ECG Course Online - Introduction

An electrocardiogram (ECG) is a picture of the electrical conduction of the

heart. By examining changes from normal on the ECG, clinicians can identify
a myriad of cardiac disease processes.
There are two ways to learn ECG interpretation which include pattern
recognition (the most common) or by understanding the exact electrical
vectors recorded by an ECG as it relates to cardiac electrophysiology. Most
people learn a combination of the two (the method of this tutorial) and basing
ECG interpretation on pattern recognition alone is often not sufficient.

How to use this tutorial

To master ECG interpretation takes time and effort, however this tutorial is
designed to be concise and focused on only what you need to know, yet very
thorough. Start by reading through the following sections on the ECG basics
and the different parts of the ECG. Once completed, be sure to read through
all of the ECG criteria and review pages to learn how to diagnose specific
conditions and rhythms such as myocardial infarctions and chamber
hypertrophies. Then go through the 100+ practice ECG quizzes that have
detailed explanations and link to the pertinent explanation pages. Lastly,
there are 50 ECG cases which test your ECG interpretation skills in the setting
of clinical scenarios. Once completed, a thorough understanding of ECG
interpretation will be attained. Keep your skills up by signing up for our ECG
Blog.

Parts of an ECG

The standard ECG has 12 leads. Six of the leads are considered "limb leads"
since they are from leads placed on the arms and/or legs of the individual.
The other six leads are considered "precordial leads" since they are placed on
the person's torso (precordium).

The 6 limb leads are called lead I, II, III, aVL, aVR and aVF. The letter a
stands for augmented as these leads are calculated as a combination of
leads I, II and III.

The 6 precordial leads are called leads V1, V2, V3, V4, V5 and V6.

Below is a normal 12-lead ECG tracing. The different parts of the ECG will be
described in the following sections.

Normal

The Normal ECG

QRSComplex

A normal ECG contains waves, intervals, segments, and one complex defined
below:

Wave: A positive or negative deflection from baseline indicates a specific

electrical event. The waves on an ECG include the P wave, Q wave, R wave, S
wave, T wave and U wave.

Interval: The time between two specific ECG events. The intervals that are
commonly measured on an ECG include the PR interval, QRS interval (also
called QRS duration), the QT interval and the RR interval.

Segment: The length between two specific points on the ECG which are
supposed to be at the baseline amplitude (not negative or positive). The
segments on an ECG include the PR segment, ST segment and the TP
segment.

Complex: The combination of multiple waves grouped together. The only

main complex on the ECG is the QRS complex.

Point: There is only one point on the ECG termed the J point which is where
the QRS complex ends the ST segment begins.

The main part of the ECG contains a P wave, QRS complex, and T wave which
will each be explained individually in this tutorial as will each segment and
interval.

The P wave indicates atrial depolarization. The QRS complex consists of a Q

wave, R wave and S wave. The QRS complex represents ventricular
depolarization. The T wave comes after the QRS complex and indicates
ventricular repolarization. Below is a normal QRS complex with the individual
parts labeled and a normal full 12-lead ECG:

Note that right-sided ECGs and posterior ECGs can be helpful and are
described elsewhere.

NEXT: APPROACH TO ECG INTERPRETATION

ECG Course Online - Introduction
An electrocardiogram (ECG) is a picture of the electrical conduction of the
heart. By examining changes from normal on the ECG, clinicians can identify
a myriad of cardiac disease processes.

There are two ways to learn ECG interpretation which include pattern
recognition (the most common) or by understanding the exact electrical
vectors recorded by an ECG as it relates to cardiac electrophysiology. Most
people learn a combination of the two (the method of this tutorial) and basing
ECG interpretation on pattern recognition alone is often not sufficient.

How to use this tutorial

To master ECG interpretation takes time and effort, however this tutorial is

designed to be concise and focused on only what you need to know, yet very
thorough. Start by reading through the following sections on the ECG basics
and the different parts of the ECG. Once completed, be sure to read through
all of the ECG criteria and review pages to learn how to diagnose specific
conditions and rhythms such as myocardial infarctions and chamber
hypertrophies. Then go through the 100+ practice ECG quizzes that have
detailed explanations and link to the pertinent explanation pages. Lastly,
there are 50 ECG cases which test your ECG interpretation skills in the setting
of clinical scenarios. Once completed, a thorough understanding of ECG
interpretation will be attained. Keep your skills up by signing up for our ECG
Blog.

Parts of an ECG

The standard ECG has 12 leads. Six of the leads are considered "limb leads"
since they are from leads placed on the arms and/or legs of the individual.
The other six leads are considered "precordial leads" since they are placed on
the person's torso (precordium).

The 6 limb leads are called lead I, II, III, aVL, aVR and aVF. The letter a
stands for augmented as these leads are calculated as a combination of
leads I, II and III.

The 6 precordial leads are called leads V1, V2, V3, V4, V5 and V6.

Below is a normal 12-lead ECG tracing. The different parts of the ECG will be
described in the following sections.

Normal

The Normal ECG

QRSComplex

A normal ECG contains waves, intervals, segments, and one complex defined
below:

Wave: A positive or negative deflection from baseline indicates a specific

electrical event. The waves on an ECG include the P wave, Q wave, R wave, S
wave, T wave and U wave.

Interval: The time between two specific ECG events. The intervals that are
commonly measured on an ECG include the PR interval, QRS interval (also
called QRS duration), the QT interval and the RR interval.

Segment: The length between two specific points on the ECG which are
supposed to be at the baseline amplitude (not negative or positive). The
segments on an ECG include the PR segment, ST segment and the TP
segment.

Complex: The combination of multiple waves grouped together. The only

main complex on the ECG is the QRS complex.

Point: There is only one point on the ECG termed the J point which is where
the QRS complex ends the ST segment begins.

The main part of the ECG contains a P wave, QRS complex, and T wave which
will each be explained individually in this tutorial as will each segment and
interval.

The P wave indicates atrial depolarization. The QRS complex consists of a Q

wave, R wave and S wave. The QRS complex represents ventricular
depolarization. The T wave comes after the QRS complex and indicates
ventricular repolarization. Below is a normal QRS complex with the individual
parts labeled and a normal full 12-lead ECG:

Note that right-sided ECGs and posterior ECGs can be helpful and are
described elsewhere.

NEXT: APPROACH TO ECG INTERPRETATION

Determining Heart Rate

There are two different rates that can be determined on ECGs. The atrial rate
is indicated by the frequency of the P waves and the ventricular rate is
indicated by the frequency of the QRS complexes.
Normally, the atrial rate should be the same as the ventricular rate in the
absence of disease, however certain conditions, such as third degree AV
nodal block or ventricular tachycardia can alter this normal relationship
causing AV dissociation. In this setting, the atrial rate (P waves) and
ventricular rate (QRS complexes) are at different heart rates.

Rate

One quick and easy way to measure the ventricular rate is to examine the RR
interval (distance between two consecutive R waves) and use a standard
scale to find the rate. If two consecutive R waves are separated by only one
large box, then the rate is 300 beats per minute. If the R waves are separated
by two large blocks, then the ventricular rate is 150 beats per minute. The
scale continues down to show that if two consecutive R waves are separated
by 8 large boxes, then the rate is 37 beats per minute. The pictorial
explanation of this method is to the right.

Another quick way to calculate the rate is based on the fact that the entire
ECG is 10 seconds. So by counting the number of QRS complexes and
multiplying by 6, the number per minute can be calculated (since 10 seconds
times 6 is 60 seconds or 1 minute). This is a better method when the QRS
complexes are irregular (such as during atrial fibrillation) which makes the
first method less accurate, since the RR intervals may vary from beat to beat
in this setting. Below are some examples using each method.

Example 1: Note that the QRS complexes are about five and a half large
boxes apart. Referencing the above image it can be determined that the
ventricular heart rate is between 50 and 60 beats per minute. This is a full 10
second rhythm strip. There are 9 QRS complexes total. Multiply the number of
QRS complexes by 6 and the exact heart rate is 54 beats per minute. There is
1 P wave for each QRS complex and thus the atrial rate is the same.

BradycardiaHR-FullStrip1

Example 2: These QRS complexes are exactly three large boxes apart and
thus the ventricular heart rate is 100 beats per minute. Now multiple the
number of QRS complexes on this strip by 6. This would be 17 x 6 = 102.
There is 1 P wave for each QRS complex and thus the atrial rate is the same.

TachycardiaHR-FullStrip1

Example 3: These QRS complexes are less than 2 large boxes apart and thus
the heart rate is between 150 and 300. Multiplying the number of QRS
complexes by 6 would give 29 x 6 = 174 beats per minute. There is likely 1 P
wave for each QRS complex (difficult to see on this strop) and thus the atrial
rate is likely the same.

HeartRateFullECGStrip-Tachycardia2

Example 4: The below ECG strip shows the irregularly irregular QRS
complexes present during atrial fibrillation. Using the first method to
determine heart rate would NOT be accurate since the R-R intervals vary
significantly. The best way to determine the ventricular heart rate would be to
simply count the QRS complexes and multiple by 6 which would be 15 x 6 =
90 beats per minute. The P waves are not able to be identified in atrial
fibrillation and it is assumed that the atrial rate is between 400-600 beats per
minute.

AtrialFibrillationHRFullStrip

Example 5: This ECG strip shows "AV dissociation" meaning the P waves
(indicating atrial activity) are at a different rate than the QRS complexes
(indicating ventricular activity). This rhythm is actually an accelerated
idioventricular rhythm (slow ventricular tachycardia). The atrial rate is
indicated by the P waves. There are almost exactly 5 large boxes between P
waves indicating an atrial rate of 60 beats per minute. There are a total of 10
P waves on this strip (difficult to see some of them as they are intermittently
buried in the QRS complexes) and 10 x 6 = 60 confirming the first method.
There are just more than 4 big boxes between each QRS complexes and thus
the ventricular rate is between 60 and 75. Since there is a total of 11 QRS
complexes in this full 10 second strip, the actual ventricular rate is 11 x 6 =
66 beats per minute.

AVDissociationECGFullStrip

NEXT: DETERMINING THE RHYTHM

Determining Rhythm
The rhythm is either sinus rhythm or not sinus rhythm. Sinus rhythm refers to
the origination of the electrical activity coming from the sinus node (SA node
or sinoatrial node). This results in an upright P wave in lead II on the ECG.

If there is a P wave before every QRS complex and it has a "sinus

morphology", then normal sinus rhythm or NSR is said to be present. A
sinus morphology is an upright P wave in lead II and biphasic (up and down)
in lead V1. The first ECG strip below shows a P wave with sinus morphology
and thus normal sinus rhythm. If the P wave has a different morphology than
the typical sinus morphology, then it is termed "ectopic" simply meaning
coming from somewhere other than the sinus node. Ectopic atrial rhythms
(including atrial tachycardia), multifocal atrial tachycardia and junctional
rhythms all have P waves that are not of sinus morphology and will be
reviewed in detail later. The second strip below shows an ectopic atrial
rhythm. Note that the P wave is down in lead II and only up (not biphasic) in
lead V1.

EctopicPWave

If there is sinus rhythm and the heart rate is greater than 100, then sinus
tachycardia is present. If the there is sinus rhythm and the heart rate is less
than 60, then sinus bradycardia is present. Below are an example of each
of these:

Sinus Tachycardia ECG

Sinus Bradycardia ECG

If there are no P waves present or the P wave morphology is not normal, then
the exact rhythm must be determined. Multiple other arrhythmias exist and
include atrial fibrillation, atrial flutter, and ventricular rhythms such as
ventricular tachycardia or ventricular fibrillation. These are discussed in detail
in the ECG criteria review sections.

Here are three more examples of rhythms other than sinus rhythm:

IrregularlyIrregularRhythms

Note that when AV dissociation is present as previously described (complete

heart block or ventricular tachycardia), there may not be a P wave before
every QRS complex, however as long as the P wave is upright in lead II, sinus
rhythm is still said to be present.

NEXT: DETERMINING AXIS

Determining ECG Axis

The axis of the ECG is the major direction of the overall electrical activity of
the heart. It can be normal, leftward (left axis deviation or LAD), rightward

(right axis deviation or RAD), or indeterminate (northwest axis). The QRS axis
is the most important to determine, however the P wave or T wave axis can
also be measured.

To determine the QRS axis, the limb leads need to be examined (not the
precordial leads). The depiction of the standard leads and their relationship to
the cardiac axis is below.

Note that lead I is at zero degrees, lead II is at +60 degrees, and lead III is at
+120 degrees. Lead aVL (L for left arm) is at -30 degrees, lead aVF (F for foot)
is at +90 degrees, and the negative of lead aVR (R for right arm) is at +30
degrees. The positive of lead aVR is actually at -150 degrees.

Memorizing the above picture is crucial to accurately determining axis,

however there are some shortcuts to quickly determine the axis as
mentioned below.

The normal QRS axis should be between - 30 and +90 degrees. Left axis
deviation is defined as the major QRS vector falling between -30 and -90
degrees. Right axis deviation occurs with the QRS axis is between +90 and
+180 degrees. Indeterminate axis is between +/- 180 and -90 degrees. This is
summarized in the image below:

LAD = Left Axis Deviation

RAD = Right Axis Deviation
NW = northwest axis or indeterminate axis

The fastest, non-specific method to determine the QRS axis is to find the
major direction of the QRS complex (positive or negative) in leads I and aVF.

Normal QRS Axis

If the QRS complex is upright (positive) in both lead I and lead aVF, then the
axis is normal. The below image demonstrates this example with the
electrical vector heading towards the positive of lead I and the positive of
lead aVF as indicated by the arrows. The QRS axis is thus between these two
arrows which falls within the normal range.

NormalQRSAxisExample

Left Axis Deviation

If the QRS is upright in lead I (positive) and downward in lead aVF (negative),
then the axis is between 0 and -90 degrees. However recall that left axis
deviation is defined as between -30 and -90 and thus this scenario is not
always technically left axis deviation. In this scenario, the QRS axis could fall
between 0 and -30 which is within normal limits. To further distinguish normal
from left axis deviation in this setting, look at lead II. If lead II is downward
(negative), then the axis is more towards -120 and left axis deviation is
present. If the QRS complex in lead II is upright (positive), then the axis is
more towards +60 degrees and the QRS axis is normal.

Causes of left axis deviation (LAD) are below. Note that the first 3 account for
almost 90% of ECG tracings with left axis deviation.

1. Normal variant

2. Left anterior fascicular block

3. Left ventricular hypertrophy (rarely, usually axis normal with LVH)

4. Left bundle branch block (rarely)

5. Mechanical shift of heart in the chest (lung disease, prior chest surgery
etc...)

6. Inferior Myocardial Infarction

7. Wolff-Parkinson-White syndrome with "pseudoinfarct" pattern

8. Ventricular rhythms (accelerated idioventricular or ventricular tachycardia)

9. Ostium primum atrial septal defect

Below is an example of left axis deviation to help visualize the above

explanation:

LeftAxisDeviationQRS

Right Axis Deviation

If the QRS is predominantly negative in lead I and positive in lead aVF, then
the axis is rightward (right axis deviation). Causes of right axis deviation
include:

1. Normal variation

2. Right Bundle Branch Block (RBBB)

3. Right ventricular hypertrophy

4. Left Posterior Fascicular Block

5. Dextrocardia

6. Ventricular rhythms (accelerated idioventricular or ventricular tachycardia)

7. Lateral wall myocardial infarction

8. Wolff-Parkinson-White Syndrome

9. Acute right heart strain/pressure overload a.k.a. "McGinn-White Sign" or

S1Q3T3 that occurs in pulmonary embolus.

Below is a pictorial example of right axis deviation:

RightAxisDeviationQRS

Indeterminate Axis

If the QRS is downward (negative) in lead I and downward (negative) in lead

aVF, then the axis is indeterminate and sometimes referred to as
"northwestern axis". This finding is uncommon and usually from ventricular
rhythms, but can also be from paced rhythms, lead misplacement and certain
congenital heart diseases.

IndeterminateQRSAxis

NEXT SECTION: P WAVE

P Wave
NormalQRS-SimpleLabels

P wave: Indicates atrial depolarization

The P wave occurs when the SA node (sinus node or sinoatrial node) creates
an action potential that depolarizes the atria. The P wave should be upright in
lead II if the action potential is originating from the SA node. In this setting,
the ECG is said to demonstrate a "normal sinus rhythm" abbreviated "NSR".
As long as the atrial depolarization is able to spread through the AV node to
the ventricles, each P wave should be followed by a QRS complex.

Multiple abnormalities of the P wave exist and are discussed in detail in the
ECG criteria review sections. Atrial enlargements can widen the P wave or
increase the P wave amplitude. Ectopic atrial rhythms can alter the normal
morphology of the P waves. There are many heart rhythms in which the P
waves are not able to be identified such as atrial fibrillation and sometimes
junctional rhythms. At times, the P waves can be buried at the end of the QRS
complex causing a short RP scenario such as seen in atrioventricular
reentry tachycardia (AVNRT).

NEXT SECTION: PR INTERVAL

PR Interval
The time from the beginning of the P wave (atrial depolarization) to the
beginning of the QRS complex (ventricular depolarization) is the PR interval.
This represents the time that it takes for the electrical impulse generated in

the sinus node to travel through the atria and across the AV node to the
ventricles. The normal PR interval is 0.12 to 0.20 seconds or 120 to 200
milliseconds (ms).

Step2-Q11-PIC2

Multiple abnormalities of the PR interval can occur including prolongation (as

depicted on the right), shortening of the PR interval and variation from beat
to beat. These are discussed in detail in the ECG criteria review sections. A
prolonged PR interval indicates delayed conduction of the SA nodal impulse
to the ventricles and is called 1st degree AV block. A short PR interval can be
seen when the AV node delay is bypassed such as in Wolff-Parkinson-White
syndrome or Lown-Ganong-Levine syndrome. The PR interval will vary in
seconds degree type I AV block (Wenckebach).

Note that the PR interval can be altered by changing sympathetic and

parasympathetic tone. Because of this, medications such as beta-blockers
can lengthen the PR interval causing a first degree AV block. Also, a longer PR
interval can cause the first heart sound on examination to sound soft and vise
versa.

NEXT SECTION: PR SEGMENT

PR Segment
The PR segment is the portion of the ECG from the end of the P wave to the
beginning of the QRS complex. The PR segment is different than the PR
interval which is measured in units of time (ms).

Remember that segments are different than intervals. The important factor to
analyze in segments on the ECG is their change from the isoelectric line
(elevation or depression) while the important thing to analyze for intervals is
their duration.

Abnormalities of the PR segment are not very common, however can

indicated certain cardiac disease states. PR segment depression can indicate

pericarditis or atrial infarction. PR segment elevation occurs in lead aVR in the
setting of pericarditis.

NEXT SECTION: Q WAVE

Q Wave
The Q wave is the first downward deflection after the P wave and is the first
element in the QRS complex. When the first deflection of the QRS complex is
upright, then no Q wave is present. The normal individual will have a small Q
wave in many, but not all ECG leads.

NormalQRS-SimpleLabels

Abnormalities of the Q waves are mostly indicative of myocardial infarctions

and are discussed in the ECG criteria review sections. The terms Q wave
myocardial infarction and non-Q wave myocardial infarction are old
designations of different types of myocardial infarctions where the end result
is Q wave development or the absence of Q wave development respectively.
ECG examples of different Q wave patterns are below:

Old Inferior Wall MI ECG Example 1

Old Inferior Wall MI ECG Example 2
Normal inferior Q waves - NOT old inferior MI ECG Exmaple
Old Anterior MI ECG Example 1
NEXT SECTION: R WAVE

R Wave
The R wave is the first upward deflection after the P wave and is part of the
QRS complex. The R wave morphology itself is not of great clinical
importance, however at times it can vary. In lead V1, the R wave should be

small. The R wave becomes larger throughout the precordial leads (V1 to V6)
to the point where the R wave is larger than the S wave in lead V4. The S
wave then becomes quite small in lead V6. This is called normal "R wave
progression". When the R wave remains small in leads V3-V4 (smaller than
the S wave), the term "poor R wave progression" is used and is depicted
below:

PRWPExamples

Remember, in lead V1 the R wave is usually quite small, however if the R

wave is large in V1 (greater in amplitude than the S wave), then significant
pathology may be present. Causes of an R wave to S wave ratio of greater
than 1 in lead V1 include a right bundle branch block, Wolff-Parkinson-White
syndrome, an acute posterior myocardial infarction, right ventricular
hypertrophy and isolated posterior wall hypertrophy (which can occur in
Duchenne's muscular dystrophy).

In the setting of a right bundle branch block there may be two R waves
present giving the classic bunny ear appearance of the QRS complex. In
this setting, the second R wave is termed R or R prime.

NEXT SECTION: S WAVE

S Wave
The S wave is the first downward deflection of the QRS complex that occurs
after the R wave.

NormalQRS-SimpleLabels

An S wave may not be present in all ECG leads in a given patient. In the
normal ECG, there is a large S wave in V1 which progressively becomes
smaller to the point where almost no S wave is present in V6. A large slurred
S wave is seen in lead I and V6 in the setting of a right bundle branch block.

The presence or absence of the S wave does not have major clinical
significance. Rarely is the morphology of the S wave discussed. In the setting
of a pulmonary embolism, a large S wave may be present in lead I (part of
the S1Q3T3 pattern seen in this disease state). At times the morphology of
the S wave is examined to determine if ventricular tachycardia or
supraventricular tachycardia with aberrancy is present. This is discussed
elsewhere.

NEXT SECTION: THE QRS COMPLEX

QRS Complex
The QRS complex is the combination of the Q wave, R wave and S wave
and represents ventricular depolarization. This term can be confusing since
not all ECG leads contain all three of these waves, yet a QRS complex is
said to be present regardless. For example, the normal QRS complex in lead
V1 does not contain a Q wave, but only a R wave and S wave, yet the
combination of the R wave and S wave is still referred to as the QRS complex
for this lead.

NormalQRS-SimpleLabels

The normal duration (interval) of the QRS complex is 0.80 and 0.10 seconds
(80 and 100 ms). When the duration is between 0.10 and 0.12 seconds it is
intermediate or slightly prolonged. A QRS duration of greater than 0.12
seconds is considered abnormal.

The QRS duration will lengthen when electrical activity takes a long time to
travel throughout the ventricular myocardium. The normal conduction system
in the ventricles is called the His-Purkinje system and consists of cells that
can conduct electricity quite rapidly. Thus, normal conduction of an electrical
impulse through the AV node then to the ventricles via the His-Purkinje
system is fast causing a normal QRS duration. When electrical activity does
not conduct through the His-Purkinje system, but instead travels from
myocyte to myocyte, a longer time is necessary and the QRS duration is
widened.

A widened QRS duration occurs in the setting of a right bundle branch block,
left bundle branch block, non-specific intraventricular conduction delay and
during ventricular arrhythmias such as ventricular tachycardia all of which are
discussed in detail in the ECG criteria review sections.

NEXT SECTION: T WAVE

T Wave
The T wave occurs after the QRS complex and is a result of ventricular
repolarization. T waves should be upright in most leads (except aVR and V1).
T waves should be asymmetric in nature. The second portion of the T wave
should have a steeper decline when compared to the incline of the first part
of the T wave. If the T wave appears symmetric, cardiac pathology may be
present such as ischemia.

TWaves2

Many abnormal T wave patterns exist which are reviewed in more detail in
the ECG criteria review sections. These include hyperkalemia, Wellens
syndrome, left ventricular hypertrophy with repolarization abnormalities,
pericarditis (stage III), arrhythmogenic right ventricular dysplasia (ARVD) and
hyperacute T waves during myocardial infarction.

NEXT SECTION: QT INTERVAL

Determining Heart Rate

There are two different rates that can be determined on ECGs. The atrial rate
is indicated by the frequency of the P waves and the ventricular rate is
indicated by the frequency of the QRS complexes.
Normally, the atrial rate should be the same as the ventricular rate in the
absence of disease, however certain conditions, such as third degree AV
nodal block or ventricular tachycardia can alter this normal relationship

causing AV dissociation. In this setting, the atrial rate (P waves) and

ventricular rate (QRS complexes) are at different heart rates.

Rate

One quick and easy way to measure the ventricular rate is to examine the RR
interval (distance between two consecutive R waves) and use a standard
scale to find the rate. If two consecutive R waves are separated by only one
large box, then the rate is 300 beats per minute. If the R waves are separated
by two large blocks, then the ventricular rate is 150 beats per minute. The
scale continues down to show that if two consecutive R waves are separated
by 8 large boxes, then the rate is 37 beats per minute. The pictorial
explanation of this method is to the right.

Another quick way to calculate the rate is based on the fact that the entire
ECG is 10 seconds. So by counting the number of QRS complexes and
multiplying by 6, the number per minute can be calculated (since 10 seconds
times 6 is 60 seconds or 1 minute). This is a better method when the QRS
complexes are irregular (such as during atrial fibrillation) which makes the
first method less accurate, since the RR intervals may vary from beat to beat
in this setting. Below are some examples using each method.

Example 1: Note that the QRS complexes are about five and a half large
boxes apart. Referencing the above image it can be determined that the
ventricular heart rate is between 50 and 60 beats per minute. This is a full 10
second rhythm strip. There are 9 QRS complexes total. Multiply the number of
QRS complexes by 6 and the exact heart rate is 54 beats per minute. There is
1 P wave for each QRS complex and thus the atrial rate is the same.

BradycardiaHR-FullStrip1

Example 2: These QRS complexes are exactly three large boxes apart and
thus the ventricular heart rate is 100 beats per minute. Now multiple the
number of QRS complexes on this strip by 6. This would be 17 x 6 = 102.
There is 1 P wave for each QRS complex and thus the atrial rate is the same.

TachycardiaHR-FullStrip1

Example 3: These QRS complexes are less than 2 large boxes apart and thus
the heart rate is between 150 and 300. Multiplying the number of QRS
complexes by 6 would give 29 x 6 = 174 beats per minute. There is likely 1 P
wave for each QRS complex (difficult to see on this strop) and thus the atrial
rate is likely the same.

HeartRateFullECGStrip-Tachycardia2

Example 4: The below ECG strip shows the irregularly irregular QRS
complexes present during atrial fibrillation. Using the first method to
determine heart rate would NOT be accurate since the R-R intervals vary
significantly. The best way to determine the ventricular heart rate would be to
simply count the QRS complexes and multiple by 6 which would be 15 x 6 =
90 beats per minute. The P waves are not able to be identified in atrial
fibrillation and it is assumed that the atrial rate is between 400-600 beats per
minute.

AtrialFibrillationHRFullStrip

Example 5: This ECG strip shows "AV dissociation" meaning the P waves
(indicating atrial activity) are at a different rate than the QRS complexes
(indicating ventricular activity). This rhythm is actually an accelerated
idioventricular rhythm (slow ventricular tachycardia). The atrial rate is
indicated by the P waves. There are almost exactly 5 large boxes between P
waves indicating an atrial rate of 60 beats per minute. There are a total of 10
P waves on this strip (difficult to see some of them as they are intermittently
buried in the QRS complexes) and 10 x 6 = 60 confirming the first method.
There are just more than 4 big boxes between each QRS complexes and thus
the ventricular rate is between 60 and 75. Since there is a total of 11 QRS
complexes in this full 10 second strip, the actual ventricular rate is 11 x 6 =
66 beats per minute.

AVDissociationECGFullStrip

NEXT: DETERMINING THE RHYTHM

Determining ECG Axis

The axis of the ECG is the major direction of the overall electrical activity of
the heart. It can be normal, leftward (left axis deviation or LAD), rightward
(right axis deviation or RAD), or indeterminate (northwest axis). The QRS axis
is the most important to determine, however the P wave or T wave axis can
also be measured.

To determine the QRS axis, the limb leads need to be examined (not the
precordial leads). The depiction of the standard leads and their relationship to
the cardiac axis is below.

Note that lead I is at zero degrees, lead II is at +60 degrees, and lead III is at
+120 degrees. Lead aVL (L for left arm) is at -30 degrees, lead aVF (F for foot)
is at +90 degrees, and the negative of lead aVR (R for right arm) is at +30
degrees. The positive of lead aVR is actually at -150 degrees.

Memorizing the above picture is crucial to accurately determining axis,

however there are some shortcuts to quickly determine the axis as
mentioned below.

The normal QRS axis should be between - 30 and +90 degrees. Left axis
deviation is defined as the major QRS vector falling between -30 and -90
degrees. Right axis deviation occurs with the QRS axis is between +90 and
+180 degrees. Indeterminate axis is between +/- 180 and -90 degrees. This is
summarized in the image below:

LAD = Left Axis Deviation

RAD = Right Axis Deviation
NW = northwest axis or indeterminate axis

The fastest, non-specific method to determine the QRS axis is to find the
major direction of the QRS complex (positive or negative) in leads I and aVF.

Normal QRS Axis

If the QRS complex is upright (positive) in both lead I and lead aVF, then the
axis is normal. The below image demonstrates this example with the
electrical vector heading towards the positive of lead I and the positive of
lead aVF as indicated by the arrows. The QRS axis is thus between these two
arrows which falls within the normal range.

NormalQRSAxisExample

Left Axis Deviation

If the QRS is upright in lead I (positive) and downward in lead aVF (negative),
then the axis is between 0 and -90 degrees. However recall that left axis
deviation is defined as between -30 and -90 and thus this scenario is not
always technically left axis deviation. In this scenario, the QRS axis could fall
between 0 and -30 which is within normal limits. To further distinguish normal
from left axis deviation in this setting, look at lead II. If lead II is downward
(negative), then the axis is more towards -120 and left axis deviation is
present. If the QRS complex in lead II is upright (positive), then the axis is
more towards +60 degrees and the QRS axis is normal.

Causes of left axis deviation (LAD) are below. Note that the first 3 account for
almost 90% of ECG tracings with left axis deviation.

1. Normal variant

2. Left anterior fascicular block

3. Left ventricular hypertrophy (rarely, usually axis normal with LVH)

4. Left bundle branch block (rarely)

5. Mechanical shift of heart in the chest (lung disease, prior chest surgery
etc...)

6. Inferior Myocardial Infarction

7. Wolff-Parkinson-White syndrome with "pseudoinfarct" pattern

8. Ventricular rhythms (accelerated idioventricular or ventricular tachycardia)

9. Ostium primum atrial septal defect

Below is an example of left axis deviation to help visualize the above

explanation:

LeftAxisDeviationQRS

Right Axis Deviation

If the QRS is predominantly negative in lead I and positive in lead aVF, then
the axis is rightward (right axis deviation). Causes of right axis deviation
include:

1. Normal variation

2. Right Bundle Branch Block (RBBB)

3. Right ventricular hypertrophy

4. Left Posterior Fascicular Block

5. Dextrocardia

6. Ventricular rhythms (accelerated idioventricular or ventricular tachycardia)

7. Lateral wall myocardial infarction

8. Wolff-Parkinson-White Syndrome

9. Acute right heart strain/pressure overload a.k.a. "McGinn-White Sign" or

S1Q3T3 that occurs in pulmonary embolus.

Below is a pictorial example of right axis deviation:

RightAxisDeviationQRS

Indeterminate Axis

If the QRS is downward (negative) in lead I and downward (negative) in lead

aVF, then the axis is indeterminate and sometimes referred to as
"northwestern axis". This finding is uncommon and usually from ventricular
rhythms, but can also be from paced rhythms, lead misplacement and certain
congenital heart diseases.

IndeterminateQRSAxis

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