Normal Sinus Rhythm

Dr. dr. Taufik Indrajaya. SpPD. KKV< FINASIM

Div. Kardiologi Dept. Ilmu Penyakit Dalam

FK UNSRI / RS dr Muhammad Husin Palembang
2018

Lancashire & South Cumbria Cardiac Network

 ECG Interpretation
• A mystery?

• An enigma?

• Confusing?

• Difficult?
ECG Paper
Schematic representation of normal ECG
Whenever you look at an EKG, you will
Need to assess the rhythm.

These four questions should become an

intrinsic part of your thinking:
1. Are normal P waves present?
2. Are the QRS complexes narrow or
wide?
3. What is the relationship between the P
waves and the QRS complexes?
4. Is the rhythm regular or irregular?
For the normal EKG (normal sinus
rhythm), the answers are easy:

1. Yes, there are normal P waves.

2. The QRS complexes are narrow.
3. There is one P wave for every QRS
complex.
4. The rhythm is essentially regular.
Normal sinus rhythm and “The Four Questions” answered.
 Irama Normal : Sinus Rhytm

1. Gel P berasal dari SA node,

Positif di II an Negatif di aVR.
2. Setiap P selalu diikuti gel QRS dan T.
3. Bentuk gel P pada satu lead sama &
konstan.
4. Interval P-P konstan.
5. Interval PR normal : 0,12 – 0,20 detik
6. Frekuensi Jantung (HR) : 60–100 /mnt
 Criteria - P wave
P Wave represents atrial depolarisation.

An upright rounded P-wave in leads II, III

and AVF, and an inverted P-Wave in AVR
which precede each QRS Complex.
The P wave does not exceed 2.5mm in
height.
It does not exceed 3mm in width.
A biphid P wave is seen in lead V1.
 Criteria - PR interval
PR Interval

• 0.12 - 0.20seconds.

• Delay at AV node
»Protect ventricles
»Allow for ventricular filling
 Criteria QRS complex

QRS Complex represents ventricular

depolarisation.

Should not exceed 0.12 seconds in

duration.
Should not exceed 27mm in height.
Sharp narrow complex
RS in V1, QRS in V6
 Criteria T wave
• The deflection produced by
repolarisation of the ventricles.

• No clearly defined range

• General rule - T wave should not be more

than 1/2 the height of the preceding QRS
 Criteria - QT interval

• QTc Interval

• Should not exceed 0.42 seconds

(QTc).

• QT interval corrected to the heart

rate.
 Correction Calculation

QTc = measured Qt interval

 cycle length
 Criteria U wave

• The origin is uncertain

• May represent repolarisation if the IVS
• May represent slow conduction of
ventricular myocardium
• Prominent U waves are abnormal
• Usually most visible in V1-V4
 Nomenclature - QRS
• The 1st negative deflection - Q

• The 1st positive deflection - R

• The 2nd negative deflection or If a

negative follows a positive - S
Nomenclature -QRS
Nomenclature - QRS
Nomenclature - QRS
–Waves > 0.5mv (5mm) high
–Capital letters e.g. QRS

–Waves < 0.5mv (5mm) high

–Lower case e.g. qrs
 Intervals

–P wave duration measured?

–PR interval measured?

–QRS interval measured?

–QT interval measured?

 Amplitudes

–P wave height measured?

–QRS height measured?

 Segments

–PR segment measured ?

–ST segment measured ?

1mm =
0.1mv
1mm = 0.04s
Paper
P speed

QRS
segments
Pr Int QT Interval
 Limb leads

–Measurements - lead II

–QRS Axis

–P wave Axis
 Chest Leads

–Progression of R waves throughout

the chest leads

–Transitional Zone

–Phases of Activation
Depolarisation Stages

1
3

2
Typical complexes in the Pre-cordial
leads

RV RV IVS IVS LV LV

V1 V2 V3 V4 V5 V6
 Progression of R waves throughout the
chest leads

• Size of the R wave should increase from

V1 to V6.

• V4 Usually at the Apex (Transitional

Zone where the first negative wave
appears).
 Normal Rhythms

• Sinus Bradycardia: Same findings as for

Normal Sinus Rhythm except

–Heart Rate less than 60 bpm

 Normal Rhythms

• Sinus Tachycardia: Same findings as for

Normal Sinus Rhythm except

–Heart Rate greater than 100 bpm

 Normal Rhythms

• Sinus Arrhythmia: Same findings as for

Normal Sinus Rhythm except

–The R - R Interval is Irregular

 Normal Rhythms !!!

• *Sinus Arrest*

• Considered a ‘Sinus rhythm’ but is

abnormal
 Summary

• Checklist

• Criteria
ECG INTERPRETATION

• If the normal ECG is

known then
interpretation of
abnormals
becomes easier
 Summary
• This Module introduced you to:
Normal ECG

• Don’t worry too much right now about

trying to remember all the details.
• You’ll focus more on advanced ECG
interpretation in your clinical years !!
Thanks for
attention