ECG

DR. DEEP PANT

 ECG Features to be examined?
1. Rate and regularity
2. P wave morphology
3. PR Interval
4. QRS Morphology
5. ST segment Morphology
6. T Wave morphology
7. QTc interval
8. Rhythm
Standard limb lead placement
Augmented Limb leads
Chest leads
placement
Right Sided ECG

• Useful in patients with Inferior

wall infarction in order to see
for the involvement of Right
Ventricle
Recording of An ECG
Rate: Regular Rhthym
• Rate = 1500 divided by number of small squares
• Rate = 1500 divided by No. of small squares

1500
No. of small squares

• Paper speed = 25 mm/sec

• In 1 sec paper passes 25 small boxes or 25 mm,
• So, in 60 secs, it travels 25 x 60 small boxes ~ 1500 small boxes.
Rate: Irregular Rhthym

Calculate the Number of R waves

in 6 seconds that is 30 big boxes
and multiply it by 10 to get the
heart rate.
 P wave
• The P wave represents electrical forces generated from atrial
activation. The first and second halves of the P wave roughly
correspond to right and left atrial activation, respectively.
Normal P wave:
A. Duration : 0.08-0.11 seconds
B. Axis : 0-75 degree
C. Morphology : Upright in I, II, aVF; upright or
biphasic in III, aVL, V1, V2. Small notching may be
present
D. Amplitude: Limb leads: < 2.5 mm; V1: positive
deflection < 1.5 mm and negative deflection < 1 mm
P wave Morphology
P wave Morphology
 P wave Morphology
• P. Mitrale : also known as left
atrial enlargement is noted by
upright P waves in lead I, a
bifid P wave in lead II.

• P pulmonale may occur as a

transient manifestation in Status
Asthmaticus And Acute
Pulmonary Embolism.
PR interval
• The PR interval =P wave+ PR segment
• From the beginning of the P wave to the first part of the QRS complex
• Time for atrial depolarization (the P wave) and conduction through the AV
node and the His-Purkinje system (which constitute the PR segment)
• PR interval : 0.12 to 0.20 sec (three to five small boxes)
• Shorter at faster heart rates due to sympathetically mediated enhancement
of atrioventricular (AV) nodal conduction
• Longer when the rate is slowed as a consequence of slower AV nodal
conduction resulting from withdrawal of sympathetic tone or an increase
in vagal inputs.
QRS COMPLEX
• If the initial deflection is negative, it is termed a Q wave
• Small Q waves are often seen in leads I, aVL, and V4-V6 as a result of
initial septal depolarization and are considered normal.
• The first positive deflection of the QRS complex is called the R wave=
depolarization of the LV myocardium
• RV depolarization is obscured because the LV myocardial mass is
much greater than that of the right ventricle
• The small R wave in lead V1 represents initial septal depolarization
• The negative deflection following the R wave is the S wave, which
represents terminal depolarization of the high lateral wall
• If there is a second positive deflection, it is known as an R'.
• Lower case letters (q, r, or s) are used for relatively small amplitude
waves of less than 0.5 mV (less than 5 mm with standard calibration)
• An entirely negative QRS complex is called a QS wave
• QRS duration = 0.06 to 0.10 seconds (1½ to 2½ small boxes) and is
not influenced by heart rate.
• The R wave should progress in size across the precordial leads V1-V6
• Normally there is a small R wave in lead V1 with a deep S wave
• R wave amplitude should increase in size until V4-V6 while the S
wave becomes less deep. This is termed R wave progression across the
precordium.
ST SEGMENT
• The ST segment occurs after ventricular depolarization has ended and
before repolarization has begun
• The time of electrocardiographic silence
• The intersection of the end of the QRS complex and the initial part of
the ST segment is termed the J point
• The ST segment is usually isoelectric
T- wave
• T wave =Period of ventricular repolarization the rate of repolarization is slower
than depolarization, the T wave is broad, has a slow upstroke, and rapidly returns
to the isoelectric line following its peak (ie, slow upstroke, rapid downstroke)
• T wave is asymmetric and the amplitude is variable
• T wave is usually smooth up and down depolarization begins at the endocardial
surface and spreads to the epicardium, while repolarization begins at the epicardial
surface and spreads to the endocardium, the direction of ventricular depolarization
is opposite to that of ventricular repolarization
• T wave vector on the ECG normally is in the same direction as the major
deflection of the QRS
• The QRS and T wave axes are concordant
Qt interval
• QT interval = QRS complex+ ST segment+ T wave
• QT interval is primarily a measure of ventricular repolarization
• JT interval= ventricular repolarization since it does not include
ventricular depolarization, but in most clinical situations, the QT
interval is used
• QRS complex duration is increased, this will lead to an increase in QT
interval but does not reflect a change in ventricular repolarization. A
widened QRS, therefore, must be considered if a prolonged QT
interval is being evaluated.
• QT (or JT) interval is dependent upon the heart rate it is shorter at
faster heart rates and longer when the rate is slower
• QT interval that is corrected for heart rate (QTc) is often calculated as
follows (based on Bazett's formula):
• QTc = QT interval ÷ square root of the RR interval (in sec)
• QTc in men is ≤0.44 sec
• QTc in women is ≤0.45 to 0.46 sec
• QTc values, however, are on a bell curve
U wave
• Seen in V2 to V4
• May be from late repolarization of the mid-myocardial M cells
• The amplitude of the U wave is typically less than 0.2 Mv
• Clearly separate from the T wave
• Hypokalemia and bradycardia
• U merge with T wave when the QT interval is prolonged (a QT-U
wave)
• Very obvious when the QT or JT interval is shortened [ digoxin or
hypercalcemia]
What is PP interval ?
• PP interval is the interval between
the P waves due to atrial
depolarization (measured from the
onset of one P wave to the onset of
the next P wave).
• Atrial Rate can be calcutated from
PP interval.
• In sinus rhythm PP interval and
RR interval are same.
• In CHB PP interval is shorter than
the RR interval
What is TP segment?
• TP segment is the isoelectric interval
on ECG
• It is the region between the end of the T
wave (ventricular repolarization or
electrical inactivation) and the next P
wave (atrial depolarization or electrical
activation).
• It represents the time when the heart
muscle cells are electrically silent.
• TP interval shortens when the heart rate
increases and vice versa.
• Ideally, elevation and depression of ST
segment and PR segment are measured
with reference to the TP segment.
Segments and Interval In ECG
• A segment in an
electrocardiogram is the region
between two waves.
• An interval in an
electrocardiogram includes one
segment and one or more wave
 Normal ECG
WAVE OR INTERVAL DURATION [ MSEC )
P WAVE DURATION < 120
PR INTERVAL <200
QRS DURATION < 120

QT INTERVAL CORRECTED < 440 – 460

How to measure Axis of the QRS
Complex?
Identify the transitional lead by locating the lead in which the QRS
complex has the most nearly equal positive and negative components.

Identify the lead that is oriented perpendicular to the transitional lead by

using the hexaxial reference system

Consider the predominant direction of the QRS Complex in the lead

identified in the step 2 . If the direction is positive, the axis is the same
as the positive pole of that lead , and if it is negative then it is same as
the negative pole of the lead.
Hexaxial Reference System
Normal ECG
Determine the QRS Axis??
Thank you