/' interval& use the lead #ith the #idest Q/' comple" !f the Q/' comple" is less than or e)ual to :,-
seconds& then no further analysis is necessary !f it is greater than :,- seconds& then you should try to determine
the reason for the a%normally long Q/' interval
@ simple approach is to consider the follo#ing three possi%le causes for Q/' #ideningJ
The type of %undle %ranch %loc$ can usually %e determined from the e"amination of three $ey leadsJ !& ., and
.5
Step 5* Inspect ,)S comple(es for undle ranch lock or fascicular lock
!n the normal heart& at the %eginning of ventricular depolari*ation& the Q/' a"is is oriented to the right %ecause
of left;to;right depolari*ation of the septum This produces a small / #ave in lead ., !mmediately follo#ing
septal depolari*ation& the left and right ventricles depolari*e The si*e of the left ventricle results in a
predominantly left#ard a"is for the remainder of the Q/' comple"
Step 5c* Inspect ,)S comple(es for undle ranch lock or fascicular lock
!n the setting of /+++& the initial part of the ECG is unchanged %ecause septal depolari*ation and
depolari*ation of the left ventricle are unaffected 9o#ever& the right ventricle depolari*es in a delayed and slo#
fashion This results in a #idening of the terminal part of the Q/' comple" and orientation of the a"is of the
terminal part of the Q/' comple" to the right
Step 5d* Inspect ,)S comple(es for undle ranch lock or fascicular lock
!n the setting of 0+++& the septum is activated in a right to left direction& and then there is depolari*ation of the
right and left ventricles through the right %undle The result is that the Q/' a"is has a predominantly left
orientation throughout and is #ide secondary to the slo# activation of the left ventricle
Step 5e* Inspect ,)S comple(es for undle ranch lock or fascicular lock
!f the ECG cannot %e characteri*ed as a typical /+++ or a typical 0+++& then it can %e categori*ed as an
intraventricular conduction delay This #ill not %e addressed in any more detail at this time
Step 6* Assess , 3a"es and determine significance
The Q #aves should %e assessed and their significance determined& particularly in regard to the diagnosis of
myocardial infarction 'mall Q #aves are commonly a normal finding in the inferior leads !!! and a.1& and in
the anterolateral leads a.0& !& .4 and .5 Q #aves of ::3 seconds (, mm) duration and greater than one third
the / #ave(s amplitude in the same lead may %e pathological
The pathological Q #aves seen in ., ; .5 indicate that this patient has had an anterior M! in the past This
patient also has evidence of an acute inferior M! as sho#n %y the 'T segment elevation in leads !!! and a.1
Step 7* Assess ST segments and T 3a"es
@ssess the 'T segment for the presence of elevations or depressions& together #ith T #ave a%normalities 'T
elevation can indicate the presence of conditions such as acute myocardial in7ury& 6rin*metal(s (variant) angina&
pericarditis& ventricular aneurysm or myocardial ischemia
This ECG is from a patient #ith an acute inferior M! Eote the 'T elevation in the inferior leads (!!& !!! and
a.1) The ECG also sho#s 'T depression in leads .,& .- and .2 ; li$ely a result of reciprocal changes
associated #ith the M!
Step #8* Measure ,T inter"al for specific diagnoses
The QT interval can %e prolonged secondary to meta%olic disorders and drug effects !t must %e corrected for
heart rate since it is rate dependent The corrected QT interval is calculated using the follo#ing formulaJ
QT! corrected K (QT! o%served) ? (s)uare root of // interval)
The QT! corrected is often reported #ith computeri*ed ECG interpretation
This ECG is from a male patient #ith familial prolonged QT syndrome The QT! corrected is appro"imately
:4- seconds Normal QTI corrected: 0.0 seconds !or males" 0. seconds !or !emales.
E%& inde(
The follo#ing represent common ECG findings that the clinician should %e familiar #ith
-ormal E%&
@ normal ECG is illustrated a%ove Eote that the heart is %eating in a regular sinus rhythm %et#een 5: ; ,::
%eats per minute (specifically G- %pm) @ll the important intervals on this recording are #ithin normal ranges
, 6 #aveJ
upright in leads !& a.1 and .2 ; .5
normal duration of less than or e)ual to :,, seconds
polarity is positive in leads !& !!& a.1 and .3 ; .5> diphasic in leads ., and .2> negative in a./
shape is generally smooth& not notched or pea$ed
- 6/ intervalJ
Eormally %et#een :,- and :-: seconds
2 Q/' comple"J
Duration less than or e)ual to :,- seconds& amplitude greater than :4 m. in at least one standard lead&
and greater than ,: m. in at least one precordial lead Upper limit of normal amplitude is -4 ; 2: m.
small septal Q #aves in !& a.0& .4 and .5 (duration less than or e)ual to ::3 seconds> amplitude less
than ,?2 of the amplitude of the / #ave in the same lead)
represented %y a positive deflection #ith a large& upright / in leads !& !!& .3 ; .5 and a negative
deflection #ith a large& deep ' in a./& ., and .-
in general& proceeding from ., to .5& the / #aves get taller #hile the ' #aves get smaller @t .2 or .3&
these #aves are usually e)ual This is called the transitional *one
3 'T segmentJ
isoelectric& slanting up#ards to the T #ave in the normal ECG
can %e slightly elevated (up to -: mm in some precordial leads)
never normally depressed greater than :4 mm in any lead
4 T #aveJ
T #ave deflection should %e in the same direction as the Q/' comple" in at least 4 of the 5 lim% leads
normally rounded and asymmetrical& #ith a more gradual ascent than descent
should %e upright in leads .- ; .5& inverted in a./
amplitude of at least :- m. in leads .2 and .3 and at least :, m. in leads .4 and .5
isolated T #ave inversion in an asymptomatic adult is generally a normal variant
5 QT intervalJ
Durations normally less than or e)ual to :3: seconds for males and :33 seconds for females
Acute anterolateral MI
@cute anterolateral M! is recongni*ed %y 'T segment elevation in leads !& a.0 and the precordial leads
overlying the anterior and lateral surfaces of the heart (.2 ; .5) Generally spea$ing& the more significant the
'T elevation & the more severe the infarction There is also a loss of general / #ave progression across the
precordial leads and there may %e symmetric T #ave inversion as #ell @nterolateral myocardial infarctions
fre)uently are caused %y occlusion of the pro"imal left anterior descending coronary artery& or com%ined
occlusions of the 0@D together #ith the right coronary artery or left circumfle" artery @rrythmias #hich
commonly preclude the diagnosis of anterolateral M! on ECG and therefore possi%ly identify high ris$ patients
include right and left %undle %ranch %loc$s& hemi%loc$s and type !! second degree atrioventricular conduction
%loc$s
Acute inferior MI
0eads !!& !!! and a.1 reflect electrocardiogram changes associated #ith acute infarction of the inferior aspect of
the heart 'T elevation& developing Q #aves and T #ave inversion may all %e present depending on the timing
of the ECG relative to the onset of myocardial infarction Most fre)uently& inferior M! results from occlusion of
the right coronary artery Conduction a%normalities #hich may alert the physician to patients at ris$ include
second degree @. %loc$ and complete heart %loc$ together #ith 7unctional escape %eats Eote that the patient
%elo# is also suffering from a concurrent posterior #all infarction as eveidenced %y 'T depression in leads .,
and .-
Acute posterior MI
Lhen e"amining the ECG from a patient #ith a suspected posterior M!& it is important to remem%er that
%ecause the endocardial surface of the posterior #all faces the precordial leads& changes resulting from the
infarction #ill %e reversed on the ECG Therefore& 'T segments in leads overlying the posterior region of the
heart (., and .-) are initially hori*ontally depressed @s the infarction evolves& lead ., demonstrates an /
#ave (#hich in fact represents a Q #ave in reverse) Eote that the patient %elo# is also suffering from an
inferior #all myocardial infarction as evidenced %y 'T elevation in leads !!& !!! and a.1
Acute right "entricular MI
!n patients presenting #ith acute right ventricular M!& a%normalities in the standard ,- lead ECG are restricted
to 'T elevation greater than or e)ual to , mm in lead a./ @lthough isolated right ventricular M! is usually
seen in patients suffering from chronic lung disease together #ith right ventricular hypertrophy& it can occur in
patients suffering a transmural infarction of the inferior;posterior #all #hich e"tends to involve the right
ventricular #all as #ell /ight ventricular M! is most commonly caused %y o%struction of the pro"imal right
coronary artery and is fre)uently associated #ith right %undle %ranch %loc$ 1urthermore& only 4M ; ,:M of
patients suffer from hemodynamic symptoms
Acute septal MI
@cute septal M! is associated #ith 'T elevation& Q #ave formation and T #ave inversion in the leads overlying
the septal region of the heart (.- and .2)
Atrial firillation
@trial fi%rillation represents disorgani*ed atrial activity #ithout contraction or e7ection The electrocardiogram
demonstrates an irregular %aseline #here the normal 6 #aves are replaced #ith rapidly )uivering small
deflection of varia%le amplitude (f #aves ; outlined %elo#) @n irregularly irregular ventricular rate
demonstrating narro# Q/' comple"es is esta%lished %et#een ,:: ; ,5: %pm @trial fi%rillation is common in
patients #ith rheumatic heart disease& pulmonary em%oli& cardiomyopathy& pericarditis& ischemic heart disease
and thyroto"icosis !t causes minimal hemodynamic compromise and often the patient presents complaining of
palpitations as the only symptom @lthough hemodynamic compromise is minimal& atrial fi%rillation is an
important ris$ factor for the development of throm%oem%olic complications& such as stro$es and transient
ischemic attac$s
Atrial flutter
The electrocardiogram in atrial flutter is typically characteri*ed %y its Isa#toothI flutter #aves (1 #aves ;
arro#s %elo#) %est demonstrated in the inferior leads (!!& !!!& a.1 and .,) @ rapid regular atrial rhythm is
generally demonstrated %et#een -4: and 24: %pm& and the )/' rate is determined %y the ratio of
atrioventricular conduction @lthough the usual ratio of @. conduction is -J, (as illustrated %elo#)& ,J,& 2J,& 3J,&
5J, and other varia%le ratios are also demonstrated& al%eit less fre)uently Typically& this results in a ventricular
heart rate %et#een ,4: and ,N: %pm @trial flutter is relatively uncommon and is most often seen in patients
presenting #ith acute ischemic heart disease or pulmonary em%olism Eevertheless& it can present as a chronic
condition in patients #ho suffer from organic heart disease
%omplete heart lock
Complete heart %loc$ refers to a form of atrioventricular dissociation #here no 6 #ave produces a Q/'
comple" @ sinus or ectopic atrial rhythm develops that fires independently of the ventricles This rhythm may
%e 7unctional (as illustrated %elo#) or ventricular in origin The rhythm is usually regular& %ut may present
irregularly as a result of intermittent premature ventricular %eats 6atients presenting #ith complete heart %loc$
complain of symptoms resem%ling profound %radycardia (loss of atrial $ic$) and reduced cardiac output
(syncope& angina& presyncope)
Digitalis effect
These glycosides can cause 'T sagging and shortening& %est seen in leads .3& .4 and .5 (see %elo#)
Dual chamer pacemaker
This electrocardiogram demonstrates an artificial cardiac pacema$er #hich is responsi%le for initiating
contractions #ithin the atria as #ell as the ventricles Eote the dou%le pacema$er spi$es associated #ith each
complete cycle of contraction The first spi$e indicates stimuli to the atria& #hile the second pacema$er spi$e
indicates initiation of ventricular contraction
9yperkalemia
6otassium overdose is fre)uently seen in patients #ith renal failure or those on O sparing diuretics !n mild
hyper$alemia (serum levels less than 54 mE)?l)& leads !!& .- and .3 demonstrate tall& tented& symmetrical T
#aves #ith a narro# %ase The 6 #ave remains normal& as does the Q/' comple" Lith moderate O overdose
(54 mE)?l ; G: mE)?l) the Q/' comple" %roadens and the ' #ave is #idened in leads .2 ; .5 This ' #ave
%ecome continuous #ith the tented T #aves and eventually the 'T segment disappears 1urthermore the
duration of the 6 #ave is increased& #hile the amplitude is decreased @t O levels greater than G: mE)?l (see
%elo#)& the 6 #ave duration and 6/ interval duration %oth increase& until the 6 #ave eventually disappears
entirely The Q/' comple" is diffusely %roadened and continuous #ith the tall& tented T #ave in all leads
9ypokalemia
9ypo$alemia is associated #ith progressive 'T depression& progressive flattening or inversion of the T #aves&
the development of U #aves& increased amplitude and duration of the 6 #aves and Q/' comple"es as #ell as a
slight increase in the duration of the 6/ interval 1urthermore& hypo$alemia affects automaticity of the
pacema$er cells and leads to multiple arrhythmias such as sinus %radycardia& atrioventricular %loc$& atrial flutter
and Torsades de 6ointes Most commonly& hypo$alemia results from thia*ide diuretic misuse& diarrhea& renal or
adrenal disease Ather causes include infusion of large amounts of glucose or al$ali su%stances& liver cirrhosis
and dia%etic coma
Left atrial enlargement
0eft atrial enlargement is typically characteri*ed %y an increase in the terminal portion of the 6 #ave +est seen
in lead !!& this terminal deflection is often demonstrated as a distinct second pea$ #ithin the 6 #ave (arro#
%elo#) !n some leads& this second pea$ gives the 6 #ave an Im;li$eI shape This deflection does not usually
affect the amplitude of the 6 #ave& %ut may increase its duration to greater than :,- seconds !n addition to this
increased 6 #ave deflection in lead !!& 0@E results in a terminal negative deflection #ithin the 6 #ave %est seen
in lead ., (see %elo#) Lith e"treme 0@E& the amplitude of the 6 #ave may %e increased& and terminal
negativity may %e demonstrated in leads !!& !!! and a.1 (see %elo#) 0eft atrial enlargement may result from left
atrial dilatation& pressure overload (ie from mitral valve disease) or a%normal intra;atrial conduction Ather
terms fre)uently used to descri%e 0@E include left atrial hypertrophy& left atrial overload and left atrial
a%normality
Left "entricular hypertrophy
Electrocardiograms from patients presenting #ith 0.9 demonstrate varia%ly increased / #ave voltage and
duration in leads over the right ventricle (.4 and .5 ; circled %elo#) !n 24M ; D:M of the cases& there is a
delay %et#een the onset of the Q/' comple" and the / #ave This intrinsicoid deflection may e"tend to greater
than ::4 seconds 1urthermore& delayed repolari*ation as a result of ventricular hypertrophy generally produces
'T depression and T #ave inversion in the same leads Enlargement of the left ventricle is commonly associated
#ith left atrial enlargement as #ell as incomplete 0+++ 0eads .- and .2 commonly demonstrate increased '
#ave amplitude (arro# %elo#)& #hile leads .4 and .5 sho# increased / #ave amplitude 0eft ventricular
hypertrophy may %e associated #ith conditions giving rise to pressure or volume overload of the left ventricle
such as aortic stenosis or systemic hypertension 1urthermore& 0.9 increases patient ris$ of other
cardiovascular diseases including myocardial infarction& congestive heart failure& stro$e& arrhythmia and sudden
death
Left undle ranch lock
!n left %undle %ranch %loc$& activation of the intraventricular septum is reversed and electrical impulses to the
left ventricle are delayed These altered electrical forces produce a #ide Q/' comple" (greater than :,-
seconds in duration) #ith an a%normal morphology !n leads ! and .5& a%normal initial forces fail to produce
any Q #ave or ' #ave& and the resultant / #ave is steep and often notched (circled %elo#) 1urthermore& a deep
rapid ' #ave is generated in lead ., (arro# %elo#) The 'T segment is slightly elevated in multiple leads and
the T #ave polarity is diffusely opposite to the ventricular comple"
Pericarditis
6atients presenting #ith acute pericarditis demonstrate diffuse 'T segment elevation in all leads e"cept a./ and
., (see %elo#) These 'T changes are sometimes associated #ith concurrent 6/ segment depression in the
same leads and an increased sinus heart rate (a%ove ,2G %pm) @t -;4 days after the acute presentation& the 'T
segments return to %aseline 1ollo#ing this return to %aseline& the T #aves in all leads e"cept a./ %ecome
inverted& eventually returning to their previously normal polarity and amplitude over the follo#ing couple of
#ee$s
Premature atrial comple(
6remature atrial comple"es (circled %elo#) are recogni*ed %y three distinct featuresJ
, a premature and unusually shaped 6 #ave (designated 6()
- a Q/' comple" resem%ling a normal sinus %eat
2 a follo#ing cardiac cycle that is less than compensatory in duration
6@C(s originate from a focus outside the '@ node 9ence the irregular shape of the 6( #ave& irregular duration
of the 66 interval and e"tended duration of the 6(/ interval to greater than :,- seconds !t is important to
remem%er that if this 6@C fires very early in the cycle& ventricular activation may not occur& or a reentrant atrial
tachycardia may develop !n normal individuals& 6@C(s may arise from various stimuli including to%acco&
caffeine and alcohol as #ell as strong emotions Ather situations #hich may lead to the development of 6@C(s
include myocardial infarction& various drugs& infections& hypo$alemia and hypomagnesemia
Premature "entricular comple(
6remature ventricular comple"es (circled %elo#) may arise in normal individuals as #ell as patients suffering
from nearly every form of structural heart disease 6remature ventricular comple"es are recogni*ed as single or
paired unifocal %eats& #ith no preceding 6 #ave& a #ide Q/' comple" of increased amplitude characteristically
lasting greater than :,3 seconds& and a T #ave demonstrating polarity opposite to that of the 6.C They arise
early in the cardiac cycle and are more li$ely to occur during periods of %radyarrhythmia @lthough no 6 #aves
precede the #ide Q/' comple"& retrograde activation of the atria may produce 6 #aves #hich occur after the
6.C or are %uried in their T #aves 6remature ventricular %eats may arise from e"cessive catecholamines&
myocardial ischemia or in7ury& electrolyte im%alances& certain medications including digitalis and class !@ and
!C antiarrhythmic agents
Prolonged ,T inter"al
The QT interval represents the time %et#een the %eginning of the Q #ave until the end of the T #ave This
interval is %est measured in lead !! and represents %oth the depolari*ation and repolari*ation phases of the
ventricles !t is significantly influenced %y many factors including heart rate& various medications (especially
)uinidine& procainaminde and disopyramide)& hypo$alemia& hypomagnesemia and athletic training Therefore&
ta%les or formulas are often needed to calculate the corrected QT interval (@Tc) to determine if the QT interval
on a particular electrocardiogram is appropriate for its demonstrated heart rate Ane accepted calculation in
determining this QTc is a modified version of +a*ett(s formula This formula states that the QTc K QT H
,N4(ventricular rate ; 5:) Eormal values for this corrected QT interval are found to appro"imate :3, seconds&
although this value is slightly longer in females and in patients of increasing age !f this calculation is applied to
the ECG demonstrated %elo#& the QTc is measured as :4- seconds PQTc K :4- H ,N4 (5: ;5:)Q
Pulmonary emolism
Electrocardiogram a%normalities can %e o%served in a minority of patients presenting #ith pulmonary
em%olism These changes are rarely diagnostic unless greater than 4:M of the pulmonary vascular compartment
is occluded 6ulmonary em%olism increases resistance to %lood flo# to the right side of the heart& commonly
resulting in cor pulmonale involving right atrial enlargement and right ventricular dilation or hypertrophy 0ead
!!! demonstrates ECG changes #hich mimic acute inferior myocardial infarction (circled %elo#) These changes
include an increase in the normal Q #ave amplitude& minimal 'T segment elevation& and often shallo# T #ave
inversion 6ulmonary em%olism is differentiated from acute inferior M! %y the a%sence of these changes in the
other inferior leads (!! and a.1) Elevated 'T segments& increased ' #ave amplitude and inverted T #ave
polarity may sometimes %e seen in the precordial leads
)ight atrial enlargement
6atients presenting #ith /@E demonstrate an ECG pattern in #hich the 6 #ave duration is unaffected& %ut its
shape is pea$ed and its amplitude is increased to greater than -4 mm in leads !!& !!!& a.1 (arro#s %elo#) and
sometimes ., Lith e"treme enlargement of the right atrium& the 6 #ave may demonstrate terminal negativity
in lead .,& resem%ling 0@E /ight atrial enlargement is commonly associated #ith congenital heart disease&
tricuspid valve disease& pulmonary hypertension and diffuse lung disease 1urthermore& patients presenting #ith
/@E often demonstrate ECG changes associated #ith right ventricular hypertrophy as #ell
)ight undle ranch lock
@s illustrated in the electrocardiogram %elo#& right %undle %ranch %loc$ presents #ith delayed activation of the
right ventricle& leading to a #ide Q/' comple" lasting greater than :,- seconds @ltered terminal Q/' forces
produce a terminal / #ave in lead a./ and terminal ' #aves in leads !& a.0& .4 and .5 Triphasic comple"es
are identified as the late intrinsicoid Im;shapedI /'/( comple" in lead .,& and the early intrinsicoid )/'
comple" in lead .5
Single chamer pacemaker
@rtificial cardiac pacema$ers are most commonly used in the management of symptomatic %radycardias These
pacema$ers provide electrical stimuli to the atria or ventricles or %oth at a desired rate to cause them to contract
regularly at that rate An the electrocardiogram& these electrical impulses are seen as Ipacema$er spi$esI
identified %y their a%rupt vertical spi$e (arro#s %elo#)& preceding the atrial or ventricular comple"& depending
on #hich cham%ers the pacema$er is responsi%le for !n this e"ample& a pacema$er has %een inserted #hich is
responsi%le for providing a regular ventricular rhythm (#ide& %i*arre Q/' comple" ; circled %elo#) Eo atrial
contractions are present
Supra"entricular tachycardia - A/ reentry
'upraventricular tachycardia commonly presents in t#o forms ; @. reentry and @. nodal reentry !n @. reentry
(%elo#)& the '.T presents as a regular tachycardia originating outside the ventricular myocardium !n this type
of '.T& the @. node is used for impulse conduction to the ventricles& #hile an accessory path#ay is used to
return electrical conduction %ac$ to the atria The heart rate is usually regular& at a rate of ,N: to -4: %pm
(%elo# K ,GG %pm) !n this type of '.T& 6 #aves are al#ays present outside of the Q/' comple"& #hile their
polarity depends on the atrial insertion of the accessory path#ay The Q/' comple" is narro# #ith a duration
less that :- seconds and an atrioventricular conduction ratio of ,J, !n -4M ; 2:M of patients demonstrating @.
reentry& Q/' alternans is present (varying amplitudes of the Q/' comple" in all leads e"cept .3) @. reentry is
not usually associated #ith structural heart disease and commonly presents as a variety of symptoms including
palpitations& nervousness& an"iety& syncope or heart failure
Supra"entricular tachycardia - A/ nodal reentry
@. nodal reentry is a form of '.T that esta%lishes its atrioventricular circuit entirely #ithin the @. node The
heart rate is usually regular& %et#een ,4: to -4: %pm (%elo# K ,G5 %pm) The Q/' comple" is narro# #ith a
duration less than :- seconds and a conduction ratio of ,J, 6 #aves are %uried #ithin the Q/' compel" (as
illustrated %elo#)& although they may %e visi%le at the end of the comple" as a distortion of the terminal forces
Due to the fact that atrial activation originates from the inferior aspect of the right atrium& 6 #ave polarity is
negative in leads !!& !!! and a.1 This form of '.T is usually %enign and is easily converted to sinus rhythm %y
vagal maneuvers
/#:/. interchanged
@ccurate electrocardiogram interpretation can only %e achieved if all ,- leads are placed in their appropriate
positions Ane of the more common errors involving lead placement involves reversal of the positioning of
leads ., and .2 (demonstrated %elo#) This mista$e produces an ECG pattern in #hich the normal / and '
#ave progressions in the precordial leads ., to .2 is lost
/entricular tachycardia
.entricular tachycardia is defined as three or more ventricular comple"es in succession at a rate greater than
,:: %pm 6atients presenting #ith ventricular tachycardia often present #ith a regular heart rate %et#een ,::
and -4: %pm (9/ %elo# K ,35 %pm)& in #hich the Q/' morphology is constant and a%normally #ide (greater
than :,- seconds) 1re)uently& these ECG(s demonstrate @. dissociation in #hich the ventricular rate is greater
than the atrial rate 6 #aves are fre)uently hidden #ithin the %road ventricular comple"es& although they can
sometimes %e identified as %umps or notches in the ventricular cycles @lthough patients #ithout heart disease
may develop paro"ysmal non;sustained ventricular tachycardia& chronic sustained .T is most commonly
associated #ith coronary artery disease& dilated cardiomyopathy and prior myocardial infarction or severe heart
disease
'olff-Parkinson-'hite syndrome
Electrocardiograms from patients presenting #ith L6L demonstrate a group of characteristic findings
fre)uently associated #ith paro"ysmal tachycardias and atrial fi%rillation !n L6L& accessory path#ays of
accelerated ventricular impulse formation lead to the development of delta #aves These #aves resem%le
pathological Q #aves and represent initial slurring of the Q/' comple" as a result of early ventricular
depolari*ation through this accessory path#ay (see lead !!& ., and .5 ; arro# %elo#) @s a result& the 6/
interval is shortened to less than :,- seconds and the Q/' direction is altered (lead !!!)& #hile its duration is
e"tended to greater than :,: seconds 'econdary T #ave anomalies resulting from a%normal ventricular
repolari*ation are often demonstrated (leads !!& !!!& .-& .2 and .3)
%ase #
This G- year old male comes to the E/ complaining of general illness @ resident notices that he has an irregular
pulse and performs an ECGJ

Lhat is the diagnosisR

@trial flutter
Complete heart %loc$
.entricular fi%rillation
@trial fi%rillation
!ncorrect
!ncorrect
!ncorrect
Correct
%ase $
This N- year old female presents in the E/ complaining of su%sternal chest pain radiating into her left arm 'he
is diaphoretic and is also complaining of nausea @n ECG is performedJ
Lhat is the most li$ely diagnosisR

@cute anterolateral M!
6osterior M!
Complete heart %loc$
'eptal M!
Correct
!ncorrect
!ncorrect
!ncorrect
%ase .
This 54 year old female presents to the E/ complaining of #ea$ness @ history reveals that she has a history of
congestive heart failure for #hich she ta$es furosemide @n ECG is performedJ
Lhat is the most li$ely diagnosisR
9ypo$alemia
@cute posterior M!
@trial fi%rillation
9yper$alemia
Correct
!ncorrect
!ncorrect
!ncorrect
%ase 1
This -D year old male presents in the E/ complaining of severe pleuritic chest pain over the left precordium
6hysical e"amination reveals a friction ru% over the left precordium @n ECG is performedJ
Lhat is the most li$ely diagnosisR

9ypo$alemia
6ulmonary em%olism
9yper$alemia
6ericarditis
!ncorrect
!ncorrect
!ncorrect
Correct
%ase 2
This 4D year old male is %rought into the E/ %y paramedics #ho he called %ecause he felt his heart pounding
@n ECG is performedJ
Lhat is the most li$ely diagnosisR
.entricular tachycardia
6ulmonary em%olism
6.C
'.T ; @. reentry
!ncorrect
!ncorrect
Correct
!ncorrect
CongratulationsS
Tou have no# completed the @nalysis and !nterpretation of the ECG module
Credits
This #e%;%ased module #as developed and edited %y @dam '*ule#s$i %ased on content #ritten %y Dr
+o% McGra#& Dr 8ason 0ord& Matthe# Lestendorp& 0isa Evans and 8ordan Chen$in for the Queen(s
University Technical '$ills 6rogram and Department of Emergency Medicine
The module #as created using e"e J e0earning U9TM0 editor #ith support from @my @llcoc$ and the
Queen(s University 'chool of Medicine MedTech Unit
0icenseJ This module is licensed under the Creative Commons @ttri%ution Eon;Commercial Eo Derivatives
license The module may %e redistri%uted and used provided that credit is given to the author and it is used for
non;commercial purposes only The contents of this presentation cannot %e changed or used individually 1or
more information on the Creative Commons license model and the specific terms of this license& please visit
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