Normal Sinus Rhythm

Looking at the ECG you'll see that:

Rhythm - Regular Rate - (60-100 bpm) QRS Duration - Normal P Wave - Visible before each QRS complex P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree block) Indicates that the electrical signal is generated by the sinus node and travelling in a normal fashion in the heart.
Sinus Bradycardia

A heart rate less than 60 beats per minute (BPM). This in a healthy athletic person may be 'normal', but other causes may be due to increased vagal tone from drug abuse, hypoglycaemia and brain injury with increase intracranial pressure (ICP) as examples Looking at the ECG you'll see that:

Rhythm - Regular Rate - less than 60 beats per minute QRS Duration - Normal P Wave - Visible before each QRS complex P-R Interval - Normal Usually benign and often caused by patients on beta blockers
Sinus Tachycardia

An excessive heart rate above 100 beats per minute (BPM) which originates from the SA node. Causes include stress, fright, illness and exercise. Not usually a surprise if it is triggered in response to regulatory changes e.g. shock. But if their is no apparent trigger then medications may be required to suppress the rhythm Looking at the ECG you'll see that:

Rhythm - Regular Rate - More than 100 beats per minute QRS Duration - Normal P Wave - Visible before each QRS complex P-R Interval - Normal The impulse generating the heart beats are normal, but they are occurring at a faster pace than normal. Seen during exercise
Supraventricular Tachycardia (SVT) Abnormal

A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not under direct control from the SA node. SVT can occur in all age groups Looking at the ECG you'll see that:

Rhythm - Regular Rate - 140-220 beats per minute QRS Duration - Usually normal P Wave - Often buried in preceding T wave P-R Interval - Depends on site of supraventricular pacemaker Impulses stimulating the heart are not being generated by the sinus node, but instead are coming from a collection of tissue around and involving the atrioventricular (AV) node
Atrial Fibrillation

Many sites within the atria are generating their own electrical impulses, leading to irregular conduction of impulses to the ventricles that generate the heartbeat. This irregular rhythm can be felt when palpating a pulse Looking at the ECG you'll see that:

Rhythm - Irregularly irregular Rate - usually 100-160 beats per minute but slower if on medication QRS Duration - Usually normal P Wave - Not distinguishable as the atria are firing off all over P-R Interval - Not measurable The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm
Atrial Flutter

Looking at the ECG you'll see that:

Rhythm - Regular Rate - Around 110 beats per minute QRS Duration - Usually normal P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but sometimes 3:1 P Wave rate - 300 beats per minute P-R Interval - Not measurable As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the atrioventricular node is not involved in this case.
1st Degree AV Block

1st Degree AV block is caused by a conduction delay through the AV node but all electrical signals reach the ventricles. This rarely causes any problems by itself and often trained athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s in length, or 3-5 small squares on the ECG.

Looking at the ECG you'll see that:

Rhythm - Regular Rate - Normal QRS Duration - Normal P Wave - Ratio 1:1 P Wave rate - Normal P-R Interval - Prolonged (>5 small squares)
2nd Degree Block Type 1 (Wenckebach)

Another condition whereby a conduction block of some, but not all atrial beats getting through to the ventricles. There is progressive lengthening of the PR interval and then failure of conduction of an atrial beat, this is seen by a dropped QRS complex. Looking at the ECG you'll see that:

Rhythm - Regularly irregular Rate - Normal or Slow QRS Duration - Normal P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0. P Wave rate - Normal but faster than QRS rate P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped
2nd Degree Block Type 2

When electrical excitation sometimes fails to pass through the A-V node or bundle of His, this intermittent occurance is said to be called second degree heart block. Electrical conduction usually has a constant P-R interval, in the case of type 2 block atrial contractions are not regularly followed by ventricular contraction Looking at the ECG you'll see that:

Rhythm - Regular Rate - Normal or Slow

QRS Duration - Prolonged P Wave - Ratio 2:1, 3:1 P Wave rate - Normal but faster than QRS rate P-R Interval - Normal or prolonged but constant
3rd Degree Block

3rd degree block or complete heart block occurs when atrial contractions are 'normal' but no electrical conduction is conveyed to the ventricles. The ventricles then generate their own signal through an 'escape mechanism' from a focus somewhere within the ventricle. The ventricular escape beats are usually 'slow' Looking at the ECG you'll see that:

Rhythm - Regular Rate - Slow QRS Duration - Prolonged P Wave - Unrelated P Wave rate - Normal but faster than QRS rate P-R Interval - Variation Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm
Bundle Branch Block

Abnormal conduction through the bundle branches will cause a depolarization delay through the ventricular muscle, this delay shows as a widening of the QRS complex. Right Bundle Branch Block (RBBB) indicates problems in the right side of the heart. Whereas Left Bundle Branch Block (LBBB) is an indication of heart disease. If LBBB is present then further interpretation of the ECG cannot be carried out. Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal QRS Duration - Prolonged P Wave - Ratio 1:1 P Wave rate - Normal and same as QRS rate P-R Interval - Normal
Premature Ventricular Complexes

Due to a part of the heart depolarizing earlier than it should Looking at the ECG you'll see that:

Rhythm - Regular Rate - Normal QRS Duration - Normal P Wave - Ratio 1:1 P Wave rate - Normal and same as QRS rate P-R Interval - Normal Also you'll see 2 odd waveforms, these are the ventricles depolarising prematurely in response to a signal within the ventricles.(Above - unifocal PVC's as they look alike if they differed in appearance they would be called multifocal PVC's, as below)

Junctional Rhythms

Looking at the ECG you'll see that:

Rhythm - Regular Rate - 40-60 Beats per minute QRS Duration - Normal P Wave - Ratio 1:1 if visible. Inverted in lead II P Wave rate - Same as QRS rate P-R Interval - Variable Below - Accelerated Junctional Rhythm

Ventricular Tachycardia (VT) Abnormal

Looking at the ECG you'll see that:

Rhythm - Regular Rate - 180-190 Beats per minute QRS Duration - Prolonged P Wave - Not seen Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse
Ventricular Fibrillation (VF) Abnormal

Disorganised electrical signals cause the ventricles to quiver instead of contract in a rhythmic fashion. A patient will be unconscious as blood is not pumped to the brain. Immediate treatment by defibrillation is indicated. This condition may occur during or after a myocardial infarct.

Looking at the ECG you'll see that:

Rhythm - Irregular Rate - 300+, disorganised QRS Duration - Not recognisable P Wave - Not seen This patient needs to be defibrillated!! QUICKLY
Asystole - Abnormal

Looking at the ECG you'll see that:

Rhythm - Flat Rate - 0 Beats per minute QRS Duration - None P Wave - None Carry out CPR!!
Myocardial Infarct (MI)

Looking at the ECG you'll see that:

Rhythm - Regular Rate - 80 Beats per minute QRS Duration - Normal P Wave - Normal S-T Element does not go isoelectric which indicates infarction
Info ECG Component Time(sec) Small Squares P Wave PR Interval QRS 0.10 0.12 - 0.20 0.10 up to 2.5 2.5-5.0 1.5-2.5

Thanks to Nixon Mcinnes for their support in producing this site

SJW 2006

ECG BASICS
The electrocardiogram (ECG) is a diagnostic tool that measures and records the electrical activity of the heart in detail. Being able to interpretate these details allows diagnosis of a wide range of heart problems.
ECG Electrodes

Skin Preparation: Clean with an alcohol wipe if necessary. If the patients are very hairy shave the electrode areas. ECG standard leads There are three of these leads, I, II and III. Lead I: is between the right arm and left arm electrodes, the left arm being positive. Lead II: is between the right arm and left leg electrodes, the left leg being positive. Lead III: is between the left arm and left leg electrodes, the left leg again being positive. Chest Electrode Placement V1: Fourth intercostal space to the right of the sternum. V2: Fourth intercostal space to the Left of the sternum. V3: Directly between leads V2 and V4. V4: Fifth intercostal space at midclavicular line. V5: Level with V4 at left anterior axillary line. V6: Level with V5 at left midaxillary line. (Directly under the midpoint of the armpit)
Click on Picture to view large image

ECG Leads - Views of the Heart

Chest Leads V1 & V2 V3 & V4 V5 & V6 View Right Ventricle Septum/Lateral Left Ventricle Anterior/Lateral Left Ventricle

The ECG records the electrical activity that results when the heart muscle cells in the atria and ventricles contract.

Atrial contractions show up as the P wave. Ventricular contractions show as a series known as the QRS complex. The third and last common wave in an ECG is the T wave. This is the electrical activity produced when the ventricles are recharging for the next contraction (repolarizing). Interestingly, the letters P, Q, R, S, and T are not abbreviations for any actual words but were chosen many years ago for their position in the middle of the alphabet. The electrical activity results in P, QRS, and T waves that are of different sizes and shapes. When viewed from different leads, these waves can show a wide range of abnormalities of both the electrical conduction system and the muscle tissue of the hearts 4 pumping chambers.

ECG Interpretation

The graph paper that the ECG records on is standardised to run at 25mm/second, and is marked at 1 second intervals on the top and bottom. The horizontal axis correlates the length of each electrical event with its duration in time. Each small block (defined by lighter lines) on the horizontal axis represents 0.04 seconds. Five small blocks (shown by heavy lines) is a large block, and represents 0.20 seconds.

Duration of a waveform, segment, or interval is determined by counting the blocks from the beginning to the end of the wave, segment, or interval. P-Wave: represents atrial depolarization - the time necessary for an electrical impulse from the sinoatrial (SA) node to spread throughout the atrial musculature.

Location: Precedes QRS complex Amplitude: Should not exceed 2 to 2.5 mm in height Duration: 0.06 to 0.11 seconds

P-R Interval: represents the time it takes an impulse to travel from the atria through the AV node, bundle of His, and bundle branches to the Purkinje fibres.

Location: Extends from the beginning of the P wave to the beginning of the QRS complex Duration: 0.12 to 0.20 seconds.

QRS Complex: represents ventricular depolarisation. The QRS complex consists of 3 waves: the Q wave, the R wave, and the S wave.

The Q wave is always located at the beginning of the QRS complex. It may or may not always be present. The R wave is always the first positive deflection. The S wave, the negative deflection, follows the R wave Location: Follows the P-R interval Amplitude: Normal values vary with age and sex Duration: No longer than 0.10 seconds

Q-T Interval: represents the time necessary for ventricular depolarization and repolarization.

Location: Extends from the beginning of the QRS complex to the end of the T wave (includes the QRS complex, S-T segment, and the T wave) Duration: Varies according to age, sex, and heart rate

T Wave: represents the repolarization of the ventricles. On rare occasions, a U wave can be seen following the T wave. The U wave reflects the repolarization of the His-Purkinje fibres.

Location: Follows the S wave and the S-T segment Amplitude: 5mm or less in standard leads I, II, and III; 10mm or less in precordial leads V1-V6.

Duration: Not usually measured

S-T Segment: represents the end of the ventricular depolarization and the beginning of ventricular repolarization.

Location: Extends from the end of the S wave to the beginning of the T wave Duration: Not usually measured

The ECG and Myocardial Infarction

During an MI, the ECG goes through a series of abnormalities. The initial abnormality is called ahyperacute T wave. This is a T wave that is taller and more pointed than the normal T wave.

Hyperacute T Wave

The abnormality lasts for a very short time, and then elevation of the ST segment occurs. This is the hallmark abnormality of an acute MI. It occurs when the heart muscle is being injured by a lack of blood flow and oxygen and is also called a current of injury.

ST Elevation

An ECG can not only tell you if an MI is present but can also show the approximate location of the heart attack, and often which artery is involved. When the ECG abnormalities mentioned above occur, then the MI can be localized to a certain region of the heart. For example, see the table below:
ECG leads II, III, aVF V1-V4 V5-V6, I,aVL Location of MI Inferior MI Coronary Artery Right Coronary Artery

Anterior or Anteroseptal MI Left Anterior Descending Artery Lateral MI Left Circumflex Artery Left Circumflex Artery or Right Coronary Artery

ST depression in V1, V2 Posterior MI

Further Reading

ecgskills.net - An online training resource for all healthcare practitioners involved in conducting and interpreting Electrocardiographs (ECG) ECG/EKG Links What's so difficult about ECG's--a bundle of what? Mind your P's and Q's Thanks to Nixon Mcinnes for their support in producing this site SJW 2006