ECG Rhythm Interpretation

Module VII b
Reading 12-Lead ECG’s
 Course Objective

• To systematically analyze a 12-lead

ECG.
 Learning Modules

• ECG Basics
• How to Analyze a Rhythm
• Normal Sinus Rhythm
• Heart Arrhythmias
• Diagnosing a Myocardial Infarction
• Advanced 12-Lead Interpretation
• Reading 12-Lead ECG’s
 Reading 12-Lead ECGs
In Module VII a we introduced a 6 step approach for
analyzing a 12-lead ECG and covered the first 3 steps. In
this module we will cover the last 3 steps.
• Calculate RATE
– Determine RHYTHM
– Determine QRS AXIS
– Calculate INTERVALS
– Assess for HYPERTROPHY
– Look for evidence of INFARCTION
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• Intervals refers to the length of the PR and QT intervals
and the width of the QRS complexes. You should have
already determined the PR and QRS during the “rhythm”
step, but if not, do so in this step.

• In the following few slides we’ll review what is a normal

and abnormal PR, QRS and QT interval. Also listed are a
few common causes of abnormal intervals.
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PR interval

< 0.12 s 0.12-0.20 s > 0.20 s

High catecholamine
states Normal AV nodal blocks
Wolff-Parkinson-White

Wolff-Parkinson-White 1st Degree AV Block

Rate Rhythm Axis Intervals Hypertrophy Infarct

QRS complex
< 0.10 s 0.10-0.12 s > 0.12 s

Bundle branch block

Incomplete bundle
Normal PVC
branch block
Ventricular rhythm

Incomplete bundle branch block 3rd degree AV block with

ventricular escape rhythm

Remember: If you have a BBB determine if it is a right or left

BBB. If you need a refresher see Module VI.
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QT interval
The duration of the QT interval is
proportionate to the heart rate. The faster
the heart beats, the faster the ventricles
repolarize so the shorter the QT interval.
Therefore what is a “normal” QT varies
with the heart rate. For each heart rate you
need to calculate an adjusted QT interval,
called the “corrected QT” (QTc):
QTc = QT / square root of RR interval
Rate Rhythm Axis Intervals Hypertrophy Infarct

QTc interval

< 0.44 s > 0.44 s Long QT

Normal Long QT

Torsades de Pointes

A prolonged QT can be very dangerous. It may predispose an individual to a type of

ventricular tachycardia called Torsades de Pointes. Causes include drugs, electrolyte
abnormalities, CNS disease, post-MI, and congenital heart disease.
Rate Rhythm Axis Intervals Hypertrophy Infarct

QT = 0.40 s
RR = 0.68 s
Square root of
RR = 0.82
QTc = 0.40/0.82
= 0.49 s

PR interval? QRS width? QTc interval?

0.16 seconds 0.08 seconds 0.49 seconds
Interpretation of intervals? Normal PR and QRS, long QT
Rate Rhythm Axis Intervals Hypertrophy Infarct
RR

23 boxes 17 boxes

10 boxes 13 boxes

QT

Normal QT Long QT

Tip: Instead of calculating the QTc, a quick way to estimate if the

QT interval long is to use the following rule:
A QT > half of the RR interval is probably long.
Rate Rhythm Axis Intervals Hypertrophy Infarct

In this step of the 12-lead ECG analysis, we use the ECG

to determine if any of the 4 chambers of the heart are
enlarged or hypertrophied. We want to determine if there
are any of the following:
– Right atrial enlargement (RAE)
– Left atrial enlargement (LAE)
– Right ventricular hypertrophy (RVH)
– Left ventricular hypertrophy (LVH)
Rate Rhythm Axis Intervals Hypertrophy Infarct
• In Module VI we introduced the concept of left ventricular
hypertrophy. As you remember the QRS voltage increases with LVH
and is characterized by tall QRS complexes in certain leads. Similarly
for right ventricular hypertrophy we look at the QRS complexes for
changes in voltage patterns.

• With right and left atrial enlargement we analyze the P wave (since
the P wave represents atrial depolarization). Here we also look for
changes in voltage patterns.

• Note: as mentioned in Module VI criteria exists to diagnose LVH,

the same goes for RAE, LAE and RVH. In the following slides we will
be presenting criteria you can use. However other criteria exists and
as a reference you might find it useful to carry a copy of Tom Evans’
ECG Interpretation Cribsheet.
Rate Rhythm Axis Intervals Hypertrophy Infarct
Right atrial enlargement
– Take a look at this ECG. What do you notice about the P waves?

The P waves are tall, especially in leads II, III and avF.
Ouch! They would hurt to sit on!!
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Right atrial enlargement

– To diagnose RAE you can use the following criteria:
• II P > 2.5 mm, or
• V1 or V2 P > 1.5 mm > 1 ½ boxes (in height)

Remember 1 small
> 2 ½ boxes (in height)
box in height = 1 mm

A cause of RAE is RVH from pulmonary hypertension.

Rate Rhythm Axis Intervals Hypertrophy Infarct
Left atrial enlargement
– Take a look at this ECG. What do you notice about the P waves?

Notched

Negative deflection

The P waves in lead II are notched and in lead V1 they

have a deep and wide negative component.
Rate Rhythm Axis Intervals Hypertrophy Infarct

Left atrial enlargement

– To diagnose LAE you can use the following criteria:
• II > 0.04 s (1 box) between notched peaks, or
• V1 Neg. deflection > 1 box wide x 1 box deep

Normal LAE
A common cause of LAE is LVH from hypertension.
Rate Rhythm Axis Intervals Hypertrophy Infarct
Right ventricular hypertrophy
– Take a look at this ECG. What do you notice about the axis and QRS
complexes over the right ventricle (V1, V2)?

There is right axis deviation (negative in I, positive in II) and

there are tall R waves in V1, V2.
Rate Rhythm Axis Intervals Hypertrophy Infarct
Right ventricular hypertrophy
– Compare the R waves in V1, V2 from a normal ECG and one from
a person with RVH.
– Notice the R wave is normally small in V1, V2 because the right
ventricle does not have a lot of muscle mass.
– But in the hypertrophied right ventricle the R wave is tall in V1, V2.

Normal RVH
Rate Rhythm Axis Intervals Hypertrophy Infarct

Right ventricular hypertrophy

– To diagnose RVH you can use the following criteria:
• Right axis deviation, and
• V1 R wave > 7mm tall

A common
cause of RVH
is left heart
failure.
Rate Rhythm Axis Intervals Hypertrophy Infarct
Left ventricular hypertrophy
– Take a look at this ECG. What do you notice about the axis and QRS
complexes over the left ventricle (V5, V6) and right ventricle (V1, V2)?

The deep S waves

seen in the leads over
the right ventricle are
created because the
heart is depolarizing
left, superior and
posterior (away from
leads V1, V2).

There is left axis deviation (positive in I, negative in II) and there

are tall R waves in V5, V6 and deep S waves in V1, V2.
Rate Rhythm Axis Intervals Hypertrophy Infarct
Left ventricular hypertrophy
– To diagnose LVH you can use the following criteria*:
• R in V5 (or V6) + S in V1 (or V2) > 35 mm, or
• avL R > 13 mm

S = 13 mm
* There are several
other criteria for the
diagnosis of LVH.

R = 25 mm
A common cause of LVH
is hypertension.
Rate Rhythm Axis Intervals Hypertrophy Infarct
A 63 yo man has longstanding, uncontrolled hypertension. Is there evidence
of heart disease from his hypertension? (Hint: There a 3 abnormalities.)

Yes, there is left axis deviation (positive in I, negative in II), left atrial enlargement
(> 1 x 1 boxes in V1) and LVH (R in V5 = 27 + S in V2 = 10  > 35 mm).
Rate Rhythm Axis Intervals Hypertrophy Infarct
• When analyzing a 12-lead ECG for evidence of an
infarction you want to look for the following:
– Abnormal Q waves
– ST elevation or depression
– Peaked, flat or inverted T waves

• These topics were covered in Modules V and VI where

you learned:
– ST elevation (or depression) of 1 mm in 2 or more
contiguous leads is consistent with an AMI
– There are ST elevation (Q-wave) and non-ST elevation
(non-Q wave) MIs
Rate Rhythm Axis Intervals Hypertrophy Infarct
Tip: One way to determine if Q waves (and R waves) are abnormal is by
looking at the width and using the following mantra (read red downwards):
Any Any Q wave in V1
Any Any Q wave in V2
Any Any Q wave in V3

20 A Q wave > 20 msec in V4 (i.e. 0.02 sec or ½ width of a box)

30 A Q wave > 30 msec in V5
30 A Q wave > 30 msec in V6

30 A Q wave > 30 msec in I

30 A Q wave > 30 msec in avL
30 A Q wave > 30 msec in II
30 A Q wave > 30 msec in avF

R40 A R wave > 40 msec in V1

R50 A R wave > 50 msec in V2
Rate Rhythm Axis Intervals Hypertrophy Infarct

This mantra corresponds to the ECG in the following way:

30 Any R40 20

30 30 Any R50 30

30 Any 30
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

To summarize:
– Calculate RATE
– Determine RHYTHM
– Determine QRS AXIS
– Normal
– Left axis deviation
– Right axis deviation
– Right superior axis deviation
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

To summarize:
– Calculate RATE
– Determine RHYTHM
– Determine QRS AXIS
• Calculate INTERVALS
– PR
– QRS
– QT
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

To summarize:
– Calculate RATE
– Determine RHYTHM
– Determine QRS AXIS
– Calculate INTERVALS
– Assess for HYPERTROPHY
– Right and left atrial enlargement
– Right and left ventricular hypertrophy
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

To summarize:
– Calculate RATE
– Determine RHYTHM
– Determine QRS AXIS
– Calculate INTERVALS
– Assess for HYPERTROPHY
– Look for evidence of INFARCTION
– Abnormal Q waves
– ST elevation or depression
– Peaked, flat or inverted T waves
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

To summarize:
– Calculate RATE
– Determine RHYTHM
– Determine QRS AXIS
– Calculate INTERVALS
– Assess for HYPERTROPHY
– Look for evidence of INFARCTION

Now to finish this module lets analyze a 12-lead ECG!

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
A 16 yo young man ran into a guardrail while riding a motorcycle.
In the ED he is comatose and dyspneic. This is his ECG.
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What is the rate? Approx. 132 bpm (22 R waves x 6)
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What is the rhythm? Sinus tachycardia
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What is the QRS axis? Right axis deviation (- in I, + in II)
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
What are the PR, QRS PR = 0.12 s, QRS = 0.08 s, QTc = 0.482 s
and QT intervals?
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Is there evidence of No (no peaked, notched or negatively
atrial enlargement? deflected P waves)
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Is there evidence of No (no tall R waves in V1/V2 or V5/V6)
ventricular hypertrophy?
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Infarct: Are there abnormal Yes! In leads V1-V6 and I, avL
Q waves?

30 Any R40 20

30 30 Any R50 30

30
Any 30
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Infarct: Is the ST elevation Yes! Elevation in V2-V6, I and avL.
or depression? Depression in II, III and avF.
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
Infarct: Are there T wave No
changes?
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
ECG analysis: Sinus tachycardia at 132 bpm, right axis deviation,
long QT, and evidence of ST elevation infarction in the
anterolateral leads (V1-V6, I, avL) with reciprocal changes (the
ST depression) in the inferior leads (II, III, avF).
This young man suffered an
acute myocardial infarction after
blunt trauma. An
echocardiogram showed
anteroseptal akinesia in the left
ventricle with severely
depressed LV function
(EF=28%). An angiogram
showed total occlusion in the
proximal LAD with collaterals
from the RCA and LCX.
 End of Module VII b
Reading 12-Lead ECGs
Proceed to Module VII b Practice
Quiz on WebCT